Inspection on 30/05/07 for St Josephs Home

This inspection was carried out on 30th May 2007.

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

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

Other inspections for this house

St Josephs Home 29/01/06

St Josephs Home 08/09/05

St Josephs Home 10/02/05

St Josephs Home 09/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE St Josephs Home Westmorland Road Newcastle Upon Tyne Tyne & Wear NE4 7QA Lead Inspector Elaine Malloy Key Unannounced Inspection 30th May 2007 09:40 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 Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Josephs Home Address Westmorland Road Newcastle Upon Tyne Tyne & Wear NE4 7QA 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) 0191 273 1279 0191 272 2893 lspnew@aol.com The Little Sisters of the Poor Sister Joseph Christine Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 15 residents to receive nursing care 44 residents to receive personal care One bedroom may be used to provide either nursing or personal care. The total number of service users accommodated at any one time must not exceed 58. 29th January 2006 Date of last inspection Brief Description of the Service: St Josephs is a large, purpose built home on the outskirts of Newcastle. The accommodation is over four floors and the building also houses its own convent and church. Car parking is located at the front of the building. There are extensive landscaped gardens surrounding the home with many seating areas available. There are three passenger lifts in the home. All bedrooms are single en-suite and meet or exceed minimum room size requirements. St Josephs is registered to provide personal care and nursing care. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fee is £373 for residents funded by the Local Authority or who are privately funded. This fee is supplemented by additional payment for people receiving nursing care, according to their level of dependency. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by: • Looking at information received since the last inspection on 29th January 2006. • The provider’s view of how well they care for people. • An inspector visiting the home unannounced on 30th and 31st May 2007. • Getting the views of people who use the service and their relatives by talking to them and from surveys they completed. • Talking to the manager and other staff about the service. • Looking at records about the people who live at the home and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they care for. • Looking around parts of the building to make sure it is clean, safe and comfortable. • Checking what improvements had been made since the last inspection. What the service does well: People admitted to the home have a thorough assessment of the care and support they require. They are kept involved in how their care is planned and reviewed. Each person has recorded care plans that show how he/she is assisted to meet their health and personal care needs. The plans are personalised to the person’s preferences and recorded in very good detail. Residents’ rights to privacy and dignity are upheld and they are treated with respect. Residents are well supported by staff and medical professionals to meet their health care needs. There are safe medication practices and staff are trained to administer medicines. Residents are supported to live the lifestyle they prefer and stay as independent as possible. Contact with family, friends and the local community is maintained. Visitors, volunteers and other people from the community join residents for activities, religious services and meals/refreshments. Residents are encouraged to make choices and decisions and keep control over their lives. The home has an inclusive atmosphere where people are treated and valued as individuals with diverse needs. Residents are provided with a varied and well balanced diet with choice of meals. People said they enjoy the food and meal times are very social occasions. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 6 The home has a clear complaints procedure that residents and relatives understand. There have been no recent concerns or complaints about the service. Residents feel safe living here. The home has procedures and trains staff in preventing vulnerable people from being abused. Residents live in clean and comfortable accommodation that is very well maintained and offers a wide range of facilities. A high level of staffing is provided to make sure all residents’ needs are met. Residents and visitors spoke very positively about the care and support provided by the staff team. A robust recruitment procedure is followed to protect residents from unsuitable people working in the home. Residents are cared for by competent staff who undertake a range of training relevant to meeting the needs of older people. Qualified nurses are employed and many of the care workers have completed care qualifications. The Mother Superior is an experienced and qualified manager and she manages the home in the best interests of the residents. There are very good systems in place to get people’s views on the quality of the service and improve standards. Residents and family and friends expressed a very high degree of satisfaction about the service. Their comments included, “The staff are wonderful, caring and kind”, “This is the best nursing home that anybody could wish to stay in”, “I have been more than happy since my mother has been in this home, knowing she is well cared for”, and “The Sisters and the care staff do a magnificent job in the home in all roles”. Resident personal finances are held safely and proper accounts are kept. Health and safety checks are carried out and staff receive training in safe working practices. What has improved since the last inspection? In the period since the last inspection more varied activities and outings have been introduced following consultation with residents. The key worker system has improved to make sure staff monitor and update resident care plans. Staff are continuing to develop how risks are assessed and managed. A training manager has been employed to co-ordinate the training needs of the large staff team. A new catering manager has started and he will be revising menus, taking into account resident suggestions. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. New residents have their care needs thoroughly assessed before admission and are assured these will be met at the home. Prospective residents have good opportunities to spend time at the home before making a decision to move in. EVIDENCE: A sample of care records for residents admitted to the home in recent months was examined. An extensive assessment of the person’s needs is carried out. The assessment has guidelines linked to scoring that indicate whether the person requires personal or nursing care and dependency levels. Information is also sought from the individual’s doctor on their medical history, current health and medication. Social Workers provide the home with assessments if a Local St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 10 Authority is funding the person’s care. Written confirmation that the person is suitable for admission is provided. People who are considering moving in are offered a gradual introduction to the service. They can spend time at the home, take meals and participate in activities. Short stay care is also offered at no obligation. Residents who completed surveys said they received enough information before moving in so they could decide if it was the right place for them. Some residents also verified that they visited the home prior to admission. One person said this was the second home they had lived in and that St Joseph’s was more superior to the other home. A number of residents who spoke to the inspector said they had moved in after having respite care at the home. A lady who was recently admitted said she is settling well and is the happiest she has been in months. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have very good standard recorded plans that show how they are assisted to meet their personal care needs and remain independent. Residents receive a high level of support in meeting their individual health care needs. Residents are properly protected by the home’s medication system and practices. Residents are treated very respectfully and have their rights to privacy and dignity upheld. EVIDENCE: A comprehensive range of assessments is completed to identify each resident’s current health, personal and social care needs. This information is used to St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 12 devise and update individual care plans. Residents are involved in planning their care and have a ‘key worker’ who monitors and updates care plans. A sample of care plans was examined. These addressed physical health, personal hygiene, continence, memory and cognition, skin integrity, communication, social and spiritual needs. The recording was detailed, specific and personalised to the person’s requirements. The plans demonstrated care and support to be provided by staff and what the person can do independently. There were also good examples of plans that showed how risks to the person are managed or minimised. Residents who completed surveys and spoke to the inspector said they always receive the care and support they need. Comments included, “The care is superb and the staff are delightful”, “The care I receive at St Joseph’s is fantastic”, and, “Sisters and carers are wonderful and do a great job”. Relatives/visitors said the care home gives the support or care expected and always meets the needs of their relative/friend. Residents have a choice of local GP practices and the home has an allocated District Nurse. There are arrangements for an optician, dentist and podiatrist to make home visits. Residents also receive input, where required from mental health care professionals, physiotherapist and phlebotomist. All contact with health care professionals is well recorded. The manager reported good working relationships with visiting medical professionals. Residents said they always receive the medical support they need. Comments included, “Medical needs fully attended to”, and, “The best medical care ever”. Residents have their moving and handling, nutrition, continence, and pressure sore risk needs assessed. There were some very good examples of care plans relating to specific health needs and medical conditions. Where necessary these incorporate aids and equipment used. Six residents continue to take responsibility for administering their medication. An assessment of the risks is completed and verified by the person’s doctor. All staff who administer medication undertake relevant training and have competency assessments completed. A sample of medication charts was examined. These were appropriately recorded and have resident photographs for identification purposes. All personal care and medical examination/treatment is carried out in private. Each person is asked the name they wish to be addressed by and this is recorded. Residents are informed that an all female staff team provides the care and support. Privacy and dignity issues are well represented in individual care plans. Residents confirmed that staff treat them with respect and personal care is carried out in a dignified manner. All single bedroom accommodation with en-suite facilities and emergency call system is provided. Residents are offered keys to their rooms and can have a St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 13 telephone if they choose, with direct number and own bill. A pay telephone is also available. The home has dedicated laundry staff. Name labels are used to identify individuals clothing. There is also a small laundry that residents can use if they wish. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with excellent support to live their preferred lifestyle and are offered a range of activities to meet their social needs. Residents are well supported to maintain contact with family, friends and the local community. Residents are encouraged to exercise choice in daily living and maintain personal autonomy. Residents are offered a balanced and varied diet with choice of meals. EVIDENCE: Each person has an assessment of their social needs that gives details of his/her background, lifestyle, routines and interests. The information is used to record individual social care plans. Spiritual needs are supported through daily Mass, celebration of Feast Days and individuals can receive Holy Communion. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 15 A weekly activities programme is displayed that includes outings and religious services and events. Residents discuss activities and outings at ‘Resident Council Meetings’. The manager said more varied activities have been introduced in the period since the last inspection, including the local ‘Search Project’ that carries out weekly activities with residents. There has also been liaison with a school to do a computer project. Wherever possible staff support individual needs and requests for one-to-one activities and outings. The home has its’ own mini-bus for transport. The majority of residents who completed surveys said there are always activities arranged by the home that they can take part in. One person said, “Many and varied, social and religious”. Residents told the inspector that they choose how they wish to spend their days, and some commented on following their individual interests. One of the activities taking place during the inspection was a session of indoor golf. This generated much lively discussion amongst residents and good-humoured competitive spirit. The home has an open visiting policy. Visitors are welcomed and can take refreshments and meals. There is also a visitor’s room where family/friends can stay overnight. Residents choose whom they wish to see and where to receive visitors. Contact with friends and family is supported through visits, telephone calls and letters/cards. Good examples were given of how relatives are actively encouraged to be involved in how individual’s care is planned and reviewed. A number of people spoke about a sense of belonging to the caring community within the home. Residents said they enjoy the opportunities for everyone to come together during religious services, meals and activities and events. This includes residents, visitors, volunteers, staff and people who live locally. Residents make use of local and wider community facilities. Some people go out alone and staff accompany others to go out for walks, on shopping trips etc. Relatives/visitors said the home always helps their relative/friend to keep in touch with them. They said they are “always” or “usually” kept up to date with important issues affecting their relative/friend. One person commented, “If mother is unwell one of the Nursing Sisters always rings to explain”. Residents told the inspector that they are encouraged to make choices and decisions, and if they wish, to take on roles within the home. Examples include residents who serve refreshments following Mass and do the washing up. Another lady was making produce to sell at the forthcoming Summer Fayre. Residents spoke of the emphasis on remaining independent and helping others where possible. A good example of this was a lady who had introduced herself to a new resident, welcomed her and offered her support. Residents and staff were helping the new lady to become familiar with the layout of the building St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 16 and the grounds. Relatives who completed surveys said the service supports people to live the life they choose and meets the different needs of people. New residents agree the extent of possessions and furnishings they will bring into the home to personalise their bedroom. Individuals are kept involved throughout the process of assessment, and planning and reviewing their care. The home has a policy on resident access to personal records. Some residents continue to manage their financial affairs. Where this is not possible they are assisted by relatives/solicitors. The home’s management does not take responsibility for finances, other than holding cash for personal spending in the safe. Resident nutritional needs are assessed and care planned where necessary, and weights are monitored. Special diets are catered for. These currently include low fat, diabetic and soft diets. Blended food is served separately. Independent eating is encouraged, with use of aids if needed. A new catering manager has recently been appointed and is revising the menus. He attended a Resident Council Meeting where residents gave their requests and made suggestions about food. The current menus showed that there is a choice of cereals, porridge, grapefruit, prunes, toast and preserves and cooked breakfast daily. Lunch is a starter of soup, main meal with alternatives of omelette or salad, followed by dessert. There is a choice of lighter meal for tea, also with dessert. Snack suppers are served. Preference sheets are completed daily to indicate each person’s choice of meals or requests for alternatives. Menus are displayed. Residents can take meals in the dining rooms on the units, the main dining area or in their bedrooms. Meal times are flexible and residents can choose to have meals sooner or later. The home runs a luncheon club each day where members of the local community dine with residents in the main dining room. The inspector dined with residents at lunch. The tables were nicely set with cloths, placemats and full range of condiments. Hot and cold drinks were available with the meal, including wine as a Feast Day was being celebrated. Soup and the main meal were presented in tureens for people to help themselves or others. The meal was served at a leisurely but timely pace, and staff and volunteers were on hand to offer discreet help if needed. There was plenty of conversation between residents, volunteers, staff and people visiting for lunch. A number of people commented about meal times being social occasions. Residents told the inspector the food is good. They confirmed choice of meals is offered and were aware that the menus were being updated. Residents who completed survey said they like the meals. One person commented that alternatives are provided at all meals. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives have good understanding of how to raise any concerns or complaints. Resident welfare is protected by the home’s procedures and practices, and training staff in preventing abuse. EVIDENCE: The home maintains a comments book where people have made numerous entries of thanks about the care and services provided. A separate book is kept for comments about the food. The complaints procedure is included in the home’s guide to services that is given to all residents. No complaints were received in the period since the last inspection. The Commission has not been contacted about any concerns about the home in this time. Residents told the inspector that their views are listened to and acted upon and they would express any concerns they had. Residents and relatives who completed surveys said they would know how to make a complaint. Comments included, “No problems in this respect”, and, “Sister or carers always available”. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 18 A range of policies and procedures are in place on preventing abuse, protecting vulnerable adults (POVA), and ‘whistle blowing’ (informing on bad practice). Staff receive POVA training and a further course was booked for June 2007. No allegations of abuse have been made. The manager understands her role to report any allegations to the relevant authorities. Residents told the inspector that they are treated well by staff and feel safe at the home. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a high standard environment that is safe and clean and has a wide range of facilities. EVIDENCE: The premises are very large yet maintain a pleasant and homely atmosphere. There are substantial facilities available including a chapel, convent, library, shop, and crafts, pool, coffee and hairdressing rooms. The home is set out into self-contained units and a variety of communal areas, all of which are accessible by residents. All parts of the building seen were clean, suitably equipped and have good quality decoration and furnishings. There is an ongoing programme of St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 20 decoration and refurbishment. Residents are consulted about the redecoration of their bedroom. The grounds are very well maintained and are used regularly by residents. A sit-on lawnmower has been bought. There are plans to buy plants for verandas and look at how to make paths more accessible. A number of residents spoke positively about their bedrooms and the accommodation in general. One lady said, “The home is lovely, it has everything you could need”. A lady recently admitted said she was happy with the comfort of her room. A relative commented on the excellent kitchen facilities that allow residents to offer their visitors refreshments. All residents said the home is always fresh and clean. Comments included, “Fresh, well-aired as required. Cleaned in every aspect, sparkling and spotless”, and “Beautifully kept”. The home has policies and procedures on hygiene and control of infection. Staff receive infection control training. There is suitable hand washing facilities throughout the building. Disposable gloves and aprons are provided for staff use. Arrangements are in place to dispose of clinical waste. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. High levels of nursing, care and ancillary staff are provided to meet the needs of residents. The home exceeds the standard for the ratio of care workers who have achieved nationally recognised care qualifications. A thorough recruitment procedure is followed to make sure residents are protected from unsuitable people being employed. Staff receive a good range of training that is relevant to caring for older people. EVIDENCE: The Little Sisters, nurses, care assistants, domestic, catering, laundry, garden/maintenance, and administrative staff, and volunteers support residents. Each of the four units in the home has designated staffing and levels are determined according to the number and dependency of residents. The home does not use agency staff. Existing staff provide cover for absences and there is a full time ‘floater’ carer. Many of the staff have worked at the home long term. Consideration has been given to employing a male carer, as St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 22 recommended at the last inspection. The manager said there has been a lack of male applicants. A male nurse is employed. Residents who completed surveys said staff listen and act on what they say, and are available when they need them. Comments about staff included “Very helpful”, “Always highly responsive”, and, “The staff are wonderful, caring and kind”. Relatives said that staff have the right skills and experience. 30 of the 43 care staff have achieved National Vocational Qualifications (NVQ) in care at Level 2 or above. Two staff are currently studying for this qualification. A sample of staff recruitment files was examined. All staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. The files contained appropriate information: photograph and proof of identification, application form, references from suitable sources, interview assessment, and health questionnaire and statement of fitness. The home has employed a training manager who co-ordinates and arranges training for the large staff team. New staff complete extensive induction training that meets standards. They do not work unsupervised until their induction is complete and they have been assessed as competent. Each staff member has a training file and portfolio. Certificates of training are kept and details are also kept on computer. All staff are either up to date, or are booked to attend courses on safe working practices and safeguarding vulnerable adults. Other training that has taken place in the past year includes pressure area care, Waterlow Assessment, continence promotion and products, anxiety and confusion, caring for people with dementia, control of substances harmful to health (C.O.S.H.H), medication, equipment training, diabetes, and palliative care. Staff confirmed to the inspector that they receive a good level of training. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is well managed by an experienced, qualified and caring manager. There are very good systems to monitor and improve the quality of the service provided to residents. Resident personal finances are suitably safeguarded. There are good health and safety systems to promote resident and staff welfare. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 24 EVIDENCE: The Mother Superior has managed the home for the past six years. She is a qualified Registered General Nurse and has completed the Registered Manager Award qualification. Throughout the inspection she demonstrated excellent leadership, knowledge and skills and a caring approach to all people involved in the service. The home uses a number of methods to monitor and improve the quality of the service. Feedback from residents is sought in a variety of ways. These include the comments and complaints system, monthly Resident Council Meetings, and satisfaction surveys. The current survey seeks opinions on the accommodation, staff, independent choices, privacy and dignity, involvement in care planning, religious practice, visiting arrangements, food, activities and complaints. Monthly ‘conduct of home’ visits are carried out and reports are written as a result. At these visits the standards of different aspects of the service are checked and can include audits of specific standards, for example care documentation. The home also receives visits from the organisation’s Quality Advisor who monitors quality and prepares reports with issues/recommendations. The home has a full range of policies and procedures relevant to caring for older people. People who spoke to the inspector and completed surveys gave very positive comments about the standard of the service. They said: “I am most happy to say how much I appreciate all that is done for me here, with love and cheerfulness now that I am dependent on help”. “In two years as a resident no carer has ever asked me to ‘wait a minute’”. “This is the best nursing home that anybody could wish to stay in”. “This home could not be faulted in any respect”. “I am extremely happy and content”. “I have been more than happy since my mother has been in this home, knowing she is well cared for”. A relative described the exceptional service her Aunt receives and said the care could not be better. Relatives/visitors who completed surveys were asked what they feel the home does well. They said, “The Sisters and the care staff do a magnificent job in the home in all roles”, “Provide a kind and caring home for residents”, “Allow people their independent personal space and freedom, while offering a range of communal activities and stimuli”, and, “Everything they are asked to do”. The only suggestion about how the home could improve was to have better television reception. One person said, “You can’t improve on perfection”. Another said, “I think they really try their best for each one of us, we are a happy crowd”. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 25 Residents receive personal allowances. Records are kept of cash held by the home for personal spending. A sample of personal finances records was examined. Transactions are appropriately recorded and the majority have two signatures for each entry. Receipts are obtained for purchases. Checks of balances and cash are carried out. Management agreed to make sure that records relating to accounts being supplemented and reimbursed are made clearer. The arrangements for staff to receive regular individual supervision were discussed. The manager has recognised this is an area that needs to be improved. Unit managers and the personnel manager are responsible for providing supervision. They have had supervisory and appraisal training. A review needs to take place of the numbers of staff each manager supervises, the frequency of supervision and planning and monitoring systems. The home has a health and safety policy and range of associated procedures. There are health and safety committee meetings. Staff are provided with training in health and safety and safe working practices (fire safety, moving and handling, first aid, food hygiene, and infection control). Audits are being formalised to check compliance with health and safety requirements. Servicing and maintenance agreements are in place for facilities and equipment. Risks in the environment and working practices are assessed, and action taken to minimise or manage identified risks. Individual resident’s risk-taking and management of assessed risks is documented in personal care records. All fire safety checks and tests are carried out at the required frequency and recorded. The records of staff receiving fire instructions need to be made clearer to demonstrate three monthly instruction to night staff and six monthly to day staff. Accident reporting was suitably recorded and includes details of any treatment provided or referral to GP/hospital. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 2 X 2 St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 27 N/A 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP36 OP38 Good Practice Recommendations The arrangements for individual staff supervision should be reviewed. The recording of fire instructions provided to staff should be made clearer. St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Josephs Home DS0000000405.V338025.R02.S.doc Version 5.2 Page 29 - 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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