Inspection on 14/06/05 for St Joseph`s Nursing Home

This inspection was carried out on 14th June 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 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 Nursing Home 14/11/06

St Joseph`s Nursing Home 15/11/05

St Joseph`s Nursing Home 13/12/04

St Joseph`s Nursing Home 21/06/04

St Joseph`s Nursing Home 09/02/04

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 Josephs Nursing Home 52 Plymouth Grove West Longsight Manchester M13 0AR Lead Inspector Geraldine Blow Unannounced 14 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Josephs Nursing Home Address 52 Plymouth Grove West Longsight Manchester M13 0AR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 273 4147 0161 273 2162 Little Sisters of the Poor Kathleen Maria Kiernan Care home with nursing (N) 53 Category(ies) of Old age, not falling within any other category registration, with number (53) (OP) of places St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 All service users are 60 years or over. 2 The maximum number of service users requiring nursing care will be 13. These service users are accommodated on the ground floor. Three named service users requiring nursing care are currently accommodated on the first floor. When these service users no longer require this accommodation the first floor will revert to accommodating service users requiring personal care only. 3 The maximum number of service users requiring personal care only will be 40. These service users are accommodated on the ground and first floors. 4 Minimum nursing staffing levels specified in the Notice dated 15th December 2004 and served in accordance with Section 13 of the Care Standards Act 2000 must be maintained. 5 The service should,at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 13 December 2004 Brief Description of the Service: St Josephs Nursing Home is registered to accommodate 13 residents assessed as requiring nursing care and a maximum of 40 residents assessed as requirng personal care only. The home is owned and run by The Little Sister’s of the Poor and managed by the Mother Superior Kathleen Kiernan.The home is located in Longsight just south of Manchester City Centre. Local facilities and bus routes are within easy walking distance. The home provided ample secure parking facilities at the front of the building. The home is a three storey ‘purpose-built building’ set in large, secure, wellmaintinaed grounds. The home is divided into 3 units and a wide variety of communal areas are available for residents. Bedroom and communal accommodation for the residents is provided on the ground floor and the first floor. All rooms are single and provide en-suite facilities. The second floor provides living accommodation for the Sisters. A daily mass is held in the chapel and for those residents who are unable to attend the chapel morning mass can be accessed via a special TV channel direct to their bedroom. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, which took place over the course of 5 hours on Tuesday 14th June 2005. During the course of the inspection time was spent talking to the manager, several of the residents and some members of staff to find out their views of the home. Time was spent examining records, documents, the residents and staff files. A tour of the building was also conducted. The requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. The home and the Commission for Social Care Inspection had not received any complaints. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well: Prospective residents have a pre admission assessment to ensure that the home can meet all of their needs. The homes décor, furniture and the facilities at the home are of a high standard. A variety of communal areas are available for residents including a chapel, a large concert hall, a library, an activities room, a small shop, a treatment room for physiotherapy and chiropody, a hairdressers and a laundrette on each floor. A very pleasant tea bar was available for the residents and their visitors to use on the ground floor. The home is divided into 3 units. Between the 3 units the home provides 1 smoking room, 2 small kitchen/dining rooms and one large dining room. There are 9 lounge areas between the 2 floors and several seating areas throughout the home. The atmosphere in the home was warm and welcoming. Staff were observed to be pleasant and courteous with residents. Staff were seen to have good interactions with residents and were observed dealing with residents individual needs. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 6 The standard of cleanliness throughout the home was high. One resident said, “I have a lovely bedroom and its always kept very clean”. The home appeared to treat residents with respect and dignity. Staff were seen to knock on doors before going into a room. The staff spoken to said that residents get choice with regard to their daily lives e.g. unless it is detrimental to their care the residents can go to bed and get up when they choose. The residents spoken to confirmed this. One resident said “ all the staff and Sisters are very nice”, another resident said “I like being here, they are all very nice”. Meals served were nutritious, well balanced and nicely presented. The staff ask residents on a daily basis what they would like to eat for that day. Alternative meals are available on request. Comments from residents were positive and included things like “the food is really nice” and “there is always a good choice of food”, “you can have meals in the lovely big dining room or in the small dining room if you want”. During lunch, in the main dining room, residents were seen to be very chatty with each other and after lunch some residents were seen helping the more disabled residents out of the dining room. The home provided a lot of organised activities and individual activities. Several residents told the inspectors about the “huge St.Patrick’s day party”, one resident said “it was really nice, each unit made floats and we had a parade in the grounds”. One member of staff said “we have loads of activities here, sometimes there are large organised parties or just individual activities”. Monthly residents meetings are held where activities are discussed. During the inspection the inspector spoke to the District Nurse who was attending to some residents. She said that “this home always asks their advice and that the staff are excellent and will go out of their way to help,” she also said that “advice given is always followed”. What has improved since the last inspection? The home has continued to make improvements to the facilities provided to residents. Since the last inspection there had been some structural alterations to the home. A new wall has been build to the front of the home, electronic gates have been fitted, the front garden area has been re-designed and the main driveway has been tarmaced. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 7 Inside the home the reception area has been re-designed and the open lounge on the first floor has been partitioned off making a quite area and a small lounge area for watching the TV. New carpets have been fitted to both areas and new furniture has been bought. Numerous bedrooms have been redecorated and the nurses’ station on each unit has been re-designed giving easier access to residents and relatives. The smoke room on the first floor has been redecorated and converted into a “quiet lounge”. The staff spoken to said it was very popular with residents to go when they had visitors for some privacy. 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 Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents are only admitted to the home after a full assessment of needs has been undertaken. This ensures that residents care needs can be met. EVIDENCE: A pre-assessment form is in use, to ensure prospective residents are only admitted on the basis of a full assessment. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. The registered manager and/or the person in charge of the individual units undertook the pre-admission assessment. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. On admission to the home, residents have a further assessment period during which time the home formulates its own care plan. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, & 10 Overall the health and personal care needs of the residents were being met at the home. However risk assessments must be implemented for the use of bed rails and a wound review must be undertaken each time the dressing is renewed so that a detailed progress report is generated. The system for recording all prescribed medicines needed some improvement to provide an accurate audit trail of medication. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 11 EVIDENCE: A limited number of care plans were inspected. Each resident had a comprehensive and detailed individual plan of care, which had been generated from a needs assessment and the homes own care planning process. Each individual file was found to contain an up to date photograph of the resident for easy identification. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by staff to ensure that all aspects of health, personal and social care needs of the residents were met. The residents plan included appropriate risk assessments, however the use of bed rails had not been independently risk assessed. It was noted that if a resident had bed rails in place, consent had been obtained from the resident or their representative and protective bumpers were in situ. The home had a pressure sore risk assessment, which was reviewed on a monthly basis. There was evidence that the tissue viability nurse had visited the home to provide advice regarding the most appropriate treatment. The daily progress report evidenced that the wound had been redressed but it did not include the exact number of times the dressing had been renewed or a progress report of the wound. Equipment necessary for the promotion of tissue viability and the prevention or treatment of pressure sores was viewed during the inspection. The plan of care documented which pressure-relieving mattress was in use for individual residents. All residents were registered with a local General Practitioner (GP). The GP visited the home every Monday and Thursday and had her own consulting room where residents could be seen. Residents could also be seen in the privacy of their own room if they prefer. There were arrangements in place for dental, optical and chiropody services for all residents. Nutritional screening, continence assessments and oral hygiene needs of residents were undertaken on admission and a plan of care had been implemented where appropriate. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 12 Following the last inspection the Pharmacy Inspector had visited the home to offer advice on medication. The requirements from that visit and the requirements made at the last inspection had been actioned with the exception of 1. On examination of the Medicine Administration Record (MAR) sheets at the last inspection and this inspection it was noted that some prescribed medication e.g. creams, bath oil and build up drinks had not been signed for. All prescribed medication must be signed for by the person administrating them to facilitate audits and to ensure that the records are clear and accurate. This requirement has been reiterated in this report. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately and all deliveries and returns of prescribed medications had been recorded and accounted for so providing a full audit trial. . St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 The home provided a good environment for the residents who live there with a wide range of activities. Residents were able to maintain contact with family and friends and were able to exercise choice and control over their lives Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The resident files contained a personal history, which included significant life events, hobbies and interests, pets, religious and spiritual observance. A games room, a therapy room, a large concert hall and hairdressers were all provided within the home. Evidence of activities, including a St.Patrick’s day party in the form of photographs were seen during the inspection. The home held a monthly resident meeting and part of the meeting was spent discussing activities so ensuring residents involvement. The home offered a wide variety of activities and residents and staff spoken to confirmed this. The home did not employ an activity organiser, it was the collective responsibility of the staff in general and each of the nursing units organised their own activities in addition to the larger group activities. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 14 Although the home provided comprehensive group and individual activities it is recommended that the home employs an activity organiser. The home had an open visiting policy and visitors could be seen in the privacy of residents own room or in any of the communal areas. Residents spoken to confirmed this. The menus had been developed on a 3 weekly basis taking into account residents likes and dislikes. The menus appeared to offer a varied, wholesome and nutritious diet. A choice of alternative meals was available. Staff consulted residents on a daily basis for their preferred meals. The daily menu was on display throughout the home. Positive comments were made by the residents spoken to in relation to the quality, quantity and choice of meals served. The home provided a large, attractive dining room on the ground floor and smaller dining rooms on each unit. Since the last inspection the kitchen has been refurbished. A large supply of food stock, including fresh fruit and vegetable, was viewed during the inspection. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home had a complaints procedure and a copy had been given to each resident. There was a policy in place for the protection of vulnerable adults and staff had received training in what to do in the event of an allegation of abuse, thus ensuring the safety and well being of the residents. EVIDENCE: The home had a complaints procedure in place that was located in the residents’ library and in the policy folder on each unit. Residents received a copy, which is included in the Service User Guide, on admission to the home. The Commission for Social Care Inspection had not received any complaints about this service and the manager informed the inspector that the home had not received any complaints. The home had policies and procedures relating to abuse/protection of vulnerable adults, a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse and a ‘Whistle Blowing’ policy. Training for staff on what to do in the event of an allegation of abuse was reported by the manger to be ongoing and had been included in the induction programme. Staff spoken to confirmed this and they were able to describe the actions they would take if there was an allegation. They knew where to locate the policies and procedures if needed. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home felt comfortable and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature and of a high standard. The home had a programme of routine maintenance and renewal of the fabric and decoration. The home provides large, attractive, well maintained grounds with a variety of garden areas which are accessible to residents in wheel chairs. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The numbers and skill mix of staff were sufficient to meet the needs of the Sisters accommodated. The homes recruitment policies and procedures promoted the safety and wellbeing of the residents. EVIDENCE: At the time of inspection the home accommodated 48 residents, 13 residents assessed as requiring nursing care and 35 residents assessed as requiring personal care only. The homes staffing levels were in excess of the minimum requirements of the previous registering authority. The skill mix, experience and numbers of staff appeared to be appropriate to meet the needs of the residents accommodated. The sample of staff files inspected contained all the information and documents listed in Schedule 2 of the Care Home Regulations 2001. Training had been made a priority in the home. Each member of staff had a detailed individual training and development programme, which also included certificates of achievement. All the staff spoken to confirmed that they had regular training sessions on care related topics. Staff seemed enthusiastic about their training and understood it was an important part of their personal development. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 The home had systems and procedures in place, which safeguards and protects residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The manger reported that the home does not handle/manage residents finances. Families assist residents who are unable to manage their own finances. All residents were in receipt of their personal allowances and all DSS payments are paid directly into individual bank accounts of residents. Evidence was seen that the manager ensures the health, safety and welfare of the residents and staff are protected at all times St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x x 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 Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 13 Requirement The use of bed rails must be thoroughly risk assessed to ensure any unnecessary risks to the health or safety of residents are identified and so far as possible eliminated.. A detailed review of pressure sores/wounds must be undertaken at each time the dressing is renewed. All prescribed medication must be signed for by the person administrating them. Timescale for action 31/8/05 2. 8 15 31/8/05 3. 9 13 31/8/05 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 12 Good Practice Recommendations It is recommended that the home employ the services of an activity organiser. St Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Josephs Nursing Home F55 F05 S21581 St Josephs V232765 D140605 Stage 4.doc Version 1.30 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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