CARE HOMES FOR OLDER PEOPLE
St Mary`s Convent & Nursing Home Burlington Lane Chiswick London W4 2QE Lead Inspector
Robert Bond Unannounced Inspection 6th January 2006 10:00 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 & Nursing Home DS0000010958.V273855.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 & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Mary`s Convent & Nursing Home Address Burlington Lane Chiswick London W4 2QE 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) 020 8994 4641 020 8995 9796 Society of St Margaret Ms Elizabeth Anne Smith Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home to provide general nursing care to service users over the age of 60 Service Users to include 38 beds providing care with nursing and 23 beds providing personal care. 7th September 2005 Date of last inspection Brief Description of the Service: St Marys Convent is a listed building, situated in Chiswick, originally built in 1896. It is a care home for nursing and personal care and is registered to provide care for sixty one service users. The Registered Providers are the Anglican Sisters of the Society of St. Margaret. The home is registered as a Company limited by guarantee and is a Charitable Organisation. Major refurbishment works have taken place to replace the existing wards with single en suite bedrooms. A new kitchen, additional sitting area and dining room, a physiotherapy room, and a hairdressing room have been added to the accommodation. There is also Chapel within the building. The accommodation is situated over two floors. The ground floor accommodates thirty eight service users requiring nursing care and the first floor accommodates twenty three service users requiring personal care. There are a total of fifty five single and two double bedrooms with en-suite facilities, which have the minimum of a toilet and wash hand basin. Some en-suite rooms have showers or baths. All bedrooms have been decorated and furnished to a high standard and there are telephone connections for private use. Portable telephones are also available. The communal areas are spacious and accessible to wheelchair users. The staff team includes a Responsible Individual, the Registered Manager, Registered Nurses and a Physiotherapist. Several members of the staff group are resident at the home. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of the inspection year. The Inspector concentrated upon assessing the key standards of the National Minimum Standards (NMS). He assessed 26 standards and found that the outcomes of 24 were fully met, whilst 2 were partly met. The Inspector made 1 requirements and 1 recommendation. The Inspector toured the home in the company of the Registered Manager, met the Managing Director and various members of staff, sisters of the convent, service users and one relative. The Inspector also examined in detail (case-tracked) three service users’ care files, and three staff recruitment files. All the service users spoken to expressed satisfaction with the home, except that one complained to the Inspector about a laundry basket that had been kept outside her room. The basket had already been moved to another location. What the service does well:
The home is well maintained, clean and attractively decorated and furnished. The grounds are also very attractive. Records, policies and procedures were in almost very case uptodate and well kept. The home is fully staffed, and the only vacancy existed because that bedroom was being refurbished. Staff are well trained and well supported. Service users told the Inspector how happy they were living in the home. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 6 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 & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 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 the following standard(s): 1, and 3 The outcome for NMS1 is partly but not fully met. The outcome for NMS3 is fully met. EVIDENCE: NMS 1. Part of the means by which prospective service users, their family or their care manager knows whether the care home is likely to be able to meet their needs is the information contained on the registration certificate that the CSCI issues each registered care home. The Inspector found that the certificate at St Mary’s Convent was placed on the wall of an office where it would not normally be seen by visitors or service users. It must therefore be relocated into a more public area such as the entry hall. Recommendation 1. NMS3: The inspector examined the care files of three recently moved in service users and found that appropriate assessments of need had been undertaken prior to them moving in. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The outcomes are all fully met. EVIDENCE: NMS 7 and 8: The Inspector found that each of the three care files examined, contained detailed and appropriate care plans that included health care needs. Risk assessments were on file and they were regularly reviewed. Care plans were also reviewed. NMS9: The Inspector examined a sample of medication records and these were in order. NMS10: Service users are accorded privacy as noted by the Inspector as he toured the property. One service user confirmed that she had a lockable drawer to use for valuables, and that she held a key to her bedroom. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 10 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): 12, 13, 14 and 15 The outcomes for all these standards are fully met. EVIDENCE: NMS12: The day of the inspection coincided with the Christian festival of Epiphany. A service was being held in the home’s chapel during part of the inspection and many of the service users attended. The Registered Manager however reported that attendance was not compulsory and that the religious views of non-Anglicans were respected. NMS13: The Inspector saw a programme of activities that included visits out of the home such as swimming, and concerts in the home. He met a relative of a service user in the home. NMS14: A service user can choose not to attend church services, and there is a choice of food at mealtimes. NMS15: The Inspector examined the menu of the week. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 11 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): 16 The outcome is fully met. EVIDENCE: The Inspector noted that the complaints procedure had been amended to provide up to date contact details for the CSCI, and that a copy was included in the welcome pack for new service users and their families. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 12 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): 19, 20, 21, 22, 23, 24, 25, and 26 All the outcomes to these standards are fully met. EVIDENCE: The Inspector toured all parts of the home including several bedrooms at the invitation of their occupants. The home was seen to be clean, odour-free, well decorated and furnished throughout. No maintenance issues were identified other than a dirty extractor fan in a bathroom. The only potential safety issue identified was that the temperatures of a refrigerator in the refectory were not being checked, recorded and adjusted if necessary. Requirement 1. Bathrooms are particularly well equipped with specialist baths. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 13 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): 27, 28, 29 and 30 All the outcomes are fully met EVIDENCE: The Registered Manager reported that the staff team was complete but that additional management posts were going to be created. Sufficient staff appeared to be on duty at the time of the inspection. The Registered Manager reported on the successful completion of a variety of training by care staff at the home. The Inspector checked three staff recruitment files and found that appropriate references had been taken and appropriate checks made. All had CRB certificates but one had not been obtained by the home but by her previous employer. The Inspector was shown evidence that a new CRB on this employee had been sent for. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 14 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): 31, 33 and 38 The outcomes for Standards 31 and 33 are fully met, that for Standard is 38 is not fully met due to the uncertainty whether a refrigerator is operating at the correct temperature to maintain safe environmental health conditions. EVIDENCE: NMS31: The home is managed by a Matron who has been approved and registered as the Manager by the CSCI. NMS33: The Inspector was provided with a copy of the home’s Business Plan for 2006/07. The Inspector commends the style and content of this plan. NMS38 As reported above, the operating temperatures of the refrigerator in the refectory must be checked. Requirement 1. St Mary`s Convent & Nursing Home DS0000010958.V273855.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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 3 3 3 3 3 3 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 x 3 x x x x 2 St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 16 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 OP38 Regulation 23 (2) © Requirement The operating temperatures of all refrigerators must be regularly checked. Timescale for action 01/02/06 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 OP1 Good Practice Recommendations The Registration Certificate should be displayed in a position where visitors to the home can easily read it. St Mary`s Convent & Nursing Home DS0000010958.V273855.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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