Inspection on 29/09/05 for St Joseph`s Hospice

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Joseph`s Hospice 14/01/10

St Joseph`s Hospice 23/02/07

St Joseph`s Hospice 22/02/06

St Joseph`s Hospice 11/02/05

St Joseph`s Hospice 06/05/04

St Joseph`s Hospice 25/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Joseph`s Hospice Ince Road Thornton Liverpool Merseyside L23 4UE Lead Inspector Mrs Trish Thomas Unannounced Inspection 29th September 2005 10:00 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 Hospice DS0000017272.V255884.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 Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Joseph`s Hospice Address Ince Road Thornton Liverpool Merseyside L23 4UE 0151 924 3812 0151 931 5727 jacintacannon@jospice.org.uk 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) St Joseph`s Hospice Association Miss Jacinta Ann Cannon Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability (3), Terminally ill (10) of places St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 12 OP and up to 10 TI and up to 3 PD. The service should employ a suitably qualified and experienced Manager who is registered with CSCI. Service users in the category TI must be in the age range of 19 years and above. 11/02/05 Date of last inspection Brief Description of the Service: St. Joseph’s is a care home, with nursing, for 25 Service Users. The home is owned by St. Joseph’s Hospice Association (Jospice International) and the manager is Mrs. Miss Jacinta Cannon. The home is registered in the following categories, 12 Elderly, 3 Physical Disability, 10 Terminal Illness. The home was founded within a Catholic ethos and this is reflected in the character of both the interior and grounds of St. Joseph’s. There are two chapels on site, one is integral to the building and the second is adjacent and can be easily accessed. St. Joseph’s is not exclusive to those of the Catholic faith and all denominations and non-believers are eligible for admission, subject to nursing assessment. The service is provided in two buildings, The Academy and San Jose, which provide a variety of lounge and sitting areas, dining room and conservatory. Both single and double bedrooms are provided and 8 bedrooms have en-suite facilities. There are extensive and beautiful grounds consisting of woodland, gardens and car parking facilities. The grounds sustain a variety of wildlife and are accessible and enjoyed by residents of the home and their visitors where seating is placed for their convenience. The home is situated on a main bus route between Southport and Liverpool with the busy shopping centre of Crosby a five-minute car journey away. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days and the methods used were, speaking with residents and their visitors, speaking with staff, reading records and quality questionnaires and by direct observation. The findings of the inspection were mainly positive with one requirement and one recommendation made in the relevant section of this report. The standards inspected were in relation to information, assessment, health and personal care, daily life and social activities, complaints and protection, environment, training and health and safety. The welcome pack provided to residents on admission is comprehensive and residents said they found this to be helpful and informative. The records, which were viewed during the inspection, were to a very good standard and stored in secure areas. The home’s policies and procedures are regularly audited through review meetings. Relatives comments on the care and attention provided in St. Joseph’s, which are recorded on quality questionnaires state, “Always very attentive, compassionate and supportive.” “Regular attention to keep my mother-in-law comfortable.” Nursing and care practice is well recorded in the care plans and care pathways, supported by documented reviews and risk assessments. Social activities are individually focused in accordance with the needs of those in residence. This is an area of the service which could be further developed in consultation with residents. A recommendation is made under standard 12. Staff numbers and training were to a very good standard and staff vacancies were in the process of being recruited. Health and safety certification, which was inspected, was satisfactory. A hazard was observed in the kitchen and a requirement is made under regulation 23. What the service does well: In addition to being a permanent home to 15 elderly and disabled residents, the St. Joseph’s specialises are care of the dying. Staff commitment and expertise was evident through their comments during the inspection, and their qualifications and experience. St. Joseph’s maintains a friendly and relaxed atmosphere while caring for frail and terminally ill residents. Visitors’ comments include, “Always very friendly.” “Four staff including the nurse in charge, came outside to welcome us. The ramp was already in place on the steps when the ambulance arrived, well prepared.” St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 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. St Joseph`s Hospice DS0000017272.V255884.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 Joseph`s Hospice DS0000017272.V255884.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): 1 and 3 The home was meeting standards 1 and 3. All prospective residents are provided with an up to date statement of purpose and service user guide. New residents are admitted only on the basis of a full assessment undertaken by relevant health professionals. EVIDENCE: Standard 1. Reference was made to the home’s welcome pack, which contains the patient guide incorporating the statement of purpose, information sheet, complaints procedure and formal contract of residence. The most recent CSCI inspection report is also made available to prospective residents and their families. The home was established within the ethos of the Catholic Faith and this is evident in the home environment and grounds. The document provided on admission states “We welcome patients and staff of any faith or of none, and aim to meet each person’s spiritual needs in the right way for them. A newly admitted resident said that he had moved in to the home quite recently. He said that staff were supportive and welcoming when he moved into St. Josephs and the care and attention they provide, is appreciated. The satisfaction questionnaire dated July 2005 scored highly on the standard of information and advice given on initial visit to St. Josephs. Comments were “very helpful” and “very informative”. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 9 Standard 3. Reference was made to residents’ care files. There is a high number of referrals from hospital for palliative care. Residents’ files contained initial ward assessments of health and personal care needs and ongoing assessment of need through the home’s nursing assessments and care planning process. There are also a number of long-term residents of St. Josephs who are elderly or who have profound disabilities and whose needs are regularly reviewed, and their care plans adjusted accordingly. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 10 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 11. The home was meeting standards 7, 8 and 11. All residents have an individual care plan, which is regularly reviewed. The home employs trained nurses throughout the day and night and has the services of two G.P.s, who attend daily. In addition, there are regular Multi-Disciplinary Meetings attended by Macmillan Nurses. St. Joseph’s follows the Care Pathways in care of the dying and staff receive training and management support, in relation to this aspect of service. EVIDENCE: Standard 7. Six care plans were inspected and contained evidence of ongoing nursing assessment and review of health and personal care, including pressure care, mobility and continence. There were relevant risk assessments in evidence and reference to spiritual and social needs. Care plans, which were read, had been regularly and recently reviewed. Subject to assessment, the Care Pathways is established in care of the dying. In commenting on the care provided to her friend, a visitor said, “She has tender loving care in a peaceful atmosphere. Nothing is too much trouble, I give them one hundred percent.” St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 11 Standard 8. Care plans contained pressure care assessments and pressure relieving equipment and monitoring systems were in place for those at risk of developing pressure sores. There was evidence in care files that residents have access to specialist medical, dental, chiropody and all paramedical services in accordance with assessment, by referral to outside agencies. Permanent residents are registered with a local G.P. The manager said that in addition to the home’s designated G.P who has particular interest in palliative care, the services of a second G.P. have been established, there is ongoing monitoring of the service by the Primary Care Trust, and weekly MDT meetings attended by Macmillan Nurses. The home’s information sheet states that the hospice receives professional advice and support from the local consultant in palliative care. Standard 11. There is consideration for the needs of relatives in providing care of the dying, and a bereavement counsellor is employed, who is based in the home, and who supports relatives through their time of grieving. A principle followed in of care of the dying, stated in the home’s literature, states “Providing care which embraces the needs of patients’ carers, families and those who matter to them, and which extends into bereavement.” St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 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 the following standard(s): 12,13 and 15. The home was meeting standard 13 and 15. Standard 13. Visitors are made welcome in the home and may be entertained in residents’ bedrooms or in communal areas. Standard 15. Residents receive a wholesome diet with choices and alternatives available. Standard 12. The home provides a range of activities, which are in keeping with residents’ preferences and capabilities and developments in this are ongoing. Some of the more frail residents may benefit from taking part in planned activities. EVIDENCE: Standard 12. There was evidence that the manager and staff are working to develop this aspect of service. Levels of dependency vary with regards to physical and mental capacity, requiring ongoing assessment, consultation and planning of activities. Miss Cannon said that activities are individually based and there is nothing really planned. She has consulted with residents and families through the Satisfaction Questionnaire. Some of the comments contained in the July 2005 responses were, “More physiotherapy, if possible.” “Patient was an excellent swimmer and I know that he would relax in water.” “Maybe a little more stimulating activities for patients.” There were instances where careful planning and thought by staff, had addressed social need through family involvement. Two residents attend a day centre and volunteers support a resident to follow his interests in the community. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 13 Miss Cannon said that she intends to employ an alternative therapist (interviews had been arranged), and that the chiropodist and hairdresser visit. A number of residents take great pleasure in sitting/walking in the grounds, which provide a beautiful and secluded setting for the home. Further developments are recommended in planning activities for permanent residents, in accordance with their preferences and capacity. Standard 13. The inspection was carried out over a two-day period and visitors were present in the home on both occasions. Eight visitors were spoken with and they said that they are made welcome by staff, and provided with privacy. Two visitors live out of the area and were driving several hours a day to visit their relative. A response on the satisfaction questionnaire July 05 states, “The whole of Jospice staff have always been very kind to ……………, myself and all her visitors and ever willing to help in what ever way they could.” Standard 15. The home was meeting standard 15. Discussion took place with the chef and menus were inspected. The menus are regularly and seasonally reviewed and residents are consulted as to their preferences, with alternatives to the main menu offered. One resident who commented said that his appetite had improved since he had moved into St. Josephs and he is enjoying his meals. Residents are not rushed with their meals and staff were observed to be supportive of a resident who requires assistance with feeding. The dining room has recently been decorated and was bright and well presented. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 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 the following standard(s): 16,18 The home was meeting standards 16 and 18 in relation to written procedures, training and staff awareness. EVIDENCE: Standard 16. The home has a written complaints procedure, which is made available to residents and their representatives on admission. A record of complaints is maintained in the home. The home provides training to staff in protection of vulnerable adults and has adult protection and “whistle blowing” policies. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 15 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, 26 The home was meeting standards 19 and 26. The home has an ongoing maintenance programme and was in generally good decorative order at the time of inspection. The home was clean and odour free in all areas which were visited. EVIDENCE: Standard 19. The satisfaction questionnaire July 05 provided responses to a question on environment and housekeeping. Six questionnaires gave a rating of 10/10, two gave a rating of 9 and one gave a rating of 8 with one not answering the question. Two residents who were asked during the inspection, said they were more than satisfied with their accommodation. One resident and his visitors, who were met with outside the building, said the grounds are beautiful. Three visitors who were spoken with said that the accommodation and grounds were peaceful, pleasing and comfortable. On discussion with Miss Cannon and from direct observation it was confirmed that decoration of the dining room has been completed and some new equipment fitted in the kitchen. A number of bedrooms have been decorated and new carpets fitted. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 16 The maintenance programme is planned to cause as little disruption as possible to the residents and home’s routines. Standard 26. The building was clean and odour free in the areas which were visited. The home employs domestics and follows C.O.S.H.H. and infection control procedures. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 17 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): 27,29,30 The home was meeting standards 27,29 and 30. Staffing levels are adjusted to meet the needs of those in residence. Staff rosters are maintained and staffing is organised in teams in order to provide continuity of care to residents. The home has a robust recruitment policy and staff files are maintained in good order in accordance with requirements. Staff training, qualifications and mandatory updates are maintained to a good standard and NVQ training is over 50 for care assistants. EVIDENCE: Standard 27. Staff rosters were seen and were in good order. Miss Cannon said that staffing is organised in teams, with named carers allocated, to address continuity of care. Taking account of days off and training, continuity is maintained as far as it is possible. Standard 29. The home has a satisfactory recruitment policy and references and CRBs are obtained for all staff employed. Staff files inspected contained satisfactory clearances. Three newly qualified nurses had not received their pin numbers at the time of inspection. Contracted domestic staff are now vetted to the satisfaction of the manager. Standard 30. There is a high level of training available to staff. The home employs at trained nurses, some of whom have specialist palliative care qualifications. Sixty percent of care staff had completed NVQ 2 at the time of inspection and mandatory training was up to date. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 18 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): 38 Fire Safety records and maintenance records were satisfactory. The home was not meeting this standard as a health and safety hazard was observed in the kitchen. EVIDENCE: Reference was made to fire safety records and maintenance certificates, which were satisfactory. Fire marshals have been appointed and a fire risk assessment has been carried out. On visiting the kitchen, the deep fat fryer was seen to be in need of cleaning. The sides of this appliance were caked in grease down to floor level, which could cause a fire or tripping hazard, if left in this condition. This was not typical of conditions in the kitchen, the remaining areas being clean and well organised. St Joseph`s Hospice DS0000017272.V255884.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 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 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 20 NO 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 OP38 Regulation 23 Requirement The manager must ensure that staff maintain the deep fat fryer in a clean and safe condition. Timescale for action 11/10/05 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 Refer to Standard OP12 Good Practice Recommendations The manager should develop a planned activities programme and maintain an activities diary. St Joseph`s Hospice DS0000017272.V255884.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hospice DS0000017272.V255884.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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