Inspection on 17/02/06 for St Joseph's Convent Nursing Home

This inspection was carried out on 17th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Joseph's Convent Nursing Home 20/02/07

St Joseph's Convent Nursing Home 06/09/05

St Joseph's Convent Nursing Home 01/12/04

St Joseph's Convent Nursing Home 21/07/04

St Joseph's Convent Nursing Home 12/01/04

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s Convent Nursing Home Lichfield Road Stafford Staffordshire ST17 4LG Lead Inspector Lynne Gammon Unannounced Inspection 17 February 2006 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Joseph`s Convent Nursing Home Address Lichfield Road Stafford Staffordshire ST17 4LG 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) 01785 251577 01785 223836 clunystaff@btinternet.com Sisters of St Joseph of Cluny Mrs Frances Knight Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability (33), Physical disability of places over 65 years of age (33), Terminally ill (3) St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 33 Physical Disability (PD) - Minimum age 60 years on admission All agreed policies and procedures to be submitted to NCSC within 3 months. All staff involved in the care of service users who are TI must receive appropriate training. The care home should employ a nurse who has achieved the Care of the Dying ENB 931 or University Course K260 Death & Dying - within 6 months. TI - minimum age 60 years. Date of last inspection 6th September 2005 Brief Description of the Service: St Josephs convent was converted as a nursing home and first registered in 1989. It is situated within walking distance of Stafford Town centre, with good road and rail links and located in extensive, well-tended gardens and grounds adjacent to a Catholic Parish Primary School, previously part of the convent. There is limited parking at both the front and rear of the building. Service users of any denomination are cared for and welcome to all the facilities offered by the Home. St Josephs convent emphasises the importance it places on individual and personal care provided by a professional team. The present certificate recognises the Home to care for: service users who are over 65 years of age but do not fall within the category of old age (33 beds), old age, not falling within any other category (12). There are three floors with a shaft lift facility and an exit ramp. The home has 33 single bedrooms, five of which are en-suite. There are no double rooms. The home is well suited to meet the needs of the stated categories of service users. Many rooms are well appointed, personalised, and some with views of the impressive garden; all are well equipped and pleasantly furnished. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 17th and 22nd February 2006 using the National Minimum Standards for Older People as the basis for the The total time spent for the inspection, including pre and inspection. fieldwork, amounted to 8 hours. The inspection included a part tour of the home, inspection of records, observation and discussions with service users and staff. Since the last inspection on 6th September 2005, one formal complaint had been received and resulted in a change to one of the processes within the home. No incidents or reports of abuse of any kind had been received. What the service does well: What has improved since the last inspection? What they could do better: Three requirements were raised as a result of this inspection as follows: • Written confirmation to be provided to the service user, following the pre-admission assessment, that the home can meet the individual’s needs and aspirations. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 6 • • Consultation systems should be developed and implemented to obtain feedback from service users and their relatives to determine the satisfaction of the service delivered and recorded and action taken accordingly. For all staff to receive appropriate supervision. One recommendation was made for formal supervision sessions for care staff to take place 6 times per annum. 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 Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Contracts were in place for each service user and they received verbal confirmation that the home could meet their needs prior to moving in. EVIDENCE: Copies of contracts for both private and social services funded service users were examined and found to contain all of the required elements within 2.2 of this Standard, e.g. details of the fees charged and any additional charges for extras such as hairdressing, chiropody etc. The registered manager confirmed that prospective service users were told that the home could meet their needs prior to moving in, however, it is a requirement of this report that written confirmation be provided that the home can meet the individual’s needs and aspirations. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. The care planning processes within the home provided detailed information to enable staff to have a clear understanding of service user needs and how those needs should be met. Service users had access to a range of other health care professionals and health care needs were met very well. The systems for the administration of medication were good with clear and comprehensive arrangements being in place to ensure service user’s medication needs were met. EVIDENCE: A sample of service user’s care plans were examined and found to be satisfactory. Daily records, reviews and risk assessments were completed well and health care needs were closely monitored and medical professionals contacted when necessary. Medication administration, storage and disposal processes were robust to ensure the on-going protection of the service users. The medicines within the home, medication administration records and controlled drugs book were all checked and no errors were noted. The registered manager confirmed she undertook a regular medication audit to ensure correct recording and management was in place at all times. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 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 the following standard(s): 14. All of the key standards were reported upon satisfactorily in the report of the previous inspection of 06/09/05 and service users continued to be supported to make their own decisions about their lives. EVIDENCE: Discussions with service users confirmed that they were supported and enabled to make their own choices throughout their day–to-day lives. One service user said that she preferred to stay in her room rather than mix with the other service users and staff co-operated with this request. Another service user told of the excellent support she had received from staff and other health professionals during her recent illness. She also said how much she liked her room and how staff had recently provided her with a reclining chair which she liked very much. Positive interaction was observed throughout the inspection between service users and staff, and service users confirmed that they felt safe and well cared for. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. A satisfactory complaints procedure was in place and service users felt that they were listened to and action was taken to resolve their issues. Service users were supported and enabled to participate in the electoral process and were protected from abuse by the home’s Adult Protection procedure and staff training on abuse awareness. EVIDENCE: The home had received one complaint since the last inspection, which had been investigated accordingly, and procedures changed within the home as a result. Service users confirmed that they did not have any complaints but if any complaints were raised, the registered manager and staff would make every attempt to resolve them as far as possible. The registered care manager confirmed that service users were able to take part in the electoral process by postal vote if they so wished. If any service user wished to visit an election polling station, this was also supported. There had been no incidents or allegations of abuse received by the home or the Commission for Social Care Inspection and the home had an Adult Protection procedure and all staff undertook abuse awareness training as part of their induction. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 12 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): 21, 22, 23 and 25. There were adequate toilet and washing facilities. Specialist equipment was available to maximise the independence of the service users. The size and layout of the bedrooms were sufficient to meet the needs of the service users and the home provided a safe and comfortable environment for them. EVIDENCE: There were sufficient toilet and bathing facilities within the home to meet the needs of the service users. A range of specialist equipment and adaptations were in place for the service users including: grab rails, hoists, and ramp, nurse call alarm, etc. The dimensions and layout of the bedrooms provided accessible room to meet the needs of the service users. All bedrooms had covered radiators, smoke alarms and emergency lighting was in place throughout the home. The corridors were found to be free from obstruction and well lit and the home provided a safe environment for those who lived there. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 13 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): 28 and 30. Service users were cared for by qualified staff that were competent and trained to carry out their jobs. EVIDENCE: Discussion with the registered manager confirmed that the home currently had 20 care staff in total, with 3 qualified to NVQ Level 2 in care and 3 care staff having achieved NVQ Level 3 in care. 2 further members of care staff were in the process of completing NVQ Level 2 and in addition to this, 2 other members of staff had applied to commence NVQ Level 2 training. Once completed, the home would have the required 50 of trained members of staff with NVQ level 2 or above working in the home. The records of the type and frequency of training undertaken by the staff within the home were examined. Training records evidenced that mandatory training had taken place and induction training for staff was extremely well documented and thorough. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 36, 37 and 38. No formal consultation took place with service users and relatives, although informal discussions took place daily. Financial procedures were robust to protect service user’s financial interests. Formal supervision sessions did not take place for staff. Records held were accurate and secure and the health, safety and welfare of service users and staff were upheld and protected. EVIDENCE: Quality assurance questionnaires for service users and relatives were seen but these had not been used for some time to determine service user satisfaction of service delivery. No service user or relatives meetings were held, however informal discussions took place between staff and service users/relatives on a daily basis. It is requirement of this report that consultation takes place with service users and their families to measure the success of the service and used as a quality assurance tool to maintain continuous improvement and be recorded and action taken accordingly. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 15 Financial procedures and processes were examined and records of service user’s personal allowances were well documented, accurate and found to balance with monies held. Formal supervision sessions did not take place for care staff and it is a requirement of this report that these be implemented. It is also a recommendation that they take place as a minimum of 6 times per annum to ensure staff are appropriately supervised. Records for the protection of service users, individual records and home records were seen to be secure, up to date and in good order. Policy and procedural documentation was examined and it was noted that these were reviewed regularly and used in staff induction training sessions. A range of records and documentation evidenced that the health, safety and welfare of service users and staff were protected. Records showed that the fire alarm system was checked on 06/01/06, the gas system was inspected on 09/09/05, a five year electrical system check was carried out in June 2004, water tanks inspected on 21/09/05, hoists checked on 28/09/05 and the nurse call system was checked and tested on 8/11/05. St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X 3 3 3 X 3 X STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 4 4 2 3 3 St Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 14 (1)(d) Requirement For written confirmation to be provided to the service user following the pre-admission assessment that the home can meet the individual’s needs and aspirations. Consultation systems should be developed and implemented to obtain feedback from service users and their relatives to determine the satisfaction of the service delivered and be recorded and action taken accordingly. For all staff to receive appropriate supervision. Timescale for action 17/02/06 2. OP33 24(1)(a)( b)16(2) (m) 30/04/06 3. OP36 18 (2) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP36 Good Practice Recommendations Formal supervision sessions for care staff to take place 6 times per annum. DS0000022371.V280983.R01.S.doc Version 5.1 Page 18 St Joseph`s Convent Nursing Home Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Joseph`s Convent Nursing Home DS0000022371.V280983.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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