Inspection on 21/07/05 for St Josephs Home

This inspection was carried out on 21st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Josephs Home 05/06/07

St Josephs Home 02/02/06

St Josephs Home 15/03/05

St Josephs Home 01/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE St Josephs Home 66 Cotham Hill Cotham Bristol BS6 6JT Lead Inspector Vanessa Carter 21 st Unannounced July 2005 09:30 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 Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Josephs Home Address 66 Cotham Hill Cotham Bristol BS6 6JT 0117 9733815 0117 9466786 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) The Little Sisters of the Poor Sister Catherine Mckinlay N Care Home with Nursing 41 Category(ies) of OP Old age (41) registration, with number of places St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 6 persons receiving nursing care. May accommodate up to 35 persons aged 65 years and over, requiring personal care. Manager must be a RN on Parts 1 or 12 of the NMC register Date of last inspection 15-Mar-2005 Brief Description of the Service: St Josephs Home is operated by The Little Sisters of the Poor. It is registered with the Commission for Social Care Inspection to provide placement for 41 people, of whom 6 people need assistance with both personal care and nursing care. All residents must be aged 65 years and over. St Josephs is situated in a busy residential area of the city, close to local amenities and bus routes. Sister Catherine McKinley (known as Sister Marie) is the current registered manager. The home was extensively refurbished 5 years ago and is now modern and tastefully decorated, with the facilities spaced over three floors. A passenger lift ensures that all parts of the home are accessable to disabled people. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection to the home that took place over one day. On this inspection not all standards were inspected, with the focus being directed at staff recruitment, care planning processes and the delivery of a care service. Evidence was gained from touring the home, speaking to the manager, administrative staff, care staff, one registered nurse, and a number of the residents. The homes records were inspected. What the service does well: 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 Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 6 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 Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 7 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) 1, 2, 3, 4 and 5 The home has an admission process that is well managed. New residents who choose to live at St Josephs are provided with clear information regarding the service provided. EVIDENCE: The home has a statement of purpose that is up to date and is available, for anybody to have a look at, and is placed in the main reception of the home. A service users guide is issued to all residents and contains all the necessary information to enable the residents and their family to know what services are available at the home. The service users guide is given to any prospective resident and enables them to make an informed choice about moving to live at the home. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 8 Each resident is issued with a statement of terms and conditions upon admission into the home. Where the placement is part funded by a local authority, a schedule of payments is drawn up. The home has six people who are also in receipt of nursing care – these people are in receipt of the nursing care contribution from the PCT. Each resident will have a comprehensive pre-admission assessment, prior to moving into the home. This will ensure that placement is only offered to those who needs can be met. The documentation for the newest resident was clear and detailed, and provided a good picture of the person’s needs. The home provides placement for people who have strong religious beliefs and therefore require a home with a catholic ethos. One resident stated that they visited the home prior to taking up placement, but their family had made all the necessary arrangements. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 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 standard(s) 7, 8,9, and 10 Residents are well cared for in respects of their health, personal, spiritual and social care needs. The care plans are person centred and provide a clear and detailed picture of each residents needs. EVIDENCE: Six randomly selected care plans were looked at. They each contained an individual plan of care that covered all aspects of the resident’s health, personal and social care needs. The plans follow on from the assessment of need, and where the resident had been in the home for a long period of time, an updated assessment is made. This is good practice. The plans gave clear instructions to the care staff, and detailed how the needs should be met. There was evidence that the resident had been consulted in the drawing up of the care plans, and where appropriate, the resident had signed their agreement to the plan. The standard of recordings in the daily notes was good, and evidenced that the identified needs had been met. It was noted that where a care assistant had made an entry in the residents care file, this was counter-signed by a registered nurse or the person-in-charge. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 10 The home follows safe practices for the receipt, storage, administration and disposal of medications. The three floors each have a medication trolley, and unqualified staff have received safe medication administration training. The home must ensure that any hand written medication administration sheets are always properly named, in order to prevent any errors being made. One resident spoken with stated that the care staff looked after them well and that they were treated with respect and dignity. Good interaction between staff and residents was seen, in many different settings. The staff were witnessed assisting residents to move around the home, luncheon being served, and in dealing with requests for assistance. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The residents have the option to participate in a stimulating and varied life. The meals provided are of a very good quality. EVIDENCE: Each resident is able to spend their time as they wish and care planning documentation makes reference to the time the resident prefers to get up and retire to bed. A social history is written for each resident. The home displays a weekly plan of activities in the main reception area, plus each resident has a copy of this in their bedroom. A range of different events, are planned. One of the residents leads one particular session each week. The home has recently organised a trip out from the home to Buckfast Abbey – one resident said that although it was a long day, it had been thoroughly enjoyable. The manager explained they were in the process of organising another trip, and that suggestions are being sought from the residents. The weekly menu plan is displayed in each of the dining rooms. This provides the residents with a well balanced and nutritious diet. There is a choice of meals at each meal time, and one resident stated that alternatives are always offered if neither choice is acceptable. The dining rooms are set out “Hotel Style” and provide a pleasant space in which to dine. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 12 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 and 18 The complaints procedure is made available to the residents and visitors, and any complaints are listened to and acted upon. The arrangements for protecting residents from abuse are good, because of staff awareness and understanding of adult protection issues. EVIDENCE: The complaints procedure is contained within the homes Statement of Purpose and the Service Users Guide. Residents spoken to during the course of the inspection stated that they were able to raise any issues or concerns with the manager. One person stated “there is nothing to complain about here”. The complaints log was not discussed on this inspection, however was noted to be well maintained on previous visits made by the CSCI. Staff who were spoken to about abuse issues were able to demonstrate good awareness of the subject. Abuse awareness training is incorporated as part of the induction training programme and this was confirmed by one of the senior carers. The home has a whistleblowing policy to enable staff to report poor or bad practice, and an adult protection policy. These were looked at on the previous inspection. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 13 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) The residents live in a beautifully maintained, calm and tranquil home that is clean tidy and free from any unpleasant odours. The home is well equipped with all the necessary facilities and items of equipment, to meet the residents needs. EVIDENCE: St Joseph’s was completely refurbished approximately five years ago. It is an older building that had been tastefully modernised inside, but still retaining an outside appearance that is in keeping with the locality. The home is situated within its own grounds, and is secured by high walling and electrically operated gates. The grounds and the home are beautifully maintained. The living and office accommodation is arranged over four floors, with the basement being entirely for staff use. The standard of decoration throughout the whole home was high. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 14 Five residents are cared for on the ground floor each in single rooms with ensuite facilities. On this floor there is also a large function room where activities and meetings are arranged. The first floor accommodates 15 residents and the second floor 19. All bedrooms are single and have an ensuite toilet and wash handbasin. A number of the ensuite rooms also have a level access showers. The manager explained that rooms are always redecorated in between residents and one room was seen being prepared for a new person. The rooms are large, furnished with high quality furniture and soft furnishings, and residents are encouraged to personalise their rooms with their own belongings. Each floor has its own lounge area and dining room. In addition the middle floor has a small lounge where smoking is permitted. The home has an abundance of nursing equipment and facilities to enable the care staff to easily meet the resident’s needs. Examples include electric beds, pressure relieving aids, hoists, assisted bathing facilities, passenger lifts, disabled toilets and grab rails throughout. The home is maintained spotlessly clean and tidy, and was odour free in all areas. A dedicated team of ancillary staff are employed to attend to all domestic, catering and laundry tasks. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 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 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 and 29 The residents are cared for by skilled and knowledgeable staff who are able to demonstrate a clear understanding of their roles. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. EVIDENCE: The manager discussed the staffing arrangements for the home. The levels of staff are above the minimum standard. Each floor has a ‘Unit Sister’, and all three are registered nurses. Several residents confirmed that the staffing levels were appropriate and that care staff were always able to assist them promptly. The home has a policy on the recruitment of new staff that follows good employment guidelines, however there have been occasions when staff have been employed prior to full checks being finalised, into their fitness for care work. Criminal Records Bureau and POVAfirst checks were not present in the staff files for two recently recruited members of care staff. The manager was advised that from now on, the home must have evidence of POVA clearance for all care staff prior to their employment. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 16 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) 37 Residents benefit from living in a home that is well managed and has a good standard of record keeping. EVIDENCE: The standards of record keeping in the home are very good. Staff and resident information is securely kept in either locked offices or filing cabinets. There was evidence that the residents are able to access their care notes – where appropriate residents had signed their agreement to the care plans. All other standards in this category were not assessed during this inspection however have previously met the national minimum standards. St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 17 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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 4 3 x 3 3 4 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x 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 x x 3 x St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 18 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 OP29 Regulation 19 Requirement The home must follow robust recruitment procedures, to ensure that the fitness of all workers is checked prior to employment. The manager must attend further development/training in valuing diversity and equality. This requirement is held over from the previous inspection Timescale for action From 21 July 2005 onwards 30 September 2005 2. OP31 10(3) 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 Good Practice Recommendations St Josephs Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 19 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Home D56S20363stjosephsV234187190705_Stage 2.doc Version 1.30 Page 20 - 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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