CARE HOMES FOR OLDER PEOPLE
St Paul`s Convent The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL Lead Inspector
Jane Walton Unannounced Inspection 21st February 2006 11 am 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.V283966.R01.S.doc Version 5.1 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.V283966.R01.S.doc Version 5.1 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 414 1063 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.V283966.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 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 Date of last inspection 23rd August 2005 Brief Description of the Service: St Paul’s infirmary is located within the Convent of St Paul’s 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 Paul’s who have nursing needs. Access to the upper floors is via stairs or passenger lifts. The building is very spacious and all residents have a single room. The home provides twenty-four hour nursing care ranging from long term nursing needs to short stay rehabilitation. The Convent has its own pleasant extensive gardens and grounds, which are very well maintained and easily accessed by residents. There is a house within the grounds for family members of Sisters of the Order to stay in when visiting their relatives. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection for year 05/06, and was Unannounced. It was undertaken by one inspector over 8 hours at the end of February 2006. There were 34 residents in the Infirmary at the time of the inspection and one in hospital. The Registered manager was present throughout. The inspector spoke with five residents. Information was also gathered by observing staff performing their duties, and informal discussions with four members of the staff. Ongoing discussions throughout the inspection process took place with the manager. The inspector also met with the responsible individual for the home, for the feedback session at the conclusion of the inspection. Care records and staff files were examined and a medication audit carried out. What the service does well:
A full assessment is carried out, and regularly reviewed to ensure that all identified needs are being met. Each Sister has a comprehensive care plan that they have been involved in producing where possible. Health care needs are met and Sisters are visited by GP’s and other health professionals as required. When a Sister requires palliative care, support is provided by the Macmillan nurses from St. Mary’s Hospice. The medicine management in the home is of a generally high standard. The dining facilities are of a high standard, and staff have a good understanding of individual likes and dislikes. Policies and procedures in the home ensure that the rights, health and welfare of the Sisters are protected at all times. The ethos and management of the home benefits the Sisters, and their views are actively sought and acted upon. St. Paul’s Infirmary provides a comfortable, clean and well-maintained environment for the Sisters to live in, and there is a high standard of housekeeping in the home. There is a high ratio of staff to residents that ensures that the high standard of care that the Sisters receive is maintained. Over 90 of the care staff are trained to NVQ level 2 or higher. A large ancillary staff is employed at the home, and all contribute to the high standard of care and environment that is provided for the Sisters. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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): 3 All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure that the home is able to fully meet their needs. EVIDENCE: As the Infirmary only admits Sisters’ of the Order, provided that a bed is available none are refused admission. The staff have demonstrated that they are able to meet a wide range of needs, including providing Palliative care in conjunction with the local St Mary’s Hospice. Staff have undergone a wide range of relevant training in order to provide a high quality service to the Sisters. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 Residents are well supported by the nursing and care staff to ensure that their health and personal care needs are met appropriately. The medication is very well managed promoting good health. EVIDENCE: A sample of care plans were examined and found to be comprehensive and easy to understand. Residents needs had been identified and in most cases the care management of these needs was documented clearly. A range of risk assessments had been undertaken, including moving and handling, pressure sore risk and nutritional status. The care plan for one Sister indicated that she had a leg ulcer that was being dressed every two days. Records stated that the wound was continuing to granulate, however there was no serial photographic evidence, or tracing of the wound, to support this. It was recommended that a record of photographs or tracings, incorporating a wound measure be used, to evidence the healing progress of wounds. It was evidenced that advice was sought from the Tissue Viability Nurse when required. The staff refer to the residents GPs and other healthcare professionals as required for medical advice and to ensure that health care needs are being met. The Macmillan nurses from St Marys Hospice provide
St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 10 regular input when required. Evidence was seen that a chiropodist and an optician visit the home when required. The Sisters are involved as far as possible in the production of their care plans, and two Sisters spoken to confirmed that they knew they had a care plan and had agreed to the care required. The medication management in the Infirmary is of a very high standard. An audit was carried out of medication administration on all 3 floors of the Infirmary, St Genevieve, Lourdes and St. Josephs. Each floor has a separate drug trolley that was securely stored. The controlled drug administration system is very robust and all counts were accurate. Weekly drug audits are carried out every Sunday to ensure that the high standard is maintained. Sisters who self medicate are regularly assessed to ensure compliance. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 11 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): 15 The dietary needs of residents are well catered for with a balanced and varied selection of food available, that promotes their well-being. EVIDENCE: The inspector joined the Sisters in the main dining room on the ground floor for lunch. This dining room has a serve yourself system operating for those sisters who are more able. There was a large choice of dishes available, including soup to start, followed by roast chicken, roast lamb, breaded fish or sausages. Vegetables included, creamed potatoes, fresh carrots and creamed leeks. A range of desserts were available including, fresh fruit, home made rice pudding, prunes and apple crumble. The food was hot and very tasty. Jugs of water were available on the tables, and tea or coffee available after the meal. Two days menus were available for examination and these demonstrated that on these days a variety of dishes were available that appeared to offer a wellbalanced and nutritious diet to the Sisters. However, it would be helpful to provide a 4 weekly menu to ensure that there is not too much repetition of dishes over the period, and to facilitate ensuring that the diet is nutritionally balanced. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection (CSCI) in relation to the home, and there were none recorded in the homes’ log. 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. The adult protection policy and procedure incorporated the Birmingham Multi Agency Guidelines. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 the following standard(s): 22, 26 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 provides a range of equipment to facilitate the care of the Sisters and to maximise their independence. This includes the provision of handrails in corridors, ramped access where needed, grab rails in bathrooms and toilets, raised toilet seats, walking aids and wheelchairs. All are maintained regularly. If a particular piece of equipment is identified as being required for one of the Sisters it will be purchased. At the time of the inspection all the areas of the Infirmary seen were of a very high standard of cleanliness, and hygiene. The Infirmary provides a very pleasant and comfortable environment for the Sisters to live in. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 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 High staffing levels ensure that the needs of the residents are met. The home has a robust recruitment procedure thus ensuring the safety of the residents. EVIDENCE: On the day of the inspection the Registered manager informed the Inspector that there were 7 members of staff off sick with the flu. Shortfalls were covered by bank and agency staff. Examination of the staff rotas indicated that there were always ample numbers of staff on duty to meet the needs of the residents. The Infirmary also employs a large ancillary staff who all contribute to the high standards of care, environment and service provided. A very high percentage of the care staff, i.e. 90 , is trained to NVQ level 2, which is commended, and far exceeds the expectation of the standard. There is a very robust recruitment procedure operating in the home, and a sixweek induction programme, to the required standard, is in place for all new employees. Evidence was seen that this had been implemented. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 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): 33, 35, 37, 38 There are good systems in place to obtain residents feedback to ensure the service provided is of a very high standard. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: As St Paul’s’ is a religious order the Sisters do not have any personal monies, however, the Infirmary and the Convent provide for all their needs. Staff and resident meetings take place regularly and a record kept. Staff spoken to confirmed that meetings take place, and the minutes for these were seen. There is a Quality Assurance assessment questionnaire sent out every six months and the analysis of these aids in the review of the services offered, and ensures continual improvement. Service user meetings take place regularly and are used to provide feedback and air views, and are an integral part of the quality review. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 16 There is a comprehensive range of policies and procedures in place that where required to do so, follow local guidelines. Fire records were all complete and of a high standard, which is commended. All fire drills, alarm tests and fire training were up to date. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 3 X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 4 4 St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 18 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 OP15 Regulation 12(2)(3) Requirement The registered manager must ensure that there is a menu (changed regularly), offering a choice of meals in written or other formats to suit the capacities of all service users, which is given, read or explained to service users. Timescale for action 10/05/06 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 OP7 Good Practice Recommendations It is recommended that where a Sister has a wound that is being treated, serial photographs or tracings, with a measure guide, are used to chart the progress of the healing process. St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI St Paul`s Convent DS0000024897.V283966.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
