CARE HOMES FOR OLDER PEOPLE
St Peter`s Convent George Lane Plympton St. Maurice Plymouth Devon PL7 2LL Lead Inspector
Andrea Peryer Announced Inspection 16th November 2005 10:00 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 Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 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.V266664.R01.S.doc Version 5.0 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.V266664.R01.S.doc Version 5.0 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 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, qualified members of staff, care assistants and housekeepers support the Sisters. 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. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was carried out over a day at the home, with the homes manager and senior staff from each floor of the home, present throughout the inspection. Residents and members of staff were part of the discussion about the home and four residents care was looked at in detail. Not all areas of the home were fully inspected with the inspector spending more time on certain floors talking to relatives. A range of documentation was also considered throughout the inspection including care plans, policies, procedures, fire logs and accident records. Residents were spoken too in their private rooms or in the homes dining and lounge areas. The home has also submitted a pre inspection questionnaire to the Commission Prior to the inspection, which gives information about the home including staff rosters, menu plans, lists of training and some of the changes in the home. The Commission also received Feedback cards from relatives and residents. What the service does well: What has improved since the last inspection?
Since the last inspection the home has changed how residents finances are banked so that they are no longer held in the organisations bank account. Instead a central account for residents finances have been set up which is clearly recorded showing residents individual finances, including receipts of anything purchased. This is an improvement as it separates out the finances so that it is easier to audit and to identify resident’s individual finances so that residents who are able could have easy access to this information and manage there own finances with support from staff. The premises had also changed with the room previously being used for three residents being turned into a lounge dining room and the previously used smaller lounge area on that floor being used as a resident’s room. This has been of benefit to residents who clearly enjoyed the additional space in the new lounge/dining area and to the resident who now has a single room.
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 6 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 Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 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.V266664.R01.S.doc Version 5.0 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): x Not inspected on this occasion. EVIDENCE: St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 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): 7,8,9,10 Residents health care needs are fully met and are set out in an individualised plan of care. Residents are treated with dignity and respect and their privacy is upheld. EVIDENCE: The inspector identified four residents residing on different floors of the home as a representative group of home, which the inspector could then look at documentation to sample. Four residents care plans and risk assessments were examined by the inspector when visiting the three floors of the home. The care plans and assessment documents are part of a computerised system of recording, which gives details of all sorts of health and social care needs that have been considered, addressed and monitored. This included weight changes, discussions with outside professionals, daily progress reports made by the staff in the home and a record of how the meets the residents needs. These records indicate a consistent approach to meeting residents needs. The resident’s care was examined in detail and documentation matched what staff said about the care this person needed and received indicating that the residents care needs were being fully met. On one floor of the home the computer records show a member of staff on care plan and assessment records who has not actually been at the home for a long time, this gives a false impression that this member of staff has been
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 10 updating records when they have not. Staff spoken too were aware of the need to change the computer system so that this does not happen. Members of staff were observe entering rooms after knocking the door and the residents said that this was normal practice in the home. The resident’s relatives and the residents praised staff for their kindness and felt that their privacy was respected. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 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): 12,13,14, Residents maintain contact with their family and friends and the local community and their lifestyles match what they prefer and met their interests and needs. EVIDENCE: A large part of the inspection was taken up with speaking to relatives who had expressed a wish to see the inspector to make sure that the inspector was aware of how “wonderful” the staff and services were at St Peters Convent. They described a flexible routine in the home, which allowed them the opportunity to visit at any time, offering the opportunity to be as involved or as distance from the care their relative received. Some Relatives visited daily and were clearly aware of the routines in the home. One relative arrived and very quickly unprompted a tray of hot drinks and biscuits were supplied by staff for the resident and the relative and this was confirmed to be normal practice in the home. The homes pre-inspection questionnaire submitted prior to the inspection lists a range of activities in the home and local community including car drives, coach tours, shopping, pantomimes, painting, needlework, ball and board games.
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 12 Two residents relatives went into detail about how the staff had supported the needs of the residents to improve their physical condition and help them then pursue individual interests even at a very basic level for example making sure they had access to books of interest. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 13 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): 16,17,18 Complaints received in the home from residents, family or the public are taken seriously and acted upon. Resident’s legal rights are protected and residents are protected from abuse. EVIDENCE: Residents said they felt able to bring any concerns or worries to the staff on duty, the manager and through their relatives. Relatives said that they felt able to raise concerns with any of the staff on duty or with the home senior staff. A complaints procedure informing people of how to raise concerns was in the homes staff file, staff induction and was displayed in the home, indicating that the home lets everyone know how to raise concerns and who to raise concerns with. Feedback cards received by the Commission said that overall residents and relatives were satisfied with the overall care provided but were not aware of the homes complaints procedure. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,24,25,26 Residents live in a safe, well- maintained home, with access to safe and comfortable indoor and outdoor facilities: including sufficient washing facilities and specialist equipment. Resident’s rooms like the rest of the home are comfortable, clean, hygienic and personalised. EVIDENCE: This home benefits from seven communal rooms and extensive well-kept grounds, with walkways and seating areas to promote service users exercise and access for wheelchair users. A communal room on the first floor lacks natural light and ventilation. This home has 6 bathrooms, 4 shower facilities and 12 WC’s, 3 bedrooms benefit from en-suite facilities. Bedrooms on the upper floor have windows that look directly onto a fairly high parapet wall, thus allowing a limited view of the sky. Some rooms have pleasant outlooks on to the garden. On the day of inspection the environment was noted to be clean and odour free. The grounds are safe, attractive and well maintained. The home is divided into 3 units on 3 floors – there is only one mechanical/disinfecting sluice. The laundry is situated at the end of a corridor, which also services the kitchen, care is taken to ensure linen is sealed when being transported. These details have been taken from last inspection report
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 15 and have remained unchanged since that time. The home has previously had a room that was used for three residents this room has now been changed into a pleasant lounge and dining room and another room has been changed to accommodate one resident. This has been of benefit to current residents who clearly enjoyed using the new facilities. Rooms entered were personalised and reflected the personality and interests of the person accommodated in the room. Relatives spoken too confirmed that the home was always clean and went on to talk about the calming and gentle atmosphere of the home was seemed to calm and relax even the most distressed of residents. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30, Residents are protected and have their needs met by the numbers and skill mix of competent staff and good recruitment policies and practices EVIDENCE: Each floor of the home is managed and staffed as a separate unit, staffed with a trained nurse at all times, care staff and support from the overall manager, an administrator and a team of domestic and catering staff. New members of staff have been recruited following a formal application to the home, after references, Criminal record checks and an interview has taken place. Three staff files were examined in detail and discussion took place on structuring set questions and expected answers in line with equal opportunities practices and to demonstrate a fair, open and consistent approach at interviews. Discussion took place on extending recruitment documentation to include ensuring that staff job descriptions were included in the employment records. The home has a system of induction that is to be extended, so that it is clearly linked to TOPPS standards. One floors induction of new staff was recorded in much more detail than the other floor and the level of detail needs to be extended across all floors and for all new staff so that they are following TOPPS standards.
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 17 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): 31,33,35,38 The home is run and managed by a person who is fit to be in charge and the home is run in the best interests, health, safety and welfare of the residents and staff. Residents finances are safeguarded by the accounting and financial procedures in the home. EVIDENCE: The manager of the home is a 1st level registered nurse and has obtained an NVQ level 4 in management, members of staff spoken too were positive in their comments about the support they received from the homes manager, confirming that the registered manager communicates a clear sense of direction and leadership. A range of health and safety policies and procedures including manual handling plans, risk assessments, accident books, medication charts, environmental health and the homes fire log were examined and had been well-maintained.
St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 18 Since the last inspection the home has changed how residents finances are banked so that they are no longer held in the organisations bank account. Instead a central account for residents finances have been set up which is clearly recorded showing residents individual finances, including receipts of anything purchased. The inspector worked through three resident’s finances in details and tracked the money coming in and out of the account on their behalf. The accounts/admin staff were very helpful and clearly had a detailed knowledge of how the accounts worked. The account is also none interest bearing and no resident owes money to the account. The accounts/admin staff confirmed that the finance records were also audited externally. Although this system does not exactly match the requirements of the regulations which states that the resident should have individual accounts, to create individual accounts would be confusing for residents, relatives and staff and as long as the current system continues to be recorded, monitored and audited it meets the best outcomes for residents. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 19 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 x 3 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 3 x 3 x 3 x x 3 St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP36 Regulation 18,19 Requirement The home has a system of induction that is to be extended, so that it is clearly linked to TOPPS standards Timescale for action 29/03/05 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 3 4 Refer to Standard OP36 OP36 OP34 OP7 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. Extend recruitment documentation to include ensuring that staff job descriptions are included in the employment records. Ensure that the current system of managing residents finances continues to be recorded, monitored and audited to meet the best outcomes for residents Update the computer records for care plans and assessments to remove the name of the member of staff no longer at the home. St Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Peter`s Convent DS0000003608.V266664.R01.S.doc Version 5.0 Page 22 - 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!
