Inspection on 14/03/07 for St Peter`s Convent

This inspection was carried out on 14th March 2007.

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 Peter`s Convent 22/02/06

St Peter`s Convent 16/11/05

St Peter`s Convent 12/01/05

St Peter`s Convent 20/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE St Peter`s Convent George Lane Plympton St. Maurice Plymouth Devon PL7 2LL Lead Inspector Mandy Norton Key Unannounced Inspection 14th March 2007 10:20 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 Peter`s Convent DS0000003608.V327779.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 Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peter`s Convent Address George Lane Plympton St. Maurice Plymouth Devon PL7 2LL 01752 337202 01752 348804 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) Trustees Augustinian Sisters Sister Eileen Holland Care Home 50 Category(ies) of Dementia - over 65 years of age (50), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (50) St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for a maximum of 50 MD(E) Registered for a maximum of 50 DE(E) Date of last inspection 22nd February 2006 Brief Description of the Service: St Peters is registered to provide care for up to 50 service users over the age of 65 years of either gender who may suffer with dementia or mental disorder. The home is divided into three Separate units; A qualified Nurse runs each unit. The home has 1 registered manager who has overall responsibility for running the home. The home is owned by the Sisters of St Augustine. A registered nurse is on duty at all times supported by a team of Health care assistants, administration, catering, domestic and maintenance staff. The home is a large listed building, situated in the village of Plympton St Maurice. The home is a large property with extensive, secluded and attractive grounds. In addition to 7 separate communal rooms, a chapel is available for use by all service users, staff and the local community. The services provided are non-denominational. There is a variety of equipment to support physically disabled Service Users needs and specialist equipment is available following an assessment of need. The fees charged range from £577.50 to £650 (February 2007). ’The latest inspection report is displayed in the entrance foyer and the manager was advised that the Statement of Purpose should be updated to include information about where people can access the latest report if they do not have access to the internet. The contracts issued include name and date of admission and who pays the fee, how the fee is broken down and the total fee, plus the homes terms and conditions of residency. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 10.20 am until 2 pm and was conducted with the matron and 3 unit managers. A tour of the home was carried out. The report contains views from the completed relatives surveys returned (12) these are reflected throughout, information taken from the completed pre inspection questionnaire and discussion with staff on the day of the inspection. Service Users seen were not always able to fully express themselves or comment on the care they received. What the service does well: St Peter’s is homely, comfortable and welcoming. The staff are trained and competent in their jobs and there was a calm atmosphere during the inspection with staff interacting well with the Service Users. The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the matron or one of the senior nurses visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home Service Users needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The processes in place protect the health and welfare of the Service Users such as the complaints procedure and health and safety procedures. Regular training for the staff helps to assure the people living in the home that they are well looked after. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet that includes home made cakes. Alternatives to the menu are always available. The home is tastefully decorated and furnished and presented as clean and hygienic. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 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 Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. This home does not provide intermediate care. EVIDENCE: The pre admission documentation was examined during the inspection. It included information about their assessed needs, equipment required, medications, next of kin and general information about the person. A brochure /Statement of Purpose is given or sent to every person wishing to move into the home. This can also be downloaded from Augustinian Cares St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 9 website at www.anh.org.uk. The website also links to the CSCI web site where previous inspection reports can be downloaded. The manager said that if a prospective Service User is local to the area she herself or one of the other senior trained nurses goes to visit the person in their current setting to make an assessment. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 10 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 manager promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. The homes medication systems protect the welfare of Service Users. Service Users are treated with respect and their right to privacy is upheld. EVIDENCE: Four (4) care plans were examined (at least one from each unit/floor); in all of those seen there were assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, use of bed rails risk assessments and nutritional screening. The information generates the plans of care, which provide the basis for the care to be delivered. The care plans are computer based and were clear and easy to understand and had been regularly reviewed. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 11 Records are maintained for all visits to the home by social or health care professionals, all Service Users are registered with a GP. Records in the diary and care plans detailed outpatient appointments and GP visits showing that Service Users are enabled to use health resources. The medication system is well managed; each unit has its own drugs trolley and storage facilities with the controlled drugs for the whole home being stored in one double locked cupboard. The nurses spoken to said stock is checked weekly and ordered monthly as often as possible. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. Staff were overheard knocking on doors prior to entering rooms of Service Users. Appropriate interactions between staff and Service Users was heard during the inspection. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 12 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. Effort is made by the home to provide an activities programme and social interaction/stimulation for Service Users. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet and are not rushed encouraging the mealtime to be a social event EVIDENCE: Staff on one unit were seen conducting a bingo/ music quiz with several Service Users. On another unit the staff were looking through magazines with and talking to the Service Users. The pre inspection questionnaire submitted prior to the inspection lists a range of other activities that take place in the home and the local community including – car drives, coach outings, pantomime, shopping, music and movement, painting and needlework and board games. An upcoming ‘clothes show’ was advertised in the entrance St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 13 foyer- where Service Users are able to buy new clothes. The matron said that in the good weather many Service Users make use of the secure outdoor space. Here there is space to walk around and seating available. The brochure states that the home has its own chapel where ‘services of the Roman Catholic faith are held weekly’. It says that the ‘Roman Catholic priest and the Church of England Vicar make personal visits to Service Users on a regular basis’. It continues with the fact that the home will make arrangements for members of other religious beliefs to visit at the request of a resident and that family and friends can take Service Users out to attend church services if that is appropriate. The menus are designed to meet the needs of people with dementia. Meals are taken to each unit in a heated trolley so that staff can serve meals of different sizes and on appropriate plates to meet the needs of the Service Users. The cook said that cakes are usually home made and some for that day were seen during the inspection. The staff said Service Users are encouraged to eat in the dining rooms (one on each unit) but are able to eat in their rooms if they wish. Records kept in the kitchen included fridge temperatures, cleaning schedules and a record of service users choices all information is kept in the Safer Food Better Business documentation (this is a system of recording recently introduced that catering staff are now required to use). St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Service Users and their relatives/friends know how to make a formal complaint. People are safe living in this home. EVIDENCE: The complaint procedure was seen displayed within the home and is in the brochure/Statement of Purpose, given to all Service Users and /or their representatives prior to admission. Twelve (12) of the fifteen (15) completed relatives surveys returned prior to the inspection indicated that they knew how to make a complaint. The complaints procedure is also included in the induction process for new staff. The pre inspection questionnaire states that there have no complaints or adult protection referrals since the last inspection. All of the nursing and care staff spoken said that that they have enough support to carry out their job. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 15 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, 22, 23, 24, 25 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and clean and hygienic ensuring the Service Users live in a satisfactory environment. EVIDENCE: The home is arranged on four (4) floors divided into three (3) units (St Josephs, St Rita’s and St Francis). A tour of the home showed that Service Users rooms contain personal items including furniture, ornaments and pictures that reflect their personality and interests. This home benefits from seven communal rooms and extensive wellkept grounds, with walkways and seating areas to promote service users exercise and access for wheelchair users. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 16 The home appeared well equipped to meet the needs of Service Users identified with moving and handling risks and disabilities that affect their ability to bathe. Specialist mattresses and adjustable beds were seen in place for those Service Users requiring them. There is call bell system throughout the home, Service Users seen in their rooms all had the bell placed within their reach. There were a variety of toilet facilities for use by Service Users throughout the home. There is a shaft lift to all floors. Hand washing facilities were seen throughout the home as were protective gloves and aprons. The laundry and kitchen were well equipped and large enough to manage the amount of laundry and catering required to meet the needs of the Service Users. The home looked well maintained during the tour of the premises, this is supported by the information supplied in the pre inspection questionnaire about dates of servicing of equipment and fire equipment tests for example. The maintenance man was seen replacing part of a windowsill during the tour. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with appropriate skills and knowledge to meet the needs of Service Users in this home. The homes recruitment procedures protect Service Users from being placed at risk of harm or abuse. EVIDENCE: The home is arranged on four (4) floors divided into three (3) units (St Josephs, St Rita’s and St Francis). Each unit has its own staff group working to their own duty rota. There is a trained nurse on each unit between the hours of 7 am and 8.30 pm and 4 carers on each unit in the morning, and 3 in the afternoon and early evening. Overnight there is one trained nurse on duty and 4 carers throughout the building. During a tour of the home staff were engaged with residents and there was a calm and organised atmosphere. Training records for 2006 submitted with the pre inspection questionnaire prior to the inspection included fire training, first aid, cardiac care and dementia care. All twelve (12) completed relatives surveys indicated that the staff appear to have the ‘right skills and experience to look after people properly’ St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 18 New members of staff are recruited following a formal application to the home, after references, Criminal record checks and an interview has taken place. The inspector was not able to see staff files as they were with the head office where the information is being transferred to a new computer system. The administrator made arrangements for copies of four (4) criminal records bureau disclosure results to be sent to the inspector. These were received three (3) days later. Previous inspections have found the recruitment procedures to be satisfactory. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 19 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 home is managed by an experienced Registered Nurse. The Service Users benefit from the ethos and leadership within the home. There is a formal quality assurance system in place. Personal money held in the home on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of Service Users and staff. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager of this home is a 1st level registered general and mental health nurse who has achieved a Registered Managers Award. The manager has managed the home for many years and is well respected by the provider, local health care professionals and friends and relatives of the residents. Augustinian Care has its own complaints process, robust recruitment procedures and numerous training opportunities. The manager confirmed that a formal quality assurance system has been introduced and is in use in the home. Staff spoken to confirmed that the ‘head office’ do take statistics from the computer and can identify if care plans for instance are not being reviewed and updated regularly. The manager has an open door policy for staff and visitors to bring any issues or concerns to her. Safety notices were displayed throughout the home including action to be taken in case of fire. The completed pre inspection questionnaire indicates that all equipment is regularly maintained and tested. Portable appliance testing (PAT) testing stickers were seen on electrical equipment throughout the home. The fire and accident book were examined and found to be up to date. The staff accident book conforms with the latest data protection requirements. The resident ones still had information about the Service User in them and it was advised that each unit lock these away to comply with data protection. The inspector was shown he records and storage of personal money held in the home on behalf of Service Users. Best practice systems are in place for the protection of both residents and staff, all receipts are stored for auditing purposes and the money is stored securely. St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 21 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 4 3 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X 3 3 4 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 X X 3 St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 22 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. Refer to Standard OP36 Good Practice Recommendations Structure set questions and expected answers in line with equal opportunities practices and to demonstrate a fair, open and consistent approach at interviews. (not inspected on this occasion) Implement as planned a quality assurance system 2. OP33 St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI St Peter`s Convent DS0000003608.V327779.R01.S.doc Version 5.2 Page 24 - 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. 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