Inspection on 22/02/06 for St Peter`s Convent

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14/03/07

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 Andrea Peryer Unannounced Inspection 22nd February 2006 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.V285387.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 Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 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.V285387.R01.S.doc Version 5.1 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.V285387.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a lunch time, with the homes manager and senior staff from one floor of the home. The inspection was focused around the residents living on the ground floor, as the ground floor was not inspected on the last 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 the ground floor talking to relatives and staff. 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. Residents spoken too were not always able to fully express themselves or comment on the care they received. What the service does well: What has improved since the last inspection? Since the last inspection the home has changed upgraded and improved the homes large dining area. On the day of the inspection the homes main large dining room was not in use as the room has been completely refurbished and redecorated, this includes new carpeting for this area. While this room has been redecorated residents have had a choice of dining area either in one of the homes lounges, which has been turned into a lounge dining area or their private rooms. The staff confirmed that these temporary arrangements were due to be end soon so that resident could return to the refurbished room in the near future. This newly decorated dining room, while never an unpleasant area will be further improved as a pleasant bright and clean area for residents to enjoy meals in. Computerised records have been updated and Staff records extended to included job descriptions. This will ensure that there is evidence available that show that staff are clear about their role and responsibilities and that they St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 6 have had a comprehensive introduction to the home covering all aspects of care and linked to nationally recognised qualifications and standards. 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.V285387.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 Peter`s Convent DS0000003608.V285387.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): 1,3,6 Prospective residents have the information they need to make an informed choice about where to live and no resident moves into the home without having his or her needs assessed. The home does not provide intermediate care. EVIDENCE: The inspector identified two residents residing on the ground floor of the home as a representative group of this floor of the home, which the inspector could then look at documentation to sample. The inspection was focused around residents living on the ground floor, as the ground floor was not inspected on the last inspection. The documents examined for these residents included detailed initial assessments of residents needs including information regarding the use of bed rails and if the resident had chosen to share a room. The staff spoken too confirmed that assessments of residents needs were carried out, as much as possible before residents came into the home or on their arriving at the home. One of the homes administrators showed the inspector new folders of information about the home and services and facilities the home provides, which she confirmed was sent or handed to relatives and/or potential residents either before entering the home or shortly after their arriving at the home. Residents were unable to comment about the information they received. St Peter`s Convent DS0000003608.V285387.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 The service users health, personal care and social care needs are well set out in an individual plan. EVIDENCE: The initial assessment of residents need is expanded through ongoing care plans and assessment documents as part of a computerised system of recording which 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 had shown a member of staff on care plan and assessment records who has not actually been at the home for a long time, giving a false impression that this member of staff has been updating records when they have not. Staff confirmed that this had now been changed and the inspector looked at computerised records that did not show this persons name. St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 10 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 Residents receive a wholesome appealing balanced diet in pleasant surroundings at times convenient to them. EVIDENCE: On the day of the inspection the homes main large dining room was not in use as the room has been completely refurbished and redecorated, this includes new carpeting for this area. While this room has been redecorated residents have had a choice of dining area either in one of the homes lounges, which has been turned into a lounge dining area or their private rooms. The staff confirmed that these temporary arrangements were due to be end soon so that resident could return to the refurbished room in the near future. This newly decorated dining room will be a pleasant bright and clean area for residents to enjoy meals in. The inspector discussed with the catering staff the menu for the day and observed staff working in the homes kitchen. The home has a team of catering staff who are additional to care staff. Catering staff described the routines of the kitchen and how food was ordered, stored and prepared. This discussion included details of how catering staff ensured service users have a level of choice in the menu and how any special diets are catered for. Fresh produce was stored in clean and tidy areas and all foods were clearly labelled. Records kept in the kitchen included fridge temperatures, cleaning schedules and a record of service users choices. All staff working in the kitchen on the day of the inspection confirmed that they had received training relevant to their jobs. St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 11 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): x Not inspected on this occasion EVIDENCE: St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 12 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): x Not fully inspected on this occasion please see previous inspection report. EVIDENCE: St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 13 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): 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: The inspector spent some time with one of the home administrators to discuss the previous inspection recommendations this included extending recruitment documentation to include ensuring that staff job descriptions were included in the employment records. The administrator confirmed that this had now been included in all new staff recruitment files and the inspector examined three new staff files, which included this information. Care and Nursing staff spoken too also confirmed that since the last inspection the homes system of induction for new staff had been extended, so that it is more clearly linked to TOPPS standards. Staff also said that this is an area of staff training that has evolved and improved and that the organisations head office was also working on extending this further. A consistent system of induction will ensure that all staff have received comprehensive training and indication linked to a nationally recognised qualification, which will assist in ensuring that residents receive consistent well managed care from well trained staff. Residents spoken too were unable to comment on staff training. St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 14 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 The home is run in the best interests of resident’s, however, the home does not have a quality assurance system. EVIDENCE: The homes care and catering staff described a variety of systems that checked the quality of the services provided to residents and there is a range of documents that demonstrate that staff make checks on the services provided. Relatives spoken too expressed no concerns with the quality of the care or services provided in the home and were pleased with the services provided to residents. The home does not currently have a system of pulling all this information together in a systematic way so that some improvements are made as a reaction to something happening rather than as a planned proactive approach. A comprehensive system of quality assurance is in the process of being developed so that this information can be submitted to the Commission as part of the ongoing inspection process. A comprehensive quality assurance system will ensure that all staff are working together to provide consistent well St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 15 managed care that meets residents wishes and needs and any areas of improvement are identified and addressed. The home must proceed with the plans to implement this. St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 16 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 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 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x x x St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 17 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 OP33 OP36 Good Practice Recommendations Implement as planned a quality assurance system 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) St Peter`s Convent DS0000003608.V285387.R01.S.doc Version 5.1 Page 18 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.V285387.R01.S.doc Version 5.1 Page 19 - 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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