Inspection on 30/05/07 for St Hilda`s Priory

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 24/03/06

St Hilda`s Priory 11/01/06

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 Whitby North Yorkshire YO21 3QN Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 30th May 2007 11:15 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 DS0000007736.V335143.R01.S.doc Version 5.2 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. DS0000007736.V335143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Hilda`s Priory Address Sneaton Castle Whitby North Yorkshire YO21 3QN 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) 01947 602079 01947 820854 ohppriorywhitby@btinternet.com 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 DS0000007736.V335143.R01.S.doc Version 5.2 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 24th March 2006 Brief Description of the Service: The care home that is known within the religious community, as 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 from the care staff are able to 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. Information about the services offered is in the format of a service user guide that is made available to people in the home. A copy of the most recent Commission for Social Care Inspection report is also made available to people. These documents are kept in communal areas of the home. The sisters do not pay a weekly fee to stay in The Infirmary. There are no other charges made. DS0000007736.V335143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from all 9 people living in The Infirmary and one healthcare professional. A visit to the home carried out by one inspector that lasted for three and a half hours. During the visit to the home five residents, two staff and one visitor were spoken with. Care records relating to two people, two staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at St Hilda’s Priory for the people living there. The manager was available to assist throughout the visit for feedback at the close. What the service does well: The home provides a service that meets the expectations and needs of people. It enables people to remain part of the religious community in which they have spent their lives. They are also able to receive care and support for their health and physical needs. Those people spoken with appreciated the quality of care received. Comments received include, ‘we’re very spoilt by the wonderful staff’ and, ‘We count our blessings every day, we are truly blessed’. Service users also appreciated the fact that staff remain in employment for a good length of time and work together well. They said, ‘The staff stay with us and are very close to us’ and ‘They are such a good team that support us and each other, they have a sense of humour’ DS0000007736.V335143.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. DS0000007736.V335143.R01.S.doc Version 5.2 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 DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 is not applicable. People who use the service experience excellent quality outcomes in this area. Details of people’s needs are gathered and recorded prior to them being admitted to the home in order that they can be assured that their needs will be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Comprehensive assessment information was seen recorded on the files examined. People enter the Infirmary from the main Priory without the involvement of outside agencies and therefore the Prioress and Manager of the home make the assessment of need. Any risks relating to providing care are identified and recorded along with action taken to ensure that people are cared for in a safe manner. Information about people is laid out in the care plans in a way that is easy for staff to find and read. DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience good quality outcomes in this area. People’s healthcare needs are met safely in a way that promotes their dignity and respect. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A plan of care was in place for each of the people living at The Infirmary. The health care needs and the involvement of health professionals was recorded. This included medical, dental and optical appointments. Records were maintained on each person on a daily basis detailing their changing needs and the care provided. The risks associated with caring for individuals were also recorded, such as risk of falling or development of pressure sores. Some people need assistance to bath, and the need for use of hoisting equipment was also recorded. The use of bed rails was subject to a risk assessment, however, the use of ‘bumpers’ DS0000007736.V335143.R01.S.doc Version 5.2 Page 10 had not been considered to prevent injury to people. People praised the care staff and the care they received. One said, ‘They are considerate and caring’. Another said that the service provided ‘much more care than I need’. A healthcare professional commented, ‘Physical health needs are well catered for as well as psychological and emotional needs’. The system for the administration of medication is a monitored dosage system. The medication policy and procedure ensure that people receive their medication safely. People are encouraged to keep their own medicines and are provided with a secure place to keep them in their rooms. Temazepam tablets should be stored in the controlled drugs cupboard but were not. The staff however, monitor this drug more closely with stock control carried out on a daily basis. Some medications had also been removed from their original packaging and placed in another container with a handwritten label applied. This could mean that there is the potential for people to receive an incorrect medication. Medications are disposed of correctly. People said that their care was provided in a way that was sensitive to their need for privacy and dignity. DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience excellent quality outcomes in this area. People are satisfied with the lifestyle that they experience. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People living at the home are able to continue the offices of their faith throughout the day. Each room is equipped with an intercom that enables people to hear services from the Priory chapel if they are not able to attend in person. There is also a chapel at the Infirmary that people may use. There was evidence in people’s private rooms that they spent time as they wished reading, listening to the radio, and one said that in better weather she spent time in the grounds. People 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 DS0000007736.V335143.R01.S.doc Version 5.2 Page 12 appetising and was served nicely. Those people who need meals in their own rooms or who choose to take them there are served their meals on a tray. One Sister said that the meals ‘are much better than I expected’ Special diets and eating needs are recognised and provided. People were seen visiting the home during the inspection and one Sister had family photographs decorating her room and had recently visited them. A healthcare professional commented, ‘Staff always respect the lifestyle that the nuns have adopted and support them in maintaining this’ DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience good quality outcomes in this area. People living at this service are listened to and protected. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People are able to make suggestions about their care their food and accommodation. A complaints procedure is in place that gives complainants information on the process and timescales for initial response and investigation. Service users spoken with said that they would speak to the registered manager who was very approachable and that they were able to speak to the Prioress of the Order also. A policy of the protection of vulnerable adults against abuse is in place as is a whistle blowing policy for staff. This needs amending to make sure it is in line with the Local Authority procedures. DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience good quality outcomes in this area. People live in an environment that is suited to their needs and wishes. We have made this judgement using a range of evidence, including a visit to the service. 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 people 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. DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience excellent quality outcomes in this area. Well-trained and experienced staff meets people’s needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff rotas were seen and showed that sufficient staff are on duty at any time. Staffing arrangements are a minimum of two staff on duty during the day and one staff member at nights with somebody available if required within the building. Staff have received training to enable them to carry out their roles effectively. 53 of care staff have achieved an NVQ qualification in care at level 2 or above. Staff files examined showed certificates for the training undertaken by individual members of staff. People living at the home appreciate the staff. Comments received include, ‘We’re very spoilt by the wonderful staff’ and, ‘We count our blessings every day, we are truly blessed’. There is a dedicated staff team who have been employed at the home for a long time. Again people living there appreciate this fact. They said, ‘The staff stay with us and are very close to us’ and ‘They DS0000007736.V335143.R01.S.doc Version 5.2 Page 16 are such a good team that support us and each other, they have a sense of humour’ Recruitment records 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 that had been updated on a regular basis. All staff have been given a copy of the General Social Care Council’s Code of Conduct. DS0000007736.V335143.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience excellent quality outcomes in this area. The home is well managed in the interests of the service users. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager Sybil Brown has fifteen 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. 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 DS0000007736.V335143.R01.S.doc Version 5.2 Page 18 medical advice. People living at the home described the staff as “very supportive” and the manager as “very approachable”. There is a formal quality assurance system in place. This is based on a basic survey of people living at the home and on their views of the service. Discussions took place around developing this system in order that the views of people about more specific areas will be sought. The results of surveys will be collated and any identified actions taken. People 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. Staff training records and discussion with staff showed that they had undertaken training in health and safety topics. The staff receive appropriate supervision that is documented and regular staff meetings are held. The manager is responsible for all health and safety checks and these were all up to date. The fire risk assessment is current and subject to regular review. Where the manager looks after any personal monies for people the records are accurate and the money is stored securely. DS0000007736.V335143.R01.S.doc Version 5.2 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 DS0000007736.V335143.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement Temazepam must be stored as a controlled drug. Medication must be kept in its’ original container to prevent the possibility of incorrect administration. Timescale for action 07/06/07 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 OP8 Good Practice Recommendations The use of ‘bumpers’ on bedrails should be considered in the risk assessment when looking at the prevention of injury. The quality assurance system should be developed further to ensure that all people involved at the home have their views sought and the results from surveys should collated and acted upon where indicated. 2. OP33 DS0000007736.V335143.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000007736.V335143.R01.S.doc Version 5.2 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. 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