CARE HOMES FOR OLDER PEOPLE
St Anne`s Convent 92 Mill Road Burgess Hill West Sussex RH15 8EL Lead Inspector
Mrs V. Gay Unannounced Inspection 18th January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Anne`s Convent Address 92 Mill Road Burgess Hill West Sussex RH15 8EL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01444 233179 Franciscan Missionary Sisters Mrs Sally-Jane Thomas Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Up to 19 male and /or female service users aged from 65 years, in the category of Old Age, not falling within any other category may be admitted/accommodated. 6th June 2005 Date of last inspection Brief Description of the Service: St Annes is registered with the Commission For Social Care Inspection to provide personal care for up to nineteen persons over the age of sixty-five years (category OP) The establishment is situated in Burgess Hill, close to a range of local amenities. The service is owned by the Franciscan Missionary Sisters, a religious order. Mrs Sally Thomas is the Registered Manager and the Responsible Individual acting on behalf of the order is Sister St Anastasia Mc Gonagle. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. The first inspection, which was announced, was undertaken in June 2005. At this inspection the Inspector looked at standards that were not looked at during the previous inspection, as well as any outstanding issues from the last report. The reader is advised to look at the reports of both inspections for a full picture of the home. Where there has been no change the report remains the same. On the day of the inspection a tour of the premises was made, discussions were held with all of the residents at the home as well as the manager, Sisters and staff. In addition, the inspector sat with a group of residents during coffee. A selection of statutory records were seen as well as residents care plans. It was evident from the resident’s comments and observations made by the inspector during the inspection, that St Anne’s Franciscan Convent continues to provide a good standard of care and comfortable accommodation. What the service does well: What has improved since the last inspection?
Since the previous inspection supervision has started, although this is still not being recorded regularly as required.
St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 6 The manager has completed National Vocational Qualification level 4 in Care Management and the Registered Manager’s Award. New laundry equipment has been purchased to meet the needs of the residents. A fax machine has been provided which enables the manager to carry out her duties in a more efficient way. Residents who like to keep their bedroom doors open have been provided with electronic fire door closures, which they appreciate. Fire training for the staff has been arranged for February 2006. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, & 6 Residents are provided with a Statement of Purpose and Service Users Guide giving full details of what they can expect of the service. People using the service do not move into the home without having their needs assessed first. St Anne’s Convent does not provide intermediate care. EVIDENCE: A sample of three assessments were seen by the inspector and they all contained information on the residents health and well-being, social contacts and personal interests. Details of individuals daily needs was also kept and this included any registered nursing input required. Residents spoken with were well informed of the day-to-day running of the home. A recently admitted resident spoke highly of the admission procedure and said all concerned made her so welcome. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, &10 Service users health, personal and social care needs are set out in an individual plan of care and these needs. Medication is managed safely. Residents who wish to manage their own prescribed medication are encouraged to do so following a risk assessment. Staff members treat residents with respect so that they feel their dignity is preserved. EVIDENCE: A sample of six care plans was seen by inspector, all of which had been reviewed by the manager. Residents said that they “see the GP on request”, can see the community nurse when she calls at the home and make direct appointments with the optician and chiropodist. Some photographs of residents were missing and this was brought to the attention of the manager. Three residents told the inspector that they looked after their own medication and this was confirmed by the manager and records kept. Residents described the staff and sisters as “kind”, “caring”, “helpful”, “reliable” and “supportive”. One person said that they “don’t forget you” and
St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 10 another said, when talking about the help she receives, that they “see it before you do so you don’t have to ask”. The inspector observed staff talking and listening to residents and that they were careful to be invited into their rooms rather than simply walking in. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, & 15 Service users enjoy their own lifestyle and can spend their day as they wish. Residents said their families and friends are made welcome whenever they visit. Residents have a choice of food and social activities within the home. EVIDENCE: Residents can attend chapel daily in the home where a service is conducted by one of the Sisters. One resident told the inspector that she can “carry on her own lifestyle”. All of them start the day at the time of their choice and are provided with breakfast in their rooms. On the day of the inspection one person was just preparing a coffee tray with fresh cakes for her friends who were visiting later in the day. Residents said they enjoyed Bingo and Musical Exercises. Another resident said that staff would take her out to the shops, which she really enjoyed. Several residents told the inspector about the wonderful Christmas the sisters and staff had provided for them. The main meal was roast lamb, with carrots, peas and a choice of mashed or roast potatoes. Followed by a choice of desserts. One resident told the Inspector “the food was really good always a choice of fresh vegetables.” The inspector noted that the meal was served on hot plates, with a selection of vegetable in a way to encourage appetites. Mint sauce was served to the residents.
St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 12 The majority of residents choose to have their meals served on individual tables in the dining room. From direct observation, the Inspector noted that the mealtime appeared to be unhurried, with residents being afforded sufficient time to eat their meal. The manager consults daily with residents to ensure their needs are being met. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17, &18 Residents are listened to and understand how to raise a complaint should they wish to. Residents’ legal rights are protected by the policies and procedures in place. Residents receive training in Adult protection to protect residents from abuse. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection or recorded at the home. Residents told the inspector that they knew who was in charge, although they could never imagine having anything to complain about. Monthly visits to the home are carried out by the Responsible Individual, or a delegated member to ensure the standards are being maintained. Reports of these visits are sent as required to the Commission For Social Care Inspection. Resident’s comments included “there is nothing you could complain about… everything is really good…I have been in the home twenty nine years and it is a wonderful place”. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21, & 26 Residents live in a safe well maintained home. The bedrooms are bright and personalised with comfortable furnishings. Communal areas are comfortably furnished and appeared homely. Cleanliness as previously stated is very high. EVIDENCE: The inspector made a tour of the building. All areas of the home are nicely decorated and furnished in a homely style and well maintained. All residents enjoy the garden, which is also well maintained. One person told the inspector that she often walks in the garden when the weather permits. The last visit by the fire service was in March 2004 and the fire safety standards were considered satisfactory at that time. All areas of the home are clean and hygienic. One resident said that it is “always a very clean home”. The inspector met the staff responsible for cleaning and they were very clear about their duties and the importance of maintaining a clean environment.
St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 15 A separate laundry room is located on the ground floor, which is well equipped. Residents have sufficient and suitable toilets and washing facilities. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, & 30 Adequate staffing is provided to meet the needs of residents. Staff training is overdue and a requirement has been made. Sound recruitment procedures are followed to ensure staff are suitable to work with vulnerable people. EVIDENCE: The inspector saw the staffing rota and asked residents if there were sufficient staff for the help and support they needed. They confirmed that staff were always available. The manager three care staff, a head cook, kitchen assistant, two cleaners and three sisters were on duty at the time of the inspection. Records and discussion with residents showed that staff did not change very often and therefore knew the residents needs and wishes very well. There are currently two staff vacancies, which are being advertised. Staff training is planned and the manager has agreed to confirm in writing to the Commission for Social Care Inspection when this has been implemented, following the requirement made. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36, & 38 Residents’ financial interests are safeguarded. Mrs Thomas has a number of years experience and appropriate qualifications to fulfil the role of a Registered Manager. There are clear guidelines of accountability in the organisation. Records needed for the safe running of a care home are kept up to date. Residents’ financial interests are safeguarded. The home is run in the best interest of the residents. EVIDENCE: Although supervision is not being regularly recorded, it was evident from the resident’s comments and discussion with the manager that staff are supervised in their working practices.
St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 18 Residents told the inspector that they took care of their own money, sometimes with the help of relatives or a solicitor. Residents confirmed that the manager was always available and was approachable and kind. Regular handovers take place at the change of shift to ensure a continuity of care is provided. A report book and care record is used to record any changes in the residents health and well being. Staff members were seen to work together as a team and to approach the residents in a respectful manner. The manager was reported to be approachable and supportive. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 X 3 St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP30 Regulation 18 Requirement The Registered Provider shall ensure that persons employed to work in the care home receive training appropriate to their work Timescale for action 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations Staff supervision is recorded. St Anne`s Convent DS0000014728.V274506.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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