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Inspection on 11/05/09 for St Paul`s Convent

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

This inspection was carried out on 11th May 2009.

CQC found this care home to be providing an Excellent service.

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.

Annual service review Name of Service: St Paul`s Convent The quality rating for this care home is: The rating was made on: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Ann Farrell Date of this annual service review: 1 1 0 5 2 0 0 9 Annual Service Review Page 1 of 9 Information about the service Address of service: The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL 01214156100 01214720603 care@sellypark.org Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: 1 place for the provision of nursing care 35 places for the provision of nursing care Sisters of Charity of St Paul the Apostle Number of places (if applicable): Under 65 Over 65 0 0 36 36 36 Sisters of the Order only may be cared for in the home That the manager successfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: The manager retired on 31st January 2009 and the organization is in the process of recruiting a new manager. Currently one of the nurses who has worked in the home for a number of years is acting up as manager. Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Annual Service Review Page 2 of 9 St Pauls infirmary is located within the Convent of St Pauls in a pleasant residential area of South Birmingham. The infirmary consists of a four-storey building attached to the main convent and only caters for Sisters of St Pauls who have nursing needs. The home provides twenty-four hour nursing care for the sisters ranging from long term nursing needs to short stay rehabilitation. The building is very spacious with a range of reception rooms and offices on the ground floor. It is set in its own beautiful, extensive grounds, which are very well maintained and easily accessed by residents from the infirmary. All residents have a single bedroom that is equipped with a wash hand basin and call bell to summon assistance if required. There is a passenger lift that gives access to all floors and a range of mobility aids and handling equipment to assist the sisters who have mobility problems. There is a house within the grounds for family members of the Sisters to stay overnight when visiting their relatives. The building is well maintained and cleaned to a high standard with easy access to local amenities. The service users for whom the Nursing Home is registered are all members of a Religious Congregation, a Registered Charity, to which all earnings, pensions etc., are covenanted. The charity is responsible for all expenses attached to the upkeep and running of the home. Information about the services and facilities are available on entering the convent enabling prospective residents to make an informed choice about moving into the home. Annual Service Review Page 3 of 9 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included; The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Any relevant information from other organizations. What has this told us about the service? The service sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clearly presented and gave us all the information we required about the improvements made over the past year and their plans for the future. They told us about how they had met Equality and Diversity, which included: St. Pauls is unlike other Care Homes, as they specifically nurse the elderly members of St. Pauls Religious congregation. The Home therefore meets the specific needs of the Religious Sisters. The Philosophy of the Home ensures that staff are aware of the spiritual needs of the Sisters as well as their physical needs. Dignity and privacy of the Sisters is maintained ensuring there is no discrimination due to disability religion or belief. The Sisters may be in the Home until the end of their natural life and therefore have the right to expect security in their physical, religious and psychological well-being. The Care Home allows the Sisters to continue to live a structured religious life within the limits of their strength and inclination to keep them happy and content. All the staff have the opportunity to undergo training about the works of religion plus Equality and diversity in line with the philosophy of the Home, which is orientated to the particular care of Religious Sisters. The home has told us of improvements they have made over the past twelve months and these include; Staff have received a variety of training from the Primary Care Trust plus Birmingham City Council, Birmingham Care Development Agency and in house training in areas such as Safer People Handling, First Aid, Health and Safety, Dementia training, Mental Capacity and Deprivation of Liberty, Deaf awareness, Tissue viability, Ear-syringing, Food-safety, Nutrition, Communication, medication and Continence etc. ensuring staff have the skill and knowledge to meet the Sisters needs. One member of staff has been trained in Phlebotomy ensuring the Sisters medical needs are met. Communication has been improved between staff and the Sisters by doing activities together e.g. charity fund raising events plus Christmas and New Year parties. The Sisters ability to lead as normal a life as possible within the confines of their abilities Annual Service Review Page 4 of 9 has developed; enhancing their well-being. As a result of Dementia training staff are aware and able to meet the Sisters needs in a more person centered manner. Staffs awareness about Health & Safety issues has improved as a result of training leading to a safer environment for everyone living and working in the home. There has been regular auditing of medication ensuring the Sisters receive the medication prescribed to them. Links with the Primary Care Trust and training agencies have been developed further leading to improved outcomes for the Sisters living in the home. The menus have been reviewed and have greatly improved the choices and presentation of food for the Sisters living in the home. Staff training has improved the quality and safety of food hygiene standards. The Dining Room decor has been upgraded with matching tableware and centerer flower decorations, enhancing the dining experience of the Sisters living in the home. The contents of the Music and Movement classes have improved and have been greatly favored by the Sisters. Email and mobile phones have been introduced to the Sisters, which has improved communication with relatives and friends. Monthly meetings have helped to improve communication and address any areas of concern. The Mobile Clothing Shop has improved the variety and standards of clothing, so there is a greater choice for the Sisters living in the home. Activities have increased at the request of the Sisters to include bingo, Christmas and New Year parties plus staff and Service User get-togethers, so quality of life and stimulation is improved. Staff have attended training on Deprivation of Liberty and Safeguarding ensuring peoples rights are safeguarded. Policies have been reviewed regularly ensuring staff have up to date guidance to practices within the home. Mental Capacity plus Equality and Diversity training are ongoing, developing staff knowledge ensuring the Sisters are supported appropriately. Bedrooms have been re-decorated, old damaged furniture has been replaced, anti slip flooring has been provided in some areas, the guttering has been cleaned, the old boiler has been replaced for a condensing boiler, gas pipe work to the gas cookers has been replaced. Also an additional fire panel has been linked to the main house, which indicates if an alarm is set off in the main house, improving the environment and safety for people living in the home. Shelves have been fitted in some of the rooms as a result of requests from people living in the home, demonstrating people are listened to and their comments taken seriously. Shelving and additional kitchen units were fitted to the Kitchenettes on the top floor, a new filing cabinet has been installed in the first floor office and key cabinets fitted. New CCTV (night vision) cameras have been installed for the safety and security of people living in the home. The old smoking room has been utilised for additional locker/changing room space, so enhancing facilities for staff. There have been improvements in infection control to include; Birmingham City Council cleans the medical waste containers on a regular basis; hand gel dispensers have been fitted to each floor and re-cycling glass bins have been installed. Some staff have gained training as a trainer, so they can disseminate the training to other staff in the home ensuring all training needs are met. Continence Care has improved as a result of staff attending training.A number of trained staff have been trained in Ear Syringing, which helps to benefit the Sisters living in the home. In house Peg Feed Co-ordinators have been appointed to ensure artificial feeding is well managed and people receive adequate nutrition. Management continue to provide necessary equipment following risk assessment to ensure peoples needs are met. They have told us about the plans they have for the next twelve months and these include; They hope to raise awareness with the Primary Care Trust in order to improve the chiropodist service within the Home. The will continue to assess and assist the Sisters in order to meet their regular needs of daily living and their special needs to the Annual Service Review Page 5 of 9 best of staffs ability. They will continue to keep staff updated through regular training to ensure staff are up to date and meet peoples needs in a person centred manner. The will Continue three monthly audits with the PCT and Birmingham City Council ensuring a high standard of care is maintained and the Sisters needs are met effectively. They plan to refurbish the sluice rooms ensuring infection control procedures are maintained. The staff room will be re-decorated and staff lockers fitted to ensure suitable facilities for staff. They will purchase essential equipment as needed to meet peoples needs and all equipment will be maintained to ensure safety within the home. They will continue to build relationships with the Multi-Disciplinary team to ensure good communication and continuity of care. They will monitor and make changes in line with new legislation and guidance to ensure the home is up to date and all staff will be updated to ensure they comply with new legislation. They will continue to monitor the standards of care and improve services as required to ensure a person centered approach involving the Sisters ensuring their needs and preferences are met. They will continue to promote individuals rights and support them to improve the quality of their living. They hope to fit non-slip Microban replacement safety flooring to some rooms and upgrade office furniture They will continue to ensure a good staff working environment with good communication links between staff members, people who live in the home and members of the multi-disciplinary team to ensure effective outcomes for the Sisters. They hope to purchase profiling beds for all people living in the home enhancing comfort and enabling easier moving and handling procedures. They will strive to continue to provide good service and happy environment for people living in the home, their families and staff. We have received surveys from six people who live in the home, eight staff and two health professionals who visit the home. People who live in the home told us; Everyone told us they had received a contract and they received enough information about the home before they moved in. They all told us they always/usually received the care and support they needed. They all told us they always received the medical support they needed. Three people told us there is always/usually staff available when they need them and the staff listen to them and act upon what they say. Six people told us they always received the medical support they required. Six people told us there were always/usually activities that they can take part in. Three people told us they always like the meals, two told us they usually like the meals and one told us they sometimes like the meals provided in the home. They all told us they knew who to speak to if they were not happy and how to make a complaint if there were any concerns. They all told us the home was always fresh and clean. Comments included; Very good care. The doctor calls every week and more often if needed. I am very happy at St Pauls. Meals very good, a choice of menus at lunch and tea. Would appreciate some home baking e.g. scones with cup of tea. Meals have definitely deteriorated of late. Usually the meat is not cooked properly. Visits from a chiropodist more frequently would be appreciated. The old matron is very much missed. Staff told us Eight people told us they are always given up to date information about the needs of people. Eight people told us the employer carried out checks before they started Annual Service Review Page 6 of 9 working in the home. Eight people told us the induction training covered everything they needed to know and they were given regular training to keep them up to date. Five people told us they met regularly/often with the manager to give them support and three told us they meet sometimes with the manager for support. Eight people told us they know what to do if any concerns are raised. Eight people told us there is always/usually enough staff to meet individuals needs. Eight people told us they felt they had the right support, experience and knowledge to meet individuals needs. They told us how the service does well; Cater for the religious and social needs of service users. Meeting service users spiritual needs. Maintaining high standards of care. Maintenance of a clean working environment . Support to staff. Keeps a very good, clean, supportive, helpful home. Working in care for over 18 years this is the most professional and caring environment I have worked in. I feel this institution is well organised and well staffed smooth running home. I am very happy with the way the nursing home is run. A friendly atmosphere, very high standards of care provided. They told us how the service could do better; Maybe introduce a few activities or outings for the service. Provide a range of activities that would interest the Sisters in the nursing home and enable Sisters to have opportunities to go into the local community. Facilitate occupational therapists/other therapists etc to come into the home and offer appropriate support to the Sisters needs. Enable/encourage volunteers to visit the Sisters on a regular basis. The health professionals told us; Staff seek advice and follow recommendations to ensure individuals health needs are met. Individuals health care needs are met by the service. Care staff always respect individuals privacy and dignity. The service supports individuals to live the life they choose. The care staff have the right skills and experience to support individuals social and health care needs. They told us staff did well in assessing and referring individuals They told us staff could improve by implementing first line dietary advice before referring individuals. Management have responded telling us the chiropody service has now improved and the catering department respond to all complaints or comments made about the food. We have received no complaints about the home since the last key inspection. The home told us they received one complaint, which they responded to within 28 days and it was upheld. They told us they have not made any safeguarding referrals since the last key inspection. The home had kept us informed about relevant important information and the action they took to address them through the notifications forwarded to us. The registered manager retired on 31st January 2009. Currently there is an acting manager in place, who has worked at the home for a number of years, whist they are recruiting a new permanent manager. We have looked at all relevant information available and in our judgement the home is still providing a good service. What are we going to do as a result of this annual service review? Annual Service Review Page 7 of 9 We are not going to change our inspection plan, and will do a key inspection by 20th June 2010. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 8 of 9 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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