Inspection on 20/06/07 for St Paul`s Convent

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Paul`s Convent 11/05/09

St Paul`s Convent 21/02/06

St Paul`s Convent 23/08/05

St Paul`s Convent 19/01/05

St Paul`s Convent 29/07/04

St Paul`s Convent 04/11/03

St Paul`s Convent 14/05/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE St Paul`s Convent The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL Lead Inspector Ann Farrell Key Unannounced Inspection 20th June 2007 08:00 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 Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 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 Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Paul`s Convent Address The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL 0121 415 6100 0121 472 0603 care@sellypark.org 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) Sisters of Charity of St Paul the Apostle Sister Eileen Frances O’Gorman Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 36 Sisters of the Order only may be cared for in the home 35 places for the provision of nursing care 1 place for the provision of nursing care That the manager successfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 23rd August 2005 Date of last inspection Brief Description of the Service: 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. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over one day commencing at 7.45am and no one was aware of the visit until the time of the inspector arrival. The registered manager and deputy manager were available for the duration of the inspection. Information to inform the inspection included a tour of the building sampled resident’s files and other documentation in relation to the management of the home. Case tracking was undertaken in respect of three residents, which included discussion with the resident, inspection of their room, any equipment used to meet their needs plus records in respect of care, medication, accidents, finances etc. to determine care from the time of admission. Direct and indirect observation was also used, as some residents were not able to communicate verbally. Ongoing discussions throughout the inspection process took place with the manager and deputy manager. The inspector also met with the Mother General (the responsible individual for the home) for the feedback session at the conclusion of the inspection. During the fieldwork the manager, deputy manager, four members of staff, eight sisters currently residing in the infirmary, the G.P. and a visitor were spoken to in order to receive feedback about the quality of care provided. In addition eight comment cards were received from the sisters prior to the inspection. All the feedback was very positive and one sister stated, “ I would have to look very hard to find anything to complain about”. Information was received about various aspects of the home in the pre inspection questionnaire to assist with the process of inspection. The high standards seen at previous inspections have been maintained, and the staff of St. Paul’s Convent Infirmary are commended. What the service does well: St. Paul’s Infirmary is set in the extensive grounds of the convent. It is cleaned and maintained to a high standard and provides a very pleasant environment for the Sisters to live. Good staffing levels are maintained and this ensures that the Sisters needs are met and they receive a high standard of care. Over 90 of the care staff are trained to NVQ level 2 or higher. In addition, an extensive range of other training is provided to all staff, ensuring that they are well trained and posses the skills and knowledge to care for the Sisters. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 6 The medicine management in the home is of a generally high standard and there are auditing systems in place to ensure the Sisters receive the medication they are prescribed in a safe manner. The assessment and care planning process is of a good standard so identifying the Sisters needs and providing staff with the information they require to meet the Sisters needs in a consistent manner. There is a good range of equipment in the home, which is individualised so reducing the risk of infection. The Sisters health care needs are well met with visits from health professionals and the G.P. visits every week. The G.P. stated, “The staff are conscientious, they work hard and are always well organised. A range of activities are provided for the Sister’s to participate in, and they are assisted to participate in the religious services and celebrations of the convent, so meeting their social and spiritual needs. A well balanced and nutritious diet is provided with an extensive choice, which is to the Sisters’ individual tastes. The dining facilities are of a high standard, and staff have a good understanding of individual likes and dislikes. The Sisters stated, “The meals were very good and the chef is excellent”. There are regular staff meetings and meetings with the Sisters so views are actively sought, minutes maintained and every effort made to disseminate the information to anyone who was unable to attend. The ethos and management of the home benefits the Sisters. Staff respected the Sisters privacy and dignity and feedback about staff included comments such as “They are marvellous”. “They could not do anymore”. There is a robust system for dealing with any complaint/concerns with a comprehensive report ensuring that the Sisters are well protected. One Sister stated, “You would have to look very hard to find a complaint here”. There are robust recruitment procedures including all relevant checks ensuring that the Sisters are safeguarded by the procedure. The manager provides strong leadership and has implemented good systems ensuring the infirmary is run in an efficient and effective manner in the best interests of the Sisters. What has improved since the last inspection? Some new armchairs, a new shower facility and some decorating had been undertaken so enhancing the environment for the Sisters. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 8 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 Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedures were of a good standard, so ensuring the needs of all prospective residents were met. Information was available to inform them of the services and facilities available, although many of the Sisters are well acquainted with the infirmary. EVIDENCE: The home only admits Sisters of the Order who require care, and no Sister is denied admission provided a bed is available. Many of the Sisters are very familiar with the convent and the facilities prior to moving into the infirmary, as it is an integral part of the convent. Information is available to inform them of the facilities available. The nurses stated that manager assesses all Sisters prior to moving in and they are informed of their needs and any equipment etc that is required. Upon the Sisters arrival to the infirmary a full assessment is carried out to further identify their needs and determine if any specialist St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 10 equipment is required. On inspection the assessments were found to be comprehensive enabling a care plan to be drawn up for each individual Sister. Contracts are made available for all the Sisters who enter the infirmary and information is available about the services and facilities enabling them to make a choice before moving in. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Sisters are well supported by the care staff to ensure that their health and personal care needs are met appropriately. The medication system is of a good standard with regular audits ensuring the Sisters receive the medication prescribed to them. The Sisters are treated with respect and their privacy is upheld. EVIDENCE: Staff draw up a care plan for all Sisters following admission to the infirmary out ling the action required by staff to meet the Sisters need. On inspection of a sample of records they were found to be of a good standard, comprehensive, signed, dated and involved the Sisters in the process. They were reviewed on monthly basis and updated when required. Risk assessments were in place for various areas such as nutrition, tissue viability, and bed rails to enable risks to be identified by staff and appropriate action taken to reduce the risk. It was obvious that a lot of work had gone into the tissue viability and nutrition assessment as links had been made between them ensuing continuity. Staff completed daily records for all Sisters and they were of a high standard with St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 12 good details about the care provided, the type of day experienced, mood, appetite etc. All the Sisters are registered with a local G.P. who visits the home on a weekly basis and when needed. It was apparent that appointments with other health professional such as the dentist, chiropodist and optician were occurring regularly either through visits at the infirmary or the Sisters go out to practices in the community. There was also evidence of liaison with other health professionals as required e.g. dietician, speech and language therapist and the Macmillan specialist nurses to ensure all health needs are met. Feedback from the G.P. was very positive, He stated, “the staff are very conscientious, they work hard and are very organised for visits”. On discussion with the nurses they had a good knowledge of the Sisters needs and the plan of care, so ensuring their needs were met in a consistent manner. Whilst touring the infirmary it was found that there was a good range of pressure relieving equipment where needed. One of the nurses took a lead in respect of tissue viability and had good documents in place for recording and monitoring any wounds or sores. There was a range of handling aids with a good number of hoists. Residents who required moving and handling equipment had individual slings and sliding sheets in their bedrooms. All Sisters with diabetes had their own blood glucose monitoring equipment, which was checked weekly and a spare was also available if required. Charts for monitoring food and fluid intake were well maintained for Sisters where there was concern ensuring adequate monitoring and intervention where required. Also fluid and food intake was recorded for all sisters overnight to enable monitoring of dietary intake. During the inspection it was noted that the bed rail risk assessment did not consistently indicate risks and in one sisters room only one bed rail was in place as the bed was against the wall. Where bed rails are used there must be two in place at all times. This was discussed with the nurse who agreed to provide another bed rail at the time of inspection. The medication is delivered on a two monthly basis and is stored appropriately in the home. An audit of medication was undertaken and it was found to be of a good standard and all audits were correct with the exception of one and the reason for the error was identified. The managers undertake regular in house audits as part of the quality assurance system. Controlled medication was stored appropriately and records were correct. Where variable doses were prescribed there was found to be some inconsistency with the recording although audits were correct. It is recommended that the system be reviewed and a consistent manner of recording is agreed for all nurses to follow. It was noted that the medication fridge reading was a little low and it is recommend that this be reviewed to ensure all medication is stored at correct temperatures. There is a medication policy in place that had been agreed by the pharmacist inspector and the staff work closely with the pharmacist from the Primary Care Trust. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 13 Staff were observed to interact well with the Sisters and were very polite and courteous. The Sisters privacy was respected at all times and feed back about staff was very positive with comments such as “they are marvellous” “ they could not do anymore”, “ they have the magic touch”. It was apparent hat there were good relationships between the staff and the Sisters. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The dietary needs of residents were well catered for with a balanced and varied selection of food available, that promotes their well-being. The systems for consultation with the residents in the home are good; with their views both sought and acted upon. The activities provided for the Sisters matched their expectations and preferences, thus contributing to their quality of life and independence. EVIDENCE: The routines of the home are flexible, as confirmed on conversation with the Sisters. One Sister commented, “Most of us rise quite early in the morning, and can go bed when we like.” Visiting is also flexible to suit visitors and enable residents to maintain contact with family and friends. It was stated by the nurse that arrangements are made for visitors depending on their length of stay to include refreshments, meals and overnight stays and a separate house is available in the grounds of the convent. . A wide range of activities are available for those Sisters who wish to take part, that includes movement to music once week, which is thoroughly enjoyed by St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 15 those who participate. Also walks in the grounds and gardens, which are extensive and very well maintained, videos, bingo, crosswords, trips to the theatre/ cinema and local parks plus talks from visiting speakers and other Sisters from the convent plus religious retreats and holidays. Daily newspapers are provided for those Sisters who want one and the hairdresser visits regularly or some Sisters go out to the hairdresser if they wish. Of significant importance for the Sisters is to be able to participate in the religious services on a daily basis and this is facilitated by staff who make arrangements for the Sisters to go to the chapel and where it is not possible the mass is broadcasted to the units via an intercom system. The Sisters are still fully involved with all decisions made in the convent and they have recently celbrated their golden jubilee. The Infirmary is an integral part of the convent, so the Sisters are able to move freely between the two, thus maintaining their contacts with other Sisters. A visitor spoke to the inspector and stated “my sister loved it here”. It ws obvious that it was their home and they had a range of personal possessions in their rooms, which help to create a homely environment. The inspector joined the Sisters for lunch in the spacious first floor dining room. Tables were very attractively laid with a menu, condiments and appropriate cutlery on each table. The menus provide a large range of choices, which included three roast meats with a choice of potatoes and vegetables plus a salad and it was stated that other options are available if the Sisters wished. The menu reflected a nutritious and balanced diet. All the Sisters spoken to stated the food was of a good standard and they enjoyed their meals. Lunch was a four-course meal consisting of a choice of starter, main course, and desert and followed by cheese and biscuits and a hot drink was served a little later in the lounge. There was several care staff in attendance during the meal offering assistance where it was required. All sisters where asked their choice of meal at the table and also what size portion they would like. It was truly a sociable occasion with talking and laughter during the meal. The inspector found the meal enjoyable, it was of a good standard, hot, well presented and staff were very courteous and helpful. Special diets are taken into consideration and Sisters likes and dislikes are confirmed and documented. Staff were observed to give assistance and support in an appropriate and effective manner where required. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Any complaints/concerns are taken seriously and acted upon in an appropriate manner, so ensuring all the Sisters are safeguarded. EVIDENCE: The Commission for Social Care Inspection (CSCI) had not received any complaints about the home. One complaint had been recorded in their own file and the record showed that it had been fully investigated and found that it was not upheld. The complaints policy and procedure includes all the information required to enable a person to make a complaint if they should wish to do so. One Sister said, “I would have to look very hard to find anything wrong”. There appeared to be a very open approach to complaints enabling learning to be achieved from any concerns raised. The adult protection policy and procedure incorporated the Birmingham Multi Agency Guidelines and on discussion with staff they had a good understanding of what constitutes abuse and the action to take if there was any such allegation. Staff have received training in safeguarding residents and the whistle blowing policy. All staff have also received training in respect of the mental capacity act so they are aware of actions to take if residents lack capacity. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 17 There is a very robust recruitment procedure ensuring all staff have appropriate checks undertaken before commencing work in the home, so protecting the Sisters. The home is run in the best interests of the Sisters. The high standard of record keeping safeguards the residents’ rights and best interests. The high standard of attention to the health and safety issues for staff and residents help promote and protect their health and welfare. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within St Paul’s Convent Infirmary is very high, providing the Sisters with a comfortable, attractive and safe place to live. EVIDENCE: The infirmary is an integral part of the convent buildings, which are well maintained and there is a rolling programme of renewal and refurbishment of the infirmary, communal rooms and bedrooms so ensuring it is a pleasant place to live. On the day of inspection a number of new chairs been delivered. The Grounds are accessible, attractive and well maintained providing a very pleasant place to sit when the weather permits. The accommodation is spacious, homely, cleaned to a very high standard and odour free. There is a range of communal rooms for use by the Sisters and any visitors. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 19 All bedrooms are single with wash hand basin and call bell to summon assistance if required. They have locks to doors and keys are available if the Sisters wish to lock them for privacy purposes. Lockable facilities are available in all rooms for the storage of valuables or medication and keys are available to Sisters. Rooms were personalised to the extent preferred each individual. There is a range of assisted bathing facilities providing the choice of a bath or shower and a new flat floor shower facility has recently been developed. Toilets have raised seats and grab rails available to assist those with mobility problems. There are passenger lifts that give access to each floor enabling the Sisters to move around the infirmary and convent as they wish. All areas are individually and naturally ventilated and restrainers are fitted on windows for security and safety. Radiators are covered and water is thermostatically controlled to ensure safe temperatures and reduce the risk of scalding. There is a large well equipped kitchen on each unit and they were clean and well maintained. Fridge and freezer temperatures were recorded using a minimum/maximum thermometer that could measure temperatures inside and outside the equipment. Some of the records suggested that they were outside recordings, as the equipment appeared to be in satisfactory working order. It is recommended that all staff are made fully aware of how to use the thermometer correctly and normal parameters, so that action can be taken if they are outside the normal range. There is a large main Kitchen on the ground floor where the main meals are prepared and cooked. It was found to be clean and orderly with a good range of food items, including fresh produce. During inspection it was noted that there appeared to be leak from the ceiling in the cold room, some fresh produce was stored on the floor, some sauces had been opened and not dated and some food items such as meats etc had not been dated to ensure they are used within appropriate timescales. The chef was not available at the time of inspecting the kitchen and the manager stated she would address the issues the next morning. There are systems in place for the control of infection and there is a policy and procedure in place. Infected material and clinical waste is handled appropriately, and the home has a current contract with an environmental services company, who remove the waste on a regular basis. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. High staffing levels are always maintained with an extensive range of staff training ensuring that staff have the appropriate skills and knowledge and all the Sisters needs are met to a high standard. There are robust recruitment procedures thus ensuring the safety of the Sisters by the employment of new staff. EVIDENCE: Examination of staffing rotas indicated that the infirmary is always well staffed with nurses and carers on each unit. The manager and deputy manager support them and there is an on call system with the manager or her deputy available in the building out of office hours. The infirmary also employs ancillary staff that includes, dedicated housekeeping staff, cook, kitchen assistants, laundry workers, and a full time maintenance officer. Together they form a dedicated team providing high standards of care that meets the Sisters needs in all aspects of daily living. There are robust recruitment procedures ensuring that an application form, health check and all other relevant checks are undertaken before a member of staff commences employment, so safeguarding the Sisters. There is a low staff turn over, but occasionally agency staff are used. The manager stated she uses the same agency and endeavours to use the same staff to ensure St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 21 continuity. They receive confirmation from the agency as to the checks they have undertaken, staff are allocated to work with a permanent member of staff initially, they are provided with an induction to the infirmary and this is recorded. The manager stated she would communicate any problems identified with staff directly to the agency. There is a strong commitment to staff training and the majority of care staff have complete NVQ level 2 or above in care, which is to be commended. Induction training is provided to all new staff and a comprehensive range of training is provided in excess of the core elements, which are kept updated. Some of the nurses in the infirmary take on a lead in various areas e.g. tissue viability, nutrition, safeguarding, deafness, medication etc. and training packs had been developed for use at staff training sessions. Staff have also received training in respect of caring for people with dementia and recently the Mental Capacity Act, which is to be implemented. This strong commitment to training provides staff with the knowledge and skills they require to care for the Sisters and this is reflected in the high standards of care that are provided. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager of the home provides strong leadership with a commitment to high standards so ensuring the Sisters well being is maintained. The management style engenders an open and inclusive atmosphere and there are good systems for consultation with residents and staff, where their views are both sought and acted upon. EVIDENCE: The manager of the infirmary is a registered nurse, who has considerable experience of running a care home, has the appropriate qualifications and is registered with the Commission. She demonstrated strong leadership, competence, commitment and dedication so ensuring that the highest levels of care and services are provided to the Sisters in the infirmary. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 23 St Paul’s is a religious institution and therefore has a very clear ethos, however staff come from a wide variety of backgrounds and religions are employed. Staff spoken to stated that they find the management approachable and receptive to views or ideas. One stated, “ I would like to be a resident here if I needed care”. Staff meetings occur every month and they are repeated three times to ensure as many staff as possible attend. Also the minutes of meetings are made available on all units. There are regular informal discussions plus formal meetings with the Sisters and records are maintained. There are regular monthly visits from the Mother General (responsible person) and records were comprehensive about the visits. A quality assurance system is in place, which involves a range of audits by the manager and her deputy plus questionnaires from the Sisters and Staff. The manager stated that she hopes to develop this further to include other stakeholders and visitors to the infirmary. There were a number of letters praising the staff for the care and attention they provided. A designated member of the congregation is appointed by the Mother General to see to the personal, pastoral and spiritual needs of the Sisters. A personal allowance is allocated to each Sister and it is managed by the designated member appointed by the Mother General for those who are unable to manage it themselves. The information provided by the manager in relation to servicing and maintenance of equipment indicted that it was all up to date. A sample was inspected to include fire, emergency lighting, electrical appliances , hoists, wheelchairs and legionella testing and all were found to be satisfactory so ensuring the health and safety of the Sisters, staff and vistors. The temperature of water form hot water outlets had not been checked recently due to problems with the water supply. It is recommended that these be recommenced regularly based on the findings of the risk assessment to ensrue thermonstatic vavles are working effectively and ensure early identification of any failures. St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 24 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 4 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 X X 4 St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 25 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. 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 2 Refer to Standard OP9 OP9 OP19 3 OP19 Good Practice Recommendations A consistent format is used for recording the administration of variable dose medication to enable easier auditing. Ensure all staff are fully aware of the use of minimum/maximum thermometers, the normal ranges and what to do if abnormal records are found, to ensure items are stored at correct temperatures in fridges. Ensure all food items in the main kitchen that are opened are dated to enable them to be used within appropriate timescales and food items are not stored on the floor for food hygiene purposes. Address the possible leak in the cold room in the main kitchen to ensure a safe working area. It is suggested that a training matrix be devised to enable easier access to information about staff’s individual training records. 4 5 OP19 OP29 St Paul`s Convent DS0000024897.V343411.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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