Inspection on 07/09/05 for St Mary`s Convent & Nursing Home

This inspection was carried out on 7th September 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 & Nursing Home 20/02/07

St Mary`s Convent & Nursing Home 06/01/06

St Mary`s Convent & Nursing Home 16/02/05

St Mary`s Convent & Nursing Home 03/08/04

St Mary`s Convent & Nursing Home 09/02/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE St Mary`s Convent & Nursing Home Burlington Lane Chiswick London W4 2QE Lead Inspector Jean Bovell Unannounced 7 September 2005 th 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. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 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 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 G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2005 Brief Description of the Service: St Mary’s Convent is a listed building, situated in Chiswick. 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 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 three single and four double bedrooms with en-suite facilities, which have the minimum of a toilet and wash hand basin. Some ensuite 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 G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was unannounced inspection, carried out on 7th September 2005 between 11.30 am and 4.30 pm. The Registered Provider and the Registered Manager were present, and assisted the Inspector throughout the inspection. The Inspector spoke to service users individually and also within a group setting. Discussions were held with four visiting relatives and friends and with three members of the care staff. Records and documents were examined. A tour was undertaken throughout the home and its surrounding gardens. Observations were carried out. Staff members, service users and visitors reported positively about the level of support and quality of care provided at the home. Overall the home was found to be organised and well run. The environment was safe, pleasant and caring. What the service does well: The home was well maintained and hygienically clean throughout. The surrounding gardens and patio areas were in good order. All records, policies and procedures examined at the time of the inspection were satisfactorily kept and up to date. Staff members who spoke to the Inspector expressed satisfaction with the level of training, supervision and support provided at the home. Members of the care support staff were observed to be attentive and competent in meeting the needs of the service users. The service users appeared happy, appropriately dressed and comfortable within their environment. Those who spoke to the Inspector confirmed that they received a high standard of care at the home. The overall indicators were suggestive of the home being committed to safeguarding and promoting the health, welfare and safety of the service users, within an environment that was pleasant, lively and homely. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 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 G61-G10 s10958 St Marys Convent v214289 070905 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 St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 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) 3 and 6. A needs led assessment is carried out on all prospective service users prior to admission. EVIDENCE: The home’s policy on admissions was in place. The Registered Manager confirmed that a pre-admission assessment is undertaken in relation to all prospective service users. The home, relatives, social workers and where appropriate, medical professionals, were involved in the assessment process. Prospective service users were invited to visit the home prior to admission and were initially placed on a month’s trial period after which a review would be convened. A letter confirming the home’s capacity to meet a service users assessed needs is issued prior to admission. The home did not provide intermediate care. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10. The personal, social and health care needs of the service users are identified within care plans and service users are treated with respect. EVIDENCE: A sample of care plans was viewed. These contained separate assessments of personal, social and health care needs. Appropriate action plans and set goals had been put into place. Service users received access to GPs, Chiropodists, Physiotherapists and other medical professionals when required. The Inspector was advised that medical professional also held regular surgeries at the home and that there was a resident Physiotherapist. Medication kept at the home was satisfactorily stored, administered and documented. Several service users were self-administering their medication at the time of the inspection. The service users who spoke to Inspector reported that their privacy and dignity were respected at the home. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15. A variety of indoor and outdoor activities are facilitated by the home and contact with relatives and friends are encouraged. Nutritional meals are provided and service users are able to make choices. EVIDENCE: The records indicated that varied and interesting indoor and outdoor activities were organised for the service users. These included bowls/skittles, musical movement, board games, bingo, tea parties, day trips and holidays. The home owned two mini-buses and a van. All were wheel chair accessible. Service users expressed interest and enthusiasm about the variety of activities in which they were able to participate. There is a Chapel at the home where daily Church of England Services are held. The Registered Provider confirmed that service users of all religious faiths were admitted at the home and that support was offered to those who wished to attend alternative church services within the community. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 11 Family contact was encouraged at the home and an open visiting policy was in place. Discussions were held with two family members and two friends who were visiting the home at the time of the inspection. All were happy with the quality of care provided at the home. The Inspector was advised that service users were able to maintain a large degree of independence and were able to go and come as they wished. Service users chose what to wear, eat, when to get up in the morning or go to bed at night. Service users were observed to move freely and comfortably around the home during the inspection. Bedrooms viewed reflected personal choices and contained individual locks. Three cooks were employed by the home and the menu indicated that varied and nutritional meals including salads were being served. Service users reported that they were offered a choice of very good cooked meals. Snacks and drinks were readily available and that breakfast - which could be cooked if requested, was always served in their bedrooms. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 12 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) 16 and 18. The home’s policy and procedures on Complaints and the Protection of Vulnerable Adults are in place. EVIDENCE: The home’s policy and procedures on Complaints were clearly and appropriately detailed and were accessible to the service users and their relatives. One complaint was made to the home by a relative on behalf of a service user following the last inspection. The complaint was appropriately investigated and concluded. The complaint was, however, eventually withdrawn. The home’s policy on the Protection of Vulnerable Adults was satisfactory. Training Certificates indicated that training on Adult Abuse had been delivered to members of the care support staff. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 13 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 and 26 The environment within the home is safe, clean and hygienic. EVIDENCE: The home was well maintained and hygienically clean throughout. Appropriate risk assessments had been carried out. The overall environment was safe, pleasant and homely. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 14 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) 27,28,29 and 30. The home’s recruitment policy was in place. A rolling training programme ensures that regular and appropriate training are being delivered to members of the care support staff. EVIDENCE: The home’s Recruitment and Retention Policy was satisfactory. Ninety-one members of staff were employed. These included sixty-four care support workers and thirteen Registered Nurses. The records indicated that new members of staff received induction training. A rolling training programme and training certificates seen at the time of the inspection confirmed that further appropriate training had been delivered, including Moving and Handling, Fire Safety, Adult Abuse and Incontinence. An appropriate number of care support staff members were on duty at the time of the inspection. They were observed to be attentive, and responded competently to the needs of the service users. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 15 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) 33,35 and 38. The home is run in the best interests of the service users and their health, safety and welfare are being protected. EVIDENCE: Hounslow’s Manual on the Protection of Vulnerable Adults was in place at the time of the inspection. Records viewed indicated that up to date health and safety checks had been undertaken. These included tests in relation to the water system, temperature and hygiene. Fire safety, emergency lighting, portable appliances and gas and electrical maintenance checks were also in order. Appropriate risk assessments relating to safety issues around the home had been carried out. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 16 The evidence gathered from observation, records, policies, discussions with staff, services users and visitors, suggested that the home was focused on ensuring the best interests of the service users were being promoted. The Inspector was advised that the home did not hold financial responsibility for any of the service users. St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 17 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 x x 3 x x 3 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 4 COMPLAINTS AND PROTECTION 3 x x x x x x 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 18 NO 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 Good Practice Recommendations St Mary`s Convent & Nursing Home G61-G10 s10958 St Marys Convent v214289 070905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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. 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