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Inspection on 18/04/07 for St Mary`s Convent

Also see our care home review for St Mary`s Convent for more information

This inspection was carried out on 18th April 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Since the last inspection the home has appointed a new manager, who is well liked and respected by people living in the home, their relatives, the homes staff and the convent Sisters. The manager has made improvements to the facilities in the home, including the office, installing a new specialist bath and making a very pleasant courtyard area for people to sit in. Staff training has continued, with a very high number of staff achieving National Vocational Qualifications (NVQ`s) in care at level 2. This has included staff being given the opportunity to progress by doing NVQ`s at levels 3 and 4.

What the care home could do better:

Recent changes in what is required of care homes means that St Mary`s Convent needs to review its Service User Guide, Statement of Purpose and contracts, to make sure that they contain all of the information that they now should. Some aspects of care planning and recording could be improved. For example, not all of the care plans were fully up to date, some didn`t cover all of the relevant areas and, although regular reviews took place, these didn`t seem to include a review of the actual care plan and the relevant risk assessments, some of which hadn`t been reviewed for a long time. Although generally highly satisfied, a few people living in the home would like to see more individual one-to-one activities and a little more variety in the meals that are provided.Some amendments are needed to the home`s protection policies and procedures. This is important so that any allegations or suspicions of abuse are handled appropriately and people are protected fully. It was found that some bedrooms have interconnecting doors that are not currently locked or sealed (although the position of some bedroom furniture does stop them being opened fully). This should be carefully considered in the interests of privacy. The home must also renew its landlords gas certificate, which was due to be renewed in December 2006. All of the required recruitment checks, including an enhanced CRB disclosure and two written references, must be carried out before new staff commence work in the home. This is very important to ensure that people are adequately protected from staff who are unsuitable to work with vulnerable people.

CARE HOMES FOR OLDER PEOPLE St Mary`s Convent St Mary`s Convent Ebchester Consett Durham DH8 0QD Lead Inspector Rachel Dean Unannounced Inspection 18th April 2007 10:30 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 Mary`s Convent DS0000007504.V336479.R01.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 Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Convent Address St Mary`s Convent Ebchester Consett Durham DH8 0QD 01207 560288 F/P stmarysconvent@tiscali.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Order of the Good and Perpetual Succour Patricia Elizabeth Birkett Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: St Mary’s Convent is owned by the nuns of The Order of the Good and Perpetual Succour, who have their own accommodation and chapel within the same building as the care home. The care home is registered to provide care and accommodation for up to 16 older people and the home has decided that it will only provide services to females. In addition to the nuns who live at the convent, St Mary’s Convent employs a staff team and manager to provide care and run the home. The convent is an old building that has been adapted for use as a care home. As a result the building has a number of different levels and accessibility varies throughout the building. All of the bedrooms are singly occupied and some bedrooms have en-suite toilets. There is a lounge, entrance sun lounge, large internal hallway with seating and a dining room on the ground floor. There is also a large office used by the manager and staff. Bathrooms, a shower room and toilets are located through out the building. The first floor is accessed by a passenger lift, while the mezzanine floors and levels are accessed by a stair lift. Some bedrooms and levels require access by two or three stairs, which have been fitted with handrails to make access easier. The convent is surrounded by well-maintained gardens and also has a pleasant internal courtyard area with seating. Car parking is available at the front of the building. At the time of this inspection the fees charged to live at St Mary’s Convert were £364.50 per week. Additional charges include hairdressing, chiropody and personal toiletries. Up to date information about fees should be sought from the manager. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of St Mary’s Convent, taking place on 18th April 2007. The inspection was carried out by an inspector and a student, who was on placement with CSCI at the time. The inspection visit took place between 10:30am and 5pm. During the visit seven people living at the home and three relatives were spoken to about life at St Mary’s. A number of staff, including the manager, were also spoken to. A number of records were inspected and the inspectors looked around the home and observed the care that was being provided. In addition to the information collected during the inspection visit a number of surveys were provided to people living in the home and their relatives. Ten people living at St Mary’s Convent completed and returned their surveys. Nine relatives also completed and returned surveys. The manager of the home completed and returned a pre-inspection questionnaire, providing information about the service. What the service does well: St Mary’s Convent provides a high level of care and attention to the people that live there. People living in the home were very complimentary about the staff and the care they receive. Comments included ‘I enjoy living in this home’, ‘could not improve on care and facilities, staff very caring’, ‘the staff are attentive, treat the residents with respect, and any health concerns are quickly dealt with’, ‘my mother can not fault the care given to her and constantly re-iterates the fact that she is extremely well cared for’ and ‘the standard of care provided is very high’. Each person living at St Mary’s Convent had their needs assessed before admission and has an individual record and plan of their care needs. These records showed a good standard of recording, with people’s needs being reviewed regularly and containing some detailed information about each person and their needs. The home has in place safe arrangements for the storage and administration of medication, with one person at the home choosing to manage their own medication. Staff at St Mary’s Convent help people to live the life they choose, offering choices about how they spend their days and the activities they take part in. Visitors are welcomed into the home and traditional, wholesome meals are provided. Comments made by people living in and visiting the home included ‘activities arranged, but I like to sit in my room’, ‘as a practicing Catholic the sisters ensure that she receives communion at least weekly’, ‘the atmosphere in the care home and the friendliness of the staff enable my mother to feel at St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 6 home and make my visits very pleasant experiences’, ‘lovely food, plenty of choice’ and ‘nice – lovely fresh vegetables’. People living in and visiting the home feel comfortable about approaching the manager or staff if they have a problem and are confident their concerns will be listened to. The home is well staffed, with a stable and trained staff team. Comments included, ‘staff always listen and act when needed’, ‘there isn’t a high turn over of staff which adds to the stability of the care home’ and ‘staff are on hand all the time and would do anything for you’. St Mary’s Convent provides a traditional and homely place for people to live. It is kept clean and tidy and the gardens are well maintained, meaning that people have a pleasant and comfortable place to live. Comments made by people included, ‘St Mary’s creates a home from home place to live when own home living is no longer safe. St Mary’s is furnished in an old fashioned way, so like the home that the old have had to give up’. What has improved since the last inspection? What they could do better: Recent changes in what is required of care homes means that St Mary’s Convent needs to review its Service User Guide, Statement of Purpose and contracts, to make sure that they contain all of the information that they now should. Some aspects of care planning and recording could be improved. For example, not all of the care plans were fully up to date, some didn’t cover all of the relevant areas and, although regular reviews took place, these didn’t seem to include a review of the actual care plan and the relevant risk assessments, some of which hadn’t been reviewed for a long time. Although generally highly satisfied, a few people living in the home would like to see more individual one-to-one activities and a little more variety in the meals that are provided. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 7 Some amendments are needed to the home’s protection policies and procedures. This is important so that any allegations or suspicions of abuse are handled appropriately and people are protected fully. It was found that some bedrooms have interconnecting doors that are not currently locked or sealed (although the position of some bedroom furniture does stop them being opened fully). This should be carefully considered in the interests of privacy. The home must also renew its landlords gas certificate, which was due to be renewed in December 2006. All of the required recruitment checks, including an enhanced CRB disclosure and two written references, must be carried out before new staff commence work in the home. This is very important to ensure that people are adequately protected from staff who are unsuitable to work with vulnerable people. 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 Mary`s Convent DS0000007504.V336479.R01.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 Mary`s Convent DS0000007504.V336479.R01.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): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs assessed, are provided with information about the home and can visit the home before they decide to move in. This makes sure that St Mary’s can look after the people who live there and helps people make an informed decision about where they live. However, some of the home’s information and documentation should be reviewed to make sure they meet new requirements. EVIDENCE: All ten people who returned surveys about living at St Mary’s Convent said that they had received a contract and had been provided with enough information about the home when they were thinking about moving in. Comments made included, ‘we have always found the information very helpful’ and ‘management keep me fully informed of all aspects of the care home from my mother health and welfare to staff changes’. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 10 An example of the home’s contracts was seen during the inspection. Due to recent changes in legislation the home needs to review the information provided in its Statement of Purpose, Service User’s Guide and contracts, to make sure that enough information is provided about the home, the service provided and the fees paid. This should include up to date information about the home’s lay out (for example, the change of use of the parlour to office space and the limited access to some parts of the building). Detailed information about these changes has been provided to the manager. People have their needs assessed before they come to live at St Mary’s Convent. Records of these assessments were available and showed that the manager made sure St Mary’s could meet peoples needs before they moved in. The manager also confirmed that people are welcome to visit the home before admission. St Mary’s Convent does not provide a specialist intermediate care service. St Mary`s Convent DS0000007504.V336479.R01.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive a high level of care at St Mary’s Convent, with staff treating people with respect and dignity. Everyone has a record and plan of their care, although some improvements could be made to these. Medication is stored and administered safely by trained staff and people who are able and want to can manage their own medication. EVIDENCE: People were extremely satisfied with the level of care and attention that they received at St Mary’s Convent. Comments made about staff and the care provided in the home included, ‘I enjoy living in this home’, ‘could not improve on care and facilities, staff very caring’, ‘regular meetings and care plans take my feelings into account’, ‘The staff are attentive, treat the residents with respect, and any health concerns are quickly dealt with’, ‘my mother can not fault the care given to her and constantly re-iterates the fact that she is extremely well cared for’ and ‘the standard of care provided is very high’. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 12 During the inspection staff were observed to treat people in a friendly and respectful way. People described staff as ‘lovely, ‘very patient’ and ‘all very understanding’. People also described how staff respected their wishes and were always on hand to help when needed. For example, staff responded quickly if someone was in their room and they buzzed for help. Each person living at St Mary’s Convent has a record and plan of their care. A selection of these were looked at during the inspection. These showed a good standard of recording, with people’s needs being reviewed regularly and some detailed information about each person and their needs. However, there were some areas that could be improved and these were discussed with the manager during the inspection. For example, not all of the care plans were fully up to date and some didn’t cover all of the relevant areas (like the help people needed with medication, the equipment needed to assist people with their mobility, regular weight monitoring or a care plan for maintaining skin integrity where people were at risk of skin damage). Although regular reviews took place these didn’t seem to include a review of the actual care plan and the relevant risk assessments, some of which hadn’t been reviewed for a long time. The home has in place arrangements for the storage and administration of medication. One person at the home manages their own medication and has been provided with suitable storage in their room to do this. A random check of medication records and storage was carried out, showing that medication was stored and handled appropriately and safely. Only staff who have completed a distance learning course on ‘the safe handling of medicines’ are allowed to administer medication. A few minor issues were raised with the manager at the time of the inspection, such as always removing or recording on the medication administration record (MAR) when medication has been discontinued and always recording the receipt of medication (date and amount) on the MAR. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff at St Mary’s Convent help people to live the life they choose, offering choices about how they spend their days and the activities they take part in. Visitors are welcomed into the home and traditional, wholesome meals are provided. EVIDENCE: The home employs two people to provide activities and social events at St Mary’s. This is supported by a high level of staffing which helps staff provide the assistance or support that people need to live the life they choose. During the inspection people described how they could choose to join in with events at the home or could spend time doing their own thing if they preferred. Comments included ‘activities arranged, but I like to sit in my room’, ‘as a practicing Catholic the sisters ensure that she receives communion at least weekly’ and ‘I know that a member of staff reads newspapers to them and they then talk about things they have heard’. On the day of the inspection a group of people and staff were going out for the afternoon to a party and St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 14 others were reading magazines and listening to music. However, a couple of people felt that more individual one-to-one activities would be beneficial. Relatives confirmed that they were made welcome and able to visit when they wanted to. Comments made by people visiting the home included, ‘the atmosphere in the care home and the friendliness of the staff enable my mother to feel at home and make my visits very pleasant experiences’. People living in the home felt that they could choose to do what they wanted during the day. For example, one lady described how she spent a lot of time away from the home visiting people and doing her own thing, others told the inspector how they liked to spend time in their rooms rather than joining in with activities. One person commented how she was always asked individually what she would like and the manager described how people could choose how often and when they wanted baths or showers. People living in the home thought that the food provided was of good quality, with nine out of ten people who returned surveys saying they always liked the meals in the home. Comments about the food included ‘lovely food, plenty of choice’, ‘nice – lovely fresh vegetables’ and ‘everything is perfect, not overdone or underdone’. A number of people described how they sometimes choose to eat in their room and another person described how they were brought a cup of tea in their room first thing each morning. One or two people felt that, although the food provided was good, that a little more variety would sometimes be nice. Observation of the home’s menus showed that a traditional range of wholesome meals are provided, although the menu’s provided did show some repetition. Discussions with the cook showed that individual needs (such as diabetic diets or other specialist dietary requirements) are provided when needed or requested. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in and visiting the home feel comfortable about approaching the manager or staff if they have a problem and are confident their concerns will be listened to. Staff are aware of how to report concerns or allegations. However, some amendments are needed to the home’s protection policies and procedures. This is important so that any allegations or suspicions are handled appropriately and people are protected fully. EVIDENCE: Comments made by people using and visiting the service included, ‘I always feel that staff and managers take my views seriously’, ‘I could talk to any member of staff if there was a problem’ and ‘I’ve never had to make a complaint’. A complaints procedure is in place and people felt that the manager and staff were all very approachable if there was a problem. Most staff have received training in the protection of vulnerable adults and were aware of how to report concerns or allegations. Policies and procedures covering the protection of people from abuse are in place. However, these need to be reviewed to make sure they provide clear information and guidance about handling and reporting allegations or suspicions of abuse. They should also include information about referring suitable staff for inclusion on the Protection of Vulnerable Adults (PoVA) list. This is a list of staff who are considered unsuitable to work with vulnerable people and helps to make sure that these people can’t get jobs with other care providers. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Mary’s Convent provides a traditional and homely place for people to live. It is kept clean and tidy and the gardens are well maintained, meaning that people have a pleasant and comfortable place to live. However, access to parts of the building are limited by steps and stairs, potentially making access difficult for some people without help from staff. EVIDENCE: St Mary’s Convent is an old building that was converted for use as a care home many years ago. As a result of this the care home is set out over several different levels and access arrangements vary around the building. For example, some bedrooms are easily reached by use of a passenger lift, while access to others require a combination of using the stair lift and climbing two or three stairs that are fitted with hand rails. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 17 Discussions with the manager about access arrangements indicated that she tries to make sure that people have a room that they can access and that any help or assistance needed with this is provided promptly. Discussions with people living in the home confirmed this. People confirmed that they had changed rooms when their mobility decreased or that they could always get staff to help them to their room when they wanted. Generally people felt that these arrangements were satisfactory and were happy with their rooms. The challenge for the manager will be balancing the limited access arrangements in the home with the changing needs of the people living at St Mary’s in the future. The home has a cosy and traditional feel, with the furnishings and fittings being traditional in style and in some cases quite old. However, everything was in working order and people living in the home liked the style of decoration, seeing this as one of the home’s strengths. A comment made by one relative to demonstrate this was, ‘St Mary’s creates a home from home place to live when own home living is no longer safe. St Mary’s is furnished in an old fashioned way, so like the home that the old have had to give up’. A new bath has recently been fitted and this was popular with the residents. However, some bedrooms have interconnecting doors that are not currently locked or sealed (although the position of some bedroom furniture does stop them being opened fully). This should be considered carefully in the interests of privacy. During the inspection the home was seen to be very clean and tidy and there were no unpleasant smells. People living in the home were happy with the laundry service and confirmed that staff were always well presented, clean and tidy, and wore gloves and aprons when appropriate. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Mary’s Convent provides a stable staff team with very good levels of staffing in the home. Staff receive training to help them do their jobs, but recruitment procedures need to be improved to make sure that people living in the home are protected from unsuitable staff. EVIDENCE: St Mary’s Convent employs a stable staff team, which provides care for the people living there. The home’s rotas show that high levels of staffing are provided and this was confirmed by discussions with the residents and staff. Comments included, ‘staff always listen and act when needed’, ‘there isn’t a high turn over of staff which adds to the stability of the care home’ and ‘staff are on hand all the time and would do anything for you’. Staff members were complimentary about the training provided, saying that they received regular training, including up dates in things like manual handling and more specialist training in areas like eye care and continence. A relative also confirmed that specialist training had been provided to help staff meet the needs of a new resident, ‘my mother has X disease (changed to protect identity) and was the first person to enter the home with this illness. Managers ensured that the proper treatment was given and arranged training St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 19 for staff to understand the illness and how it affected my mother’. All but two of the home’s staff have already achieved a National Vocational Qualification (NVQ) in care. Individual staff training records are kept in staff files, but it is recommend that the manager develops an overall staff training record or matrix that can be easily accessed and updated and will help to plan what training is needed more easily. The manager confirmed that new staff would be completing a ‘Skills for Care’ based induction and some information to assist with this was provided during the inspection. A random selection of staff recruitment records were inspected. These showed that in one case a new staff member had started work a considerable time before her Criminal Record Bureau (CRB) disclosure and one of her written references had been received by the manager. All of the required recruitment checks, including an enhanced CRB disclosure and two written references, must be carried out before new staff commence work in the home. This is very important to ensure that people are adequately protected from staff who are unsuitable to work with vulnerable people. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Mary’s Convent is managed by a suitable person and in a way that puts the people living in the home first. The financial interests of people living in the home are safeguarded and staff feel well supported by the management. The health and safety of people living and working in the home is protected by regular maintenance work and safety checks, although a new gas safety certificate is needed and hot water checks need to be extended to areas where full body immersion is possible. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the last inspection the manager of the home has changed. The new manager is registered with CSCI and has completed the Registered Managers Award. Staff and people living in and visiting the home were complimentary about the manager, who was described as ‘approachable’. Other comments made about the management of the home included, ‘capable management and staff carry their responsibility with care and good humour’ and ‘before going to St Mary’s my mother had had a couple of spells of respite in other care homes – neither of which were anywhere as good as St Mary’s. When I told the manager this her response was ‘as far as we are concerned everyone here is our mother and that is how we treat them’. A lovely ethos – St Mary’s is a special place’. The home holds meetings for residents and relatives every six weeks, giving people the opportunity discuss any issues or changes. The manager also operates an ‘open door’ policy, so that people can approach her at any time. People living in the home confirmed that they felt able to talk to the staff and manager about anything that was troubling them. Regular monitoring visits are undertaken by someone who does not work in the home, to make sure that it is being well run and that people are being well looked after. Arrangements are in place to help people manager their personal finances. These arrangements are flexible, depending on whether people want to look after their own money, have access to money at the home when they need it or be invoiced regularly for their personal expenditure. Records and receipts of all financial transactions are kept and a random check of these found them to be up to date and accurate. At the time of this inspection one of the Sisters at the convent was acting as appointee for two people living in the home, and bank statements and records of all transactions were available. Staff confirmed that they had staff meetings every three months, where they could discuss any changes, problems and make suggestions. Staff also felt that they could approach the manager or deputies at any time if they needed to. Records of formal staff supervision sessions were available in the staff records that were inspected. However, these records suggested that two staff had not received formal one-to-one supervision since October and August 2006. The national minimum standards suggest that staff should receive formal supervision six times a year. Random checks of maintenance records were carried out and showed that most routine maintenance and servicing work in the home was up to date. However, checking this took some time, as the maintenance records were disorganised and the manager couldn’t easily find them. The only outstanding issue was the renewal of the gas safety certificate that was due in December St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 22 2006. The manager was made aware of this during the inspection. A fire risk assessment was completed by a specialist company in April 2006 and staff receive fire training on a regular basis. At the moment routine checks are carried out on the hot water outlets in bedrooms, but this doesn’t include the communal baths and showers. The home needs to carry out regular safety checks of the hot water temperatures in any places where full body emersion is possible. This is important because it checks that thermostatic valves fitted to baths and showers are functioning properly and reduces any risks of serious scalding. St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 23 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP1 & OP2 Regulation 5A & 6 Requirement The home’s Statement of Purpose, Service User’s Guide and contracts must be reviewed to ensure all the required information is included and accessible. This particularly relates to information about fees and facilities in the home. Care plans must cover all of the areas relevant to people’s care and must be kept fully up to date. The policies and procedures covering abuse must be reviewed to provide clear information and guidance about responding to suspicions and allegations of abuse. This should include referring appropriate staff for inclusion on the PoVA List. All new staff must complete the required recruitment checks, including a new Criminal Records Bureau disclosure, before they start work in the home. A new gas safety certificate must be obtained for the home. Timescale for action 31/07/07 2. OP7 15 31/08/07 3. OP18 13(6) 31/07/07 4. OP29 19 & Schedule 2 13)4)(a) & (c) 30/06/07 5. OP38 30/06/07 St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 25 Regular checks of hot water temperatures must be carried out where full body immersion is possible (for example, hot water outlets on baths and showers). 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 OP9 Good Practice Recommendations Medication that has been discontinued should be recorded on or removed from the medication administration record (MAR). The date and amount of new medication entering the home should always be recorded on the medication administration record (MAR). It is recommended that the home looks at ways of increasing the variety of their routine menus. The interconnecting doors between bedrooms should be locked or permanently sealed in the interests of privacy. It is recommended that a training matrix or spreadsheet of all staff and the training they have completed (including dates so that the need for up date training can be easily identified) is developed. The manager should improve the organisation of records in the home, to ensure that they can be easily located when needed. It is recommended that formal staff supervision takes place at least six times each year. 2. 3. 4. OP15 OP19 OP30 5. 6. OP31 OP36 St Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Mary`s Convent DS0000007504.V336479.R01.S.doc Version 5.2 Page 27 - 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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