This inspection was carried out on 8th December 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.
CARE HOMES FOR OLDER PEOPLE
St Mary`s Convent St Mary`s Convent Ebchester Consett Durham DH8 0QD Lead Inspector
Belinda Parker Unannounced Inspection 8th December 2005 09:00 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.V257563.R01.S.doc Version 5.0 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.V257563.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Mary`s Convent Address St Mary`s Convent Ebchester Consett Durham DH8 0QD 01207 560288 01207 560288 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 Sister Teresa Mary Turner 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.V257563.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th July 2005 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. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 8/12/05 over a period of 5 hours. During the inspection we spoke to service users, staff and a relative. A number of records were examined. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 7 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This standard section was not assessed at this inspection. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 8 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 the following standard(s): EVIDENCE: This standard section was not assessed at this inspection. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 9 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 the following standard(s): EVIDENCE: This standard section was not assessed at this inspection. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 10 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 the following standard(s): Standards 16, 17 and 18 There is a clear complaints process in place. The home ensures service users are safe from harm or neglect and their rights are protected. EVIDENCE: The home has a complaints procedure in place. The complaints procedure is displayed in the foyer and contained in the Service Users Guide for service users information. There have been no recorded complaints since the last inspection. During the recent general election arrangements where put in place to enable service users if they so wished to participate in the electoral process. Evidence was available to show that the majority of staff had attended POVA training. The manager said arrangements are being made for two new members of staff to attend this course. To ensure all staff have an awareness of the process in protecting service users from abuse or harm. A relative spoken to during the inspection said, “ It is the type of place I would like to live in when I get older”, “ The care is exceptional”, “ The quality of the food superior to other homes I have been in”. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 11 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 the following standard(s): Standard 19 New carpet has enhanced the environment and comfort standards for the people who live in the home. EVIDENCE: Since the last inspection new carpet has been laid in the foyer, ground floor corridors, stairs and landing. This has increased comfort standards for the people who live in the home. A service user spoken to said, “ The new carpet is really soft under my feet”. A new and more efficient chair lift has been installed for the transfer of service users to the upper floor. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 The home has robust recruitment procedures in place to ensure the protection of service users. Training available equips staff with the necessary skills and abilities to enable them to meet the needs of the people who live in the home. EVIDENCE: Staffing levels in the home are adequate to meet the individual and collective needs of service users. The manager said the home is continuing with the programme on NVQ2 training to ensure all care staff have the skills and abilities to carry out a good standard of service for the people who live in the home. Staff training records examined showed that all mandatory training had been completed in this current year. Staff personnel files examined showed that the home followed a thorough recruitment process. To ensure the people living there were protected from harm or neglect. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 37 and 38 Management arrangements in the home are good. Quality systems and quality monitoring ensures the efficient running of the home and the safety of service users, staff living and working in the home and visitors to the home. EVIDENCE: The current manager has many years experience in working and believes in an open door policy, promoting team work and good channels of communication, for staff and service users. The home has effective quality assurance and quality monitoring systems in place. To ensure the effective and efficient running of the home. Evidence was available to show that service user meetings are held regularly to enable service users to make their views known.
St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 14 Money held in the home on behalf of service users was evidenced to be recorded accurately and is stored individually for each in an appropriate locked facility. Evidence was available to show that staff receives formal supervision from their line manager on a regular basis. This process covers all aspects of care, philosophy of care and career development. The manager said this process is important to ensure staff are performing within their role and responsibility. And have the necessary skills and abilities to meet the needs of the people living in the home. Records examined during the inspection were accurate and up to date. Health and safety records examined showed that major systems and equipment was maintained to ensure the safety of service users, staff and visitors. St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 15 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 3 3 St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations St Mary`s Convent DS0000007504.V257563.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Darlington Area Office 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
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