Inspection on 11/01/06 for St Hilda`s Priory

This inspection was carried out on 11th January 2006.

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 Hilda`s Priory 30/05/07

St Hilda`s Priory 24/03/06

St Hilda`s Priory 25/01/05

St Hilda`s Priory 06/09/04

St Hilda`s Priory 21/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE St Hilda`s Priory Sneaton Castle Sneaton Whitby North Yorkshire YO21 3QN Lead Inspector Gill Sample Unannounced Inspection 10:45 11 January 2006 th 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 Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Hilda`s Priory Address Sneaton Castle Sneaton Whitby North Yorkshire YO21 3QN 01947 602079 01947820854 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) Chapter of the Order of the Holy Paraclete Mrs Sybil Brown Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 10 Elderly Residents some of whom may have Dementia and or Physical Disabilities All residents are of the Order of the Holy Paraclete. Date of last inspection 25th January 2005 Brief Description of the Service: The Infirmary is a purpose built unit, which forms part of St Hilda’s Priory. It is designed to provide care for up to ten Sisters of the Order of the Holy Paraclete. Only Sisters of the Order are eligible for admission and with support of the care staff, continue with their chosen lifestyle. There are nine single rooms with en-suite facilities and one single room without en suite facilities. All the areas of the home are accessible via a passenger lift. The infirmary is situated within the Priory grounds and all the rooms have a countryside view. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on the findings of an unannounced inspection made on 11th January 2006. The inspection focussed on a number of key standards and those requirements and recommendations made at the last inspection. There were nine residents living at the home. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A range of written records were also examined. Residents were spoken with individually and three of these service users’ records were examined. Discussions were held with the registered manager Mrs. Sybil Brown and staff on duty at the home and with Sister Jocelyn, who is the Health and Safety representative for the premises. What the service does well: What has improved since the last inspection? What they could do better: The Certificate of Registration was displayed in the office of the home. This must be displayed in a public place so that visitors can see the details of the home’s registration and be able to identify the organisation and registered manager. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 6 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 Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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): 3. Standard 6 does not apply. Service users are aware of the services provided at the Infirmary because it forms part of the Priory and service users belong to the religious Order. Details of needs are gathered and recorded prior to a service user being admitted to the home so that they can be assured that their needs will be met. EVIDENCE: Comprehensive assessment information was seen recorded on three files examined. Service users enter the Infirmary from the main Priory without the involvement of outside agencies and therefore assessment of need is made by the Prioress and Manager at the home. Service users are exclusively from the religious Order and activities reflected the personal preference of individual service users and the routine of the priory. Any risks relating to providing care are identified and recorded along with action taken to ensure that service users are cared for in a safe manner. Information about service users is laid out logically and uniformly so that staff can find and read information easily. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 and 10 The health and personal care needs of service users are recognised and recorded so that service users can be sure that they are being looked after in a way which suits them. EVIDENCE: A plan of care was in place for each of the service users. The health care needs and the involvement of health professionals was seen noted, for example, medical, dental and optical appointments. Records were maintained on each service user on a daily basis detailing their changing needs and the care provided. The risks associated with caring for individual service users was also recorded, such as risk of falling or development of pressure sores. Some service users need assistance to bath, and the need for use of hoisting equipment was noted. Service users praised the care staff and the care they received. One said “they anticipate our needs”. Another said that the service had “surpassed expectations.” St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 10 The system for the administration of medication was seen which is a monitored dosage system supplied by a qualified pharmacist. This showed that medication is stored, administered, recorded and disposed of in a proper manner which ensures that service users are safe. Service users spoken with said that their care was provided in a way which was sensitive to their need for privacy and dignity. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 and 15 Daily life and social activities offer service users opportunities to maintain their links within the religious community, extended families and the community in Whitby. EVIDENCE: Service users are all Sisters of the religious Order and are able to continue the offices of their faith throughout the day. The home is equipped with an intercom which enables them to hear services from the Priory chapel if they are not able to attend in person. There is also a chapel at the Infirmary which service users may use. There was evidence in service users’ rooms that service users spent time as they wished reading, listening to the radio, and one said that in better weather she spent time in the grounds. Service users have opportunities to meet together within the Infirmary at mealtimes, in the main sitting area or with Sisters in the Priory. Breakfast and teatime meals are prepared in the kitchen of the Infirmary as are drinks and snacks, and lunch is prepared at the Priory and brought to the home in a “hot trolley”. The lunchtime meal seen being served looked appetising and was served nicely. Those service users who need meals in their St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 12 own rooms are served their meals on a tray. One Sister said that staff “are very good at doing things I like, such as omelette.” Special diets and eating needs are recognised and provided. People were seen visiting the home at the inspection and one Sister had family photographs decorating her room and talked about her contact with them. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 and 18 Service users are able to make a complaint using information provided by the home. Service users are protected by the awareness of staff of potential abuse. EVIDENCE: Service users are able to make suggestions about their care their food and accommodation. A complaints procedure is in place which gives complainants information on the process and timescales for initial response and investigation. Service users spoken with said that Sybil Brown, the registered manager, was very approachable and that they would also be able to speak to the Prioress of the Order. A policy of the protection of vulnerable adults against abuse is in place as is a whistle blowing policy for staff. The system for the handling of money placed for safekeeping was seen, and was satisfactory. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 and 26 The people using this service live in a clean and well maintained environment. EVIDENCE: A number of bedrooms, bathrooms and communal areas of the home were seen. All areas were decorated and furnished in keeping with the overall style of the building and it’s layout and facilities enable service users the choice to have company or not. Facilities are provided for Sisters to worship within the home or to use a quiet room away from others. Those parts of the home seen were uniformly warm and free from unpleasant odours. The home appeared clean and well maintained. Laundry facilities were seen and were satisfactory. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 15 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 and 30 Staffing levels and staff skills are at a sufficient level to ensure the needs of service users are met. Recruitment and selection procedures ensure that people who are unsuitable to work with vulnerable adults are not employed. EVIDENCE: Staff deployment was discussed with the registered manager and rotas were seen. Staffing arrangements are minimum of two staff on duty during the day and one waking staff member at night. Depending on the assessed needs of service users an additional member of staff is deployed at night to provide extra care when required. A number of staff are employed by the home on a relief basis and these staff can be called upon by the manager if the need arises. There are fourteen care staff employed at the home, five of whom have achieved the NVQ level 2 in care and one is currently undertaking the award. Two of the five who have NVQ level 2 are registered to undertake the NVQ Assessors Award from 19th January 2006. Staff files were examined which showed that a robust recruitment and selection procedure is in place to ensure that no person who is unsuitable to work with vulnerable adults is employed. Records showed that staff had been issued with a contract of employment which had been updated on a regular St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 16 basis. All staff have been given a copy of the General Social Care Council’s Code of Conduct. A discussion was held with two staff who confirmed they had undertaken training in mandatory health and safety topics and in other subjects pertinent to the needs of service users. Staff files examined showed certificates for the training undertaken by individual members of staff though some updating of the summaries of training needed updating with fire training which had been undertaken and certificated. There was no overall record being maintained to show the achievements of the staff group. Staff confirmed that they had team meetings on a quarterly basis. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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): 31, 33, 35 and 38 People using the service can be assured that their needs will be met by staff who are trained and competent in providing their care. The health, safety and welfare of service users is addressed by the arrangements to ensure the building and its systems are maintained in a safe manner. EVIDENCE: The manager Sybil Brown has thirteen years experience at the home. She is a qualified registered general nurse and maintains her registration with the Nursing and Midwifery Council by training and research. Because of her nursing qualification Mrs. Brown has attained the required standard for qualification in care. While she does not provide nursing tasks as part of her role, her experience enables health problems to be identified and addressed at an early stage by referral for medical advice. Service users described the staff St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 18 as “very supportive” and the manager as “very approachable”. The manager said that she did not intend to undertake the NVQ Level 4 in management. There is a formal quality assurance system in place which was a requirement made at the last inspection. This is based on a survey of service users on their views of the service. Users of the service are from the religious Order and have recourse to the registered manager and Prioress should they be unhappy with any aspect of the service. All service users spoken with were very able to articulate their views about their care. One bath hot water outlet was checked which was delivered at a safe temperature. The home’s washing machine is capable of washing at 90 degrees to eliminate the risk of cross contamination. A notice was seen to guide staff on washing temperatures to achieve this. Staff training records and discussion with staff showed that they had undertaken training in health and safety topics. A number of documents were seen relating to the provider’s health and safety obligations. These were: • • • • • • Fire and emergency lighting servicing and maintenance records Fire alarm testing records -weekly Electrical appliance safety tests dated 6/9/05 Electrical Installation Certificate dated 19/2/04 (valid for five years) Gas Safety Certificate dated 19/1/05 (valid for one year) Fire Risk Assessment dated 13/5/05 St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 X X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 3 St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 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 N/A Regulation Section 28(1) Requirement The Certificate of Registration must be displayed in a conspicuous place. Timescale for action 31/01/05 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 2 Refer to Standard 28 31 Good Practice Recommendations An overall view of the training needs and achievements of staff should be kept to assist the registered manager in planning staff training. The manager must have NVQ level 4 in management or equivalent qualification by 2005. St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI St Hilda`s Priory DS0000007736.V271422.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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