CARE HOMES FOR OLDER PEOPLE
St Euphrasias Chain Road Blackley Manchester M9 6GN Lead Inspector
Geraldine Blow Unannounced 24 May 2005 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 Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Euphrasias Address Chain Road Blackley Manchester M9 6GN 0161 653 2010 0161 6538564 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) The Trustees of the Congregation of our Lady of Charity of the Good Shepherd Ann Hosie Care home with nursing (N) 14 Category(ies) of Old age, not falling within any other category registration, with number (OP) (14) of places St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 Care will be provided to those who belong to the Good Shepherd order. 2 The maximum number of service users requiring personal care only shall be 9. 3 The maximum number of service users requiring nursing care shall be 5. 4 Minimum nursing staffing levels specified in the Notice served in accordance with Section 25(3) of the Registered Homes Act 1984 on 31 January 2002 must be maintained. Date of last inspection 21 December 2004 Brief Description of the Service: St Euphrasia’s is a purpose built single storey building situated in the extensive grounds of the convent with ample car parking facilities. The home is situated in Blackley in the North of the City and provides care for the older Sisters of the Good Shepherd. The home is close to local amenities and transport links into Manchester City Centre. Admission to the home is restricted to the Sisters who belong to the Order of The Good Shepherd. The home provides accommodation for up to 14 Siters, 5 of whom, have been assessed as requiring nursing care and 9 Sisters assessed as requiring personal care only. Accommodation is in offered single bedrooms. Three bedrooms have en-suite facilities. A variety of bathing facilities are available. Toilets and bathrooms are located close to bedrooms and communal areas. There is a main lounge and a separate dining room. A conservatory is situated off the main lounge. The need for privacy and the facilities for prayer are important for the Sisters and a small chapel is available within the home, alternatively the Sisters can access the chapel in the convent via a corridor from the home.
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This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, which took place over the course of 5 hours on Tuesday 24th May 2005. During the course of the inspection time was spent talking to the manager, several of the sisters and some members of staff to find out their views of the home. Time was spent examining records, documents, the Sisters and staff files. A tour of the building was also conducted. The requirement from the previous inspection had been addressed and there was evidence that the home was continuing to work hard in continuing to meet the National Minimum Standards. The home and the Commission for Social Care Inspection had not received any complaints. As this inspection only looked at a limited number of standards this report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the residents living there. What the service does well:
Prospective Sisters have a pre admission assessment to ensure that the home can meet their needs. The home continued to provided detailed plans of care that staff were able to follow when giving care to the Sisters. The home worked on a system called a ‘key worker system’. This means that each Sister has their own named nurse and named carer that are responsible for the care of individual Sisters. The home had a warm friendly atmosphere and staff were observed to be pleasant and courteous with the Sisters. Staff were seen to have good relationships with the Sisters and were seen giving individual attention to various Sisters. During the inspection it was obvious that the manager was visible and approachable to the Sisters who all spoke to her as she walked past and knew her name.
St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 6 The Sisters appeared happy and content with their lives at the home. The Sisters spoken to indicated that they were given personal choice with regard to the routine of their daily lives. Meals times are given a high priority within the home. The meals served appeared nutritious, nicely presented and the Sisters could choose what they eat. The menus were in the process of being reviewed and to obtain the Sisters views, a questionnaire had been sent out prior to the arranged meeting on the 25/5/05. The number of staff working at the home was above home was above the minimum staffing numbers on the staffing notice issued by the previous registering authority. The manager said they regularly employed more staff as and when the assessed needs of the Sisters increased. What has improved since the last inspection? 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 Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 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 Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 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) 3 and 6 New Sisters are admitted only after a full assessment of needs has been undertaken. EVIDENCE: The Sisters are only admitted to the home following a full assessment of needs. The Primary Health Care Team assesses the needs of the Sisters requiring nursing care and a qualified social worker assesses the needs of the Sisters requiring personal care prior to admission. Copies of the assessments are held on file within the home. On admission the Sisters have a further assessment period during which time the homes own care plan are formulated. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 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, 8, 9 and 10 The health and personal care needs of the Sisters were being met at the home. The homes policies and procedures were sufficient to provide a medication administration system that protected the Sisters. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 10 EVIDENCE: Each Sister had a comprehensive and detailed individual plan of care, which had been generated from a needs assessment and the homes own care planning process. Each individual file was found to contain an up to date photograph of the Sisters for easy identification. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by care staff to ensure that all aspects of health, personal and social care needs of the Sisters were met. Appropriate risk assessments had been included and the plans of care had been reviewed on a monthly basis to reflect changing needs and current objectives for health and personal care. Where appropriate the Sisters had been involved in the development of the care plans. The home worked on a named nurse system and the individual file clearly identified the named nurse and the named carer. All of the Sisters individual files were held in a locked filing cabinet. Discussions with members of staff provided evidence that they had a good understanding of the care planning process and knew how to use the documents as a working tool to assist them in providing individual care to Sisters in the home. Each Sister was registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs for example District Nurses, Tissue Viability Nurse, Dentist, Dietician and Chiropodists. Nutritional screening was undertaken on admission and subsequently on a periodic basis. Sisters’ weight had been recorded on a monthly basis, including weight loss and gain and appropriate action taken. Continence assessments were carried out on admission and reviewed on a regular basis. A plan of care had been implemented where appropriate. All of the Sisters had an assessment of their personal and oral hygiene needs to enable care staff to support the Sisters own capacity for self-care. The home had a large supply of pressure relieving equipment and it was evident that this was deployed in a preventative manner following a risk assessment of potential pressure area breakdown. If a pressure relieving
St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 11 mattress was in use for individual Sisters this was found to be clearly documented within the individual plan of care. The requirement from the last inspection that the home must keep a copy of the Sisters current medication i.e. the prescription forms had been met. The home had appropriate medication policies and procedures in place to protect the Sisters with regard to mediation administration. The policy included a risk assessment to ensure the safety of the Sisters prior to the commencement of self-medication. At the time of inspection 2 of the Sisters were selfadministrating medication. An appropriate risk assessment had been completed. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately and all deliveries and returns of prescribed medications had been recorded and accounted for so providing a full audit trial. Since the last inspection the manager had liaised with the dispensing pharmacist and the GP’s and had implemented a Homely Remedy Policy. From observations made during the inspection and discussions with members of staff and Sisters it was obvious that the nurses and care staff treated the Sisters with respect and dignity. The home had a cordless phone, which was available for the Sisters to use in private. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 12 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) 14 and 15 The Sisters were able to exercise choice and control over their lives Meals were nutritious, well balanced and offered a healthy and varied diet for the Sisters. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 13 EVIDENCE: The Sisters spoken to during the inspection stated that they were given choice in all aspects of daily living and this was confirmed by the manager who stated that all of the Sisters were encouraged to exercise personal autonomy and choice. The home held regular meetings with the Sisters and the Sisters were regularly consulted on an individual basis. Bedrooms were found to be personalised and it was evident that the Sisters were able to bring personal possessions with them. In the main meals were served in the dining room. Since the last inspection the home had obtained some new dining tables and were awaiting the delivery of new chairs. The inspector observed lunchtime to be a social occasion with staff promoting a relaxing, friendly atmosphere. The main meal was provided at lunchtime. This meal is prepared and cooked in the convents kitchen and then transferred to the home in a heated trolley via a link corridor. A small kitchenette situated off the dining room is where breakfast and evening meal are prepared and served. The meal observed during the inspection looked and smelt appetising. Drinks and snacks are provided throughout the day or night. Ample stocks of food were observed. The menus are planned on a 4-week rota and a varied alternative menu is available. The home was in the process of reviewing the menus. The manager had recently sent out a questionnaire to all Sisters to ascertain their views on the meals served and their personal preference. The manager said that in the main the vegetables served were frozen but the Sisters would have preferred more fresh vegetables. A meeting to discuss menus was scheduled to take place on the 25/5/05. The Sisters spoken to were complimentary with regard to the quality and quantity of food. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 14 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 and 18 The homes complaints procedure was known to the Sisters and they knew how to make a complaint There was a policy in place for the protection of vulnerable adults and staff had a good understanding and knowledge of how to put the policy into practice to ensure the safety and well being of the Sisters in the home. EVIDENCE: The home had a complaints procedure in place. The Commission for Social care Inspection had not received any complaints about this service and the manager informed the inspector that the home had not received any complaints. She was aware of the need to keep a record of all complaints made and include details of the investigation and any action taken. The manager appeared to have a high profile within the home and made herself available to the Sisters. In conversation with several of the Sisters it appeared that they felt confident about raising issues or complaints on any subject to the staff and the management team without any fear of incurring disapproval. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 15 The home had policies and procedures relating to abuse/protection of vulnerable adults and a Whistle Blowing policy. The home subscribed to the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse. Training had been arranged to take place on “No secrets – working with vulnerable adults”. This training was organised by the Primary Care Trust in November 2004, however this had been cancelled. The home had planned for all staff to be trained over the summer of 2005 by Local Authority, Social Services Training Department. In-house training had already taken place for staff on the action to be taken in the event of an allegation of abuse. Policies and practice relating to Sisters’ money and financial affairs provided safeguards against financial abuse. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 16 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, 21 and 26 The home was fit for its stated purpose and provided clean and comfortable surroundings as well as equipment necessary to sustain and meet the Sisters personal and health care needs. Bathing and toilet facilities were available in sufficient numbers to meet the Sisters needs. EVIDENCE: The home felt comfortable and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature. The home had a programme of routine maintenance and renewal of the fabric and decoration. The home was a single story building and access to the front of the home was at ground level. An enclosed courtyard was available for the Sisters to sit in or walk around. The Sisters had access to the convent’s extensive and well maintained gardens. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 17 The home had ample bathing and toilet facilities to meet the needs of the Sisters currently accommodated. Bathrooms/sluice rooms and toilets were all clearly marked. The bathrooms and toilets were found to be clean and equipped with the necessary aids and equipment to assist in the bathing of the Sisters with physical disabilities. Since the last inspection the home had purchased a new Argo bath ‘Malilbu’ and had arranged for staff to receive training prior to it being used. The home was also awaiting the delivery of a new mobile hydraulic hoist. Emergency call bells were fitted throughout. Sluicing facilities were provided separately from toilet facilities and kept locked when not in use. The home was clean, tidy and free from offensive odour. The home offered a lounge area with sliding doors leading into a conservatory. Some of the garden furniture was being stored at one end of the conservatory. The home had plans to remove the furniture so making the conservatory more appealing for the Sisters to use. Patio doors led off the conservatory onto a small covered patio area. This led onto a paved patio and accessed the extensive, well maintained gardens. Discussions had taken place with an architect with a view to make some alterations to the conservatory patio doors to allow easier access to outside and to include some alterations to fully enclose the covered patio area. Since the last inspection the small quiet lounge, situated off the main lounge area had been converted into the office of the newly appointed Business Manager. The home had plans to acquire some new lounge chairs. A small kitchen was situated off the dining room where breakfast and evening meals were prepared. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 18 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 and 29 The numbers and skill mix of staff were sufficient to meet the needs of the Sisters accommodated. The homes recruitment policies and procedures promoted the safety and wellbeing of the Sisters. EVIDENCE: At the time of the inspection the home accommodated 12 Sisters. Four Sisters had been assessed as requiring nursing care and 8 Sisters assessed as requiring personal care only. The numbers and skill mix of the staff, at the time of inspection were above that of the staffing notice issued by the previous registering authority and appeared to be sufficient for the number of Sisters accommodated. The staffing rota included staff names, a key to identify which staff were on duty at any time during the day and night and in what capacity. The sample of staff files inspected contained all the information and documents listed in Schedule 2 of the Care Home Regulations 2001. The manager reported that the CRB checks were kept in a separate locked place to which she did not have access. These will be inspected at the next inspection. The home had 3 volunteer workers who had undergone the recruitment process and had received clear Criminal Records Bureau Checks.
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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) 33 and 38 The home has a quality monitoring system in place, which included obtaining the views and opinions of the Sisters. The home was seen to promote the health, safety and welfare of the sisters and staff. EVIDENCE: The home had developed a system of quality assurance monitoring. Questionnaires had been produced and were completed by the Sisters, relatives and visitors. The questionnaire asked for views and opinions regarding the service provided by the home. The questionnaires were sent out twice a year, an action plan is then generated, which is based on CARED 4. There were extensive policies and procedures in place, which were accessible to all staff. The Sisters were informed of the unannounced inspection and were introduced to the inspector giving them the opportunity to speak if they so wished.
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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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3
COMPLAINTS AND PROTECTION 3 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 21 yes 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 No requirements have been made as a result of this inspection 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 15 Good Practice Recommendations It is recommonded that the home is less reliant on the use of frozen vegetables. St Euphrasias F55 F05 s21659 St Euphrasias V228518 D250505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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