Inspection on 19/07/05 for St Mary`s Convent

This inspection was carried out on 19th 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 Mary`s Convent 18/04/07

St Mary`s Convent 08/12/05

St Mary`s Convent 16/11/04

St Mary`s Convent 11/05/04

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 Marys Convent Ebchester Consett County Durham DH8 0QD Lead Inspector Belinda Parker Unannounced 19 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Marys Convent Address Ebchester Consett County Durham DH8 0qd 01207 560288 01207 560288 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 Order of the Good and Perpetual Succour Sister Teresa Mary Turner CRH Care Home only 16 Category(ies) of OP Old age, not falling within any other category registration, with number of places None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 November 2004 Brief Description of the Service: St Mary’s Convent is a well-established care home for 16 Older Persons. The home has chosen only to accommodate female service users. The home is run by the nuns of The Order of the Good and Perpetual succour and has lay staff as part of its staffing complement.All accommodation is single occupancy and many bedrooms have en-suite wcs. There is a large domestic style dining room on the ground floor, two separate lounges and an entrance/sun lounge. The home is well equipped with a range of wcs and bathrooms/showers and meets National Minimum Standards. The home consists of a ground floor, mezzanine and first floor, access is via two separate sets of stairs; one having a stair lift, and a 5 person vertical shaft lift is provided between ground and first floor.The home is located on the edge of Ebchester with good road links and access to public transport services. It is surrounded by extensive, well cared for gardens with good access for service users and seating is provided at various locations. The home is bordering on pasture and woodland owned by the convent and affords service users attractive views. There is satisfactory parking space for visitors to the home. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 19/7/05 over a period of 5 hours. During the inspection discussion took place with management, service users and a relative. What the service does well: What has improved since the last inspection? What they could do better: None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 6 In general the quality of furniture and furnishings are good. It was observed while walking around the home that an area of carpet in the main foyer and on the stairs was frayed which may put service users, staff and other visitors at risk of trips or falls. 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. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 The home’s Statement of Purpose, Service User Guide and the pre - admission procedures are good providing prospective service users with information to make an informed decision as to whether they wish to live in the home. EVIDENCE: The home has an up to date Statement of Purpose and Service User Guide. This provides prospective service users and their family with information about the home and the service offered. Evidence was available to show that a full pre – admission assessment is carried out to ensure the home has the capacity to meet the needs of the service user. The deputy manager said service user’s family is involved in the process. Each service user is provided with a Statement of Terms and Conditions of residency. This document sets out the terms of the service provision. The deputy manager had evidence available to show that the service users’ or their family sign as to there agreement. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 9 The deputy manager said all prospective service users and their family are invited to visit and spend time in the home prior to admission. This allows service users’ to decide if they wish to move in. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 The care planning process is clear and up to date. This provides staff with the necessary information to adequately meet the needs of the service users. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. Personal support in this home is offered in a way to promote and protect service users’ privacy, dignity and independence. EVIDENCE: Evidence was available to show that the plan of care was generated from a full pre – admission assessment process , which provided staff with the information required to meet the needs of the service users. The care plans are reviewed regularly to meet the changing needs of the service users. The policy and procedure for the receipt, recording, storage, handling and disposal of medication for the protection of service users is good. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 11 The deputy manager is able to demonstrate that in the event of illness or death service users and the wishes of their family are respected. A service user who was ill said staff respect her privacy and look after her very well. Staff where observed interacting with service users and listening to what support the service user required. The deputy manager said staff support service users and encourage them to maintain their independence. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Service users are supported by staff to lead an independent and fulfilling lifestyle of their choice in the home and the community. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users spoken to said the routines of daily living in the home were flexible and said they could follow the lifestyle of their choice. One service users said “ I join in some activities but I like the privacy of my own room”. One service user said she attends coffee mornings and a lunch club in the local community. Another service user waiting to have her hair done said, “ A lady has to keep up her appearance ”. One service user said she likes to keep in touch with her family and uses the pay phone regularly to do this (The payphone was not working on the day of the inspection). The deputy manager said service users are encouraged to look after their own finances. Where the service user lacks capacity the family or an advocate acts on their behalf. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 13 Service users spoke positively about the quality and choice of food served in the home. Comments from service users’ included, “ Food excellent, my tummy does not object to anything”, “ Good wholesome food ”. The cook said service users are given a choice of main meals, but will prepare whatever the service users’ wish to eat. Sometimes the requests for other foods is many, but the cook meets all requests if she can. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: This standard section was not assessed at this inspection. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The overall quality of furnishings and fittings in the home are good with the exception of one identified area that may put service users, staff and visitors at risk. EVIDENCE: On touring the home it was observed that the home provides a comfortable environment with a range of communal seating areas for service users to sit. Externally the grounds are tidy and well maintained. Service users spoken to said they were satisfied with their personal accommodation. The furniture and furnishings in the home are domestic in style. Service users said they are able to have their own bits and pieces in their rooms. A relative spoken to said the accommodation is very comfortable and clean. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 16 It was observed that an area of carpet in the foyer and on the stairs was frayed and well worn. This could put service users, staff and other visitors at risk of trips or falls. The home has a range of disability equipment in place to meet the collective needs of the service users. One service user said she had a room on the ground floor, which adequately meets her needs. The home was commendably clean and a policy and procedure was in place to prevent and control the spread of infection. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: This standard area was not assessed at this inspection. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: This standard area was not assessed at this inspection. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 20 NA 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 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. Refer to Standard 19 Good Practice Recommendations The registered person should consider replacing the frayed areas of carpet in the foyer and on the stairs. None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 None B54 S7504 St Marys Convent V232427 190705 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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