Inspection on 06/06/05 for St Anne`s Convent

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Anne`s Convent 25/07/08

St Anne`s Convent 31/05/06

St Anne`s Convent 18/01/06

St Anne`s Convent 17/02/05

St Anne`s Convent 31/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Annes Convent 92 Mill Road Burgess Hill West Sussex RH15 8EL Lead Inspector Veronica Gay Announced 6 June 2005, 09:00 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 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 Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Annes Convent Address 92 Mill Road, Burgess Hill, West Sussex, RH15 8EL Telephone number Fax number Email 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 (CRH) 19 Category(ies) of Old age, not falling within any other category registration, with number (OP), (19) of places St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 19 persons in the category OP Date of last inspection 17 February 2005 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 Catherine Ann McLaughlin St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. This was an announced inspection, made at 9am, which lasted six hours During this inspection the Inspector toured the building, visited every room, and spoke with staff members to gain a sense of what it was like to work in the home. As well as talking to the Manager and five of the staff members, the Inspector spoke at length to 11 of the 15 residents plus the Responsible Individual who acts on behalf of the order. The Inspector examined records about care being provided to residents; as well as records of any accidents, or concerns or complaints, to make sure that the residents are being taken care of. Prior to this inspection “comment cards” were circulated in order that people could make their views known to the Commission for Social Care Inspection. The comments made are incorporated in this report. Standards that were not met at the last inspection were checked for compliance. During the course of the day the Manager Mrs. Thomas, her staff and several of the Sisters ably assisted the Inspector. The inspector would like to thank them, and everyone else who cooperated with her at this inspection. What the service does well: What has improved since the last inspection? What they could do better: St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 6 Due to the unforeseen illness of the Registered Manager there have been some gaps in mandatory training and supervision sessions for the staff. However the manager has now returned and has started to address these matters. Progress will be reviewed at the next unannounced inspection. 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 Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,5 Prior to moving into St Anne’s people were given sufficient information about what the home offers, to enable them to make a choice as to whether or not they want to live there. People using the service do not move into the home without having their needs assessed first. Trial visits are arranged and family members visit to discuss the arrangements as appropriate. EVIDENCE: Some of the residents spoken with on the day of inspection confirmed that they had been given information all about St Ann’s and that they had been invited to visit the home before they came to stay. A Statement of Purpose and Service Users Guide was available in each of the bedrooms visited by the inspector. All residents said they thought their needs were being met “ couldn’t fault the care in any way” said one resident. Detailed plans of the resident’s daily needs were kept and this included any GP or nursing input. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 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 standard(s) 7,9 Resident’s health, personal care and social care needs are set out in an individual care plan. Residents make decisions about their lives with assistance being available as needed. Medication is managed safely, and residents who wish to self medicate would be able to do so following a risk assessment. EVIDENCE: Where resident are not able to be involved with the drawing up of their care plans, then the residents relative or advocate is involved. One resident told the inspector that she thought the home was a wonderful place, but at 103 years old she considered the government was making mistakes regarding the “care of the elderly”. Whilst she said she realised rules must be obeyed she did not see why she should have a window restrictor, radiator guard, or door closure fitted in her room. Residents comment cards and feedback received from Relatives praised the care and attention provided in the home. One resident said, “ couldn’t fault the place staff never grumble about anything”. Another resident said, “ When I was ill I felt safe in the knowledge that I was being so well cared for”. Resident said they could manage their own medication if they wish, but only three choose to do so. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,15 People living at St Anne’s are able to make the day-to-day decisions about how they want to live their life. There are a few activities for those who wish to participate, and residents are encouraged to maintain contact with all their old friends and family wherever possible. The food is of a good standard, and offers a choice of menu, with people able to eat either with other residents or in their own room should they prefer EVIDENCE: St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 11 There were a few activities on offer at St Anne’s, which seem to meet with the resident’s approval. The majority of residents told the Inspector that they felt they were free to choose, no restrictions were placed upon them. One resident said she enjoyed playing Bingo, another resident said she preferred the privacy of her room Residents told the inspector that they enjoyed being able to have their meals served on separate tray tables in the dining room, which at first appeared somewhat institutionalised. However from the evidence available and the manager’s comments it would seem that when trays were replaced with a large dining table, residents complained. There fore trays were used again and the usual practice was resumed. Several residents said they thought that living in St Anne’s had improved their quality of life because of the kind people around them. One resident said she enjoyed attending “Chapel” daily for prayer and doing her crossword puzzles. The inspector noted that the meal was served on hot plates and in a way to encourage appetites. One resident told the Inspector that “the food was good” and another said that she “could have what she wished although food was not terribly important to her ”. From direct observation, the Inspector noted that the mealtime appeared to be unhurried, with residents being afforded sufficient time to eat their meal. The Cook has worked at the home for sometime and therefore knew the likes and dislikes of the residents. A staff member consults daily with each resident in order that they can choose what they want to eat from the menu. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,18 Residents are listened to and understand how to make a complaint should they wish to. Regular training sessions for staff, plus policies and procedures regarding abuse, ensure that, as far as is possible, the people who live at St Anne’s are protected from bad practice. EVIDENCE: The Commission has received no complaints since the previous inspection. Relatives completed questionnaires prior to the inspection and stated that they had no concerns regarding the home. The manager confirmed that the majority of residents have regular contact with families or friends. During the inspection the inspector observed the manager, staff and sisters approach residents in a friendly warm manner. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,25,26 Residents live in a safe well-maintained environment. The bedrooms are bright and personalised with comfortable furnishings. Communal areas are comfortably furnished and appeared homely. Cleanliness and hygiene throughout the home is of a high standard. EVIDENCE: The inspector toured the building. All areas of the home used by residents are spotlessly clean and nicely decorated and furnished in a manner that appears “homely”. The inspector met the cleaners who knew their delegated areas of work. Residents said they appreciated living in such a clean building with views of the attractively laid out garden and grounds. Risk assessments have been undertaken to ensure the safety of residents and to enable them to enjoy a fulfilled life. The manager confirmed that a Fire officers report dated 26 March 2004 was satisfactory. The radiators are guarded and hot water temperatures monitored to safe guard residents from unnecessary burns. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30, Adequate staffing is provided to meet the needs of the residents. Staff members are trained and competent to do their jobs EVIDENCE: The inspector saw the staffing rota and asked residents if they thought there were sufficient staff members on duty to help them with their individual needs. Residents comments included “ staff are wonderfully kind”.” they answer call bells promptly”.” they always seem to make time even though they are so busy”. Staff members spoken with were able to demonstrate a clear understanding of the resident’s needs. They were committed to their work and thought they worked together as a team. The inspector was shown an induction-training checklist, which is used for all new staff. This was detailed and covered all relevant topics. Several staff members have obtained National Vocational Qualification level 3 in care, which they thought gave them a better understanding of the needs of the residents. Mandatory training has been planned and progress will be reviewed at the next inspection. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 Residents live in a home, which is managed and run by a person who is fit to be in charge. The manager communicates a clear sense of direction and her approach creates an open and inclusive atmosphere. EVIDENCE: Mrs Thomas the registered manager is a state registered nurse and therefore has the necessary skills and knowledge to carry out her duties in the best interest of residents. The manager’s assessor was present for a part of the inspection and he informed the inspector Mrs Thomas had almost finished The Registered Manager’s Award. The feedback was that he was confident she would be successful. Residents and staff, members spoke positively of the manager and said they found her approachable and supportive. St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x x x x x St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 17 Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations St Annes Convent H60-H11 S14728 St Annes Convent V222154 060605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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