Inspection on 16/10/06 for St Peters Convent

This inspection was carried out on 16th October 2006.

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 Peters Convent 02/05/08

St Peters Convent 03/05/07

St Peters Convent 13/02/06

St Peters Convent 24/08/05

St Peters Convent 16/01/05

St Peters Convent 02/06/04

St Peters Convent 26/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Peters Convent 15 St George`s Terrace Herne Bay Kent CT6 8RQ Lead Inspector Jenny McGookin Unannounced Inspection 16th October 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 Peters Convent DS0000023549.V312500.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 Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters Convent Address 15 St George`s Terrace Herne Bay Kent CT6 8RQ 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) 01227 744000 Sisters of the Sacred Hearts of Jesus and Mary Post Vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: St. Peter’s Convent is a care home providing personal care and accommodation for older people aged 65 years and over. It is owned by the Sisters of the Sacred Hearts of Jesus and Mary. The home is located on the seafront in Herne Bay. It is within easy reach of the local shops, amenities and public transport. The home was opened in 1997 and consists of a four storey listed building. The property also houses a convent. Residents’ accommodation is on the first and second floors. All residents occupy single rooms with en-suite toilet facilities and some with a shower. A shaft lift provides access to all floors. At the rear of the property there is an attractive, well-maintained enclosed garden with a patio, lawns and flowerbeds. The current fees for the service at the time of the visit were £303-456 per week. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. There is also an e-mail address for personnel at this home, e.g. the current manager’s is: patsy@stpeters.ws St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit, which was used to inform this year’s key inspection process and to check on any developments since the last available inspection report (February 2006), given no matters were raised for attention on that occasion. It was also used to review findings on other aspects of the day-to day running of the home not covered by the previous inspection report. The inspection process took just under ten and a half hours. It involved meetings with four residents (including one group of three over lunch), two visitors and one visitor, the manager and four staff, representing the care side as well as catering and health and safety / maintenance. Interactions between staff and residents were observed throughout the day. The inspection also involved the examination of records and policy documents and the selection of three residents’ case files, to track their care. Four bedrooms were inspected for compliance with the National Minimum Standards on this occasion, along with communal areas / facilities. What the service does well: What has improved since the last inspection? St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 6 There have been no requirements or recommendations arising from inspections since January 2005, indicating the registered person is working well with the regulators and other agencies to maintain its high 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 Peters Convent DS0000023549.V312500.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 Peters Convent DS0000023549.V312500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 1. Not all the documentary information necessary for potential residents to make an informed choice is available. 2. Each placement is governed by a contract, but it requires further attention to be fully compliant with the elements of this standard. 3. There is a systematic preadmission assessment process in place, which is designed to ensure the home is taking the lead in the process and is obtaining a consistent approach 4, 5. The admission process includes an invitation to visit the premises, taste the food and a trial stay so that residents know what to expect. 6. This home does not provide intermediate care. EVIDENCE: St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 9 This home has a Statement of Purpose and Service User Guide, each of which usefully describes the facilities, services and principles of care, but work will need to be done to obtain full compliance with all the elements of this standard. These have been reported back to the home separately. No other languages are currently warranted, but the inspector would recommend that the home’s “Enquiry and Preadmission” documents record when the Statement of Purpose and Service User Guide are issued and whether other languages or formats are warranted – so that the home can evidence that residents have all the information they need, in readily accessible formats, to make informed choices. The home’s own contract was assessed against the elements of this standard on this occasion and judged compliant with almost all the elements of this standard. Matters requiring further attention have been reported back to the home separately. Feedback on the day of this inspection confirmed that the decision to apply to this home was influenced more by its locality (i.e. close to where the resident, or relatives lived), or previous contact or recommendation, than by any public information produced by the home itself. The residents spoken to on this visit were satisfied with the choice of home made on their behalf. All three files selected for care tracking contained assessments by healthcare agencies, which predated the residents’ admission as well as the home’s own preadmission questionnaire, though these were not always dated and there were gaps. The manager said that prospective resident or their representative is invited to visit the home, and stay for a meal, but the residents spoken to on this occasion could not on this occasion recall having done so. Two relatives and a visitor did. Each resident is offered a trial stay of four weeks before their admission is confirmed by contract. See section on “Environment” for a description of equipment and adaptations, and section on “Health and Personal Care” for a description of services provided. Intermediate Care This home does not provide intermediate care. Should it do so, all the elements of National Minimum Standard 6 will apply. St Peters Convent DS0000023549.V312500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 7. The assessment and care planning processes cover a health and personal care needs, as well as some social care needs. 8. The home is served by a range of healthcare professionals as appropriate, and there are generally adequate facilities for privacy. 9. Residents are protected by the home’s medication arrangements. 10. Residents feel they are treated with respect and their right to privacy is upheld. Observed interactions between staff and residents were respectful during this inspection. EVIDENCE: Three residents’ files were selected for case tracking on this occasion. The format of the care plans used by this home is clearly designed to build on information obtained in preadmission assessments and to address a wide St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 11 range of personal, health and some social care needs of the residents. And they are usefully underpinned by a range of risk assessments covering the individuals, their activities and environments. Mobility, skin integrity and risk of falls featured in all three. However, despite a lot of information on the individuals’ backgrounds, preferences and interests, there was clearly a personal and healthcare bias thereon in the care plans seen. One would need to see records of activities to obtain a rounder view of these residents’ lives at this home. And the inspector judged some staff instructions in care plans would apply universally. Records confirm that care plans are being reviewed monthly, or more frequently as required. When asked, however, none of the residents showed any recognition of the formal care planning process as such on this occasion, though they all recalled being asked questions about their care needs on a day-to-day basis thereon. Without exception, the residents and relatives / friends spoken to on this occasion each expressed a high level of satisfaction with the care provided by the staff at this home. Observed interactions were judged appropriately familiar and respectful. Records and feedback obtained on the day confirmed that residents have access to the same range of healthcare services as are available to other residential care homes – GPs, hospitals, opticians and community nursing. Some services are available through GPs e.g. physiotherapy, occupational therapy, speech therapy. The home uses the Monitored Dosage System and has a policy and procedure for the acquisition, storage, administration and disposal of medication, to comply with accredited practice models. This is properly underpinned by staff training (initially a presentation by Boots, with more advanced training booked for November this year), reference material and day-to-day liaison with its dispensing chemist. Red tabards are worn by staff while administering medication so that any need to disturb them is kept to a minimum. Residents can self medicate, subject to their risk assessment. There is a dedicated clinical area and the inspector judged the storage arrangements and record keeping seen on this occasion generally sound, though this element of the standard will be subject to closer scrutiny at a later date. All the bedrooms in this home are single occupancy, which means personal care and treatments can be given in privacy. See also section on “Environment” for details of equipment and adaptations. St Peters Convent DS0000023549.V312500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 12, 14. The routines of daily living are flexible to suit the individuals’ expectations, preferences and capacities. Residents are generally content with their lifestyles in this home, and the home offers a range of activities inside and outside the home. Records of individuals’ activities require updating. 13. There are open visiting arrangements, and the home is well placed for access to local shopping outlets 15. The home offers residents a varied diet and staff are readily available to assist residents. Mealtimes are unhurried and the settings are congenial. EVIDENCE: The residents who met with the inspector on this occasion were not able to give many examples of any particular interests and hobbies being promoted by the home, but said they were generally content with their lifestyles there. Something like a half of the residents are able to go out independently, but the home has access to its own minibus and two cars. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 13 There is no dedicated activities co-ordinator, nor is there an activities programme as such. But an examination of records of past events arranged by the home (on average, four a month) included: musical and entertainment events on and off site (at local venues), outings, seasonal events such as Valentines day, summer garden fete etc, exercises to music and games. The home has a Loop system (for use with hearing aids) in its lounge and has ample stock of DVD’s and videos. There is also a visiting clothing shop. The home has its own Chapel but visits to and from clergy from other denominations can also be arranged, along with escorts (if residents are unable to arrange this for themselves) subject to staffing levels. Important contacts (families and friends) are properly established as part of the admission process, and the home has open visiting arrangements. Visitors are asked to sign in and out the visitors’ book and to inform staff if they intend taking any of the residents out. They can also stay for meals. The daily routines are as flexible as healthcare needs will allow. Residents confirmed that they can choose when to get up and go to bed, and can choose to eat in their rooms. They were observed being supported to make choices and decisions during the day of this inspection. There are residents’ group meetings (one was planned for the day of this inspection visit), which address a range of matters to do with the running of the home. The meals at this home tend to be traditional English fare and were singled out as one of the home’s strengths. The inspector met with one of the cooks to discuss menu planning, and was satisfied that fresh meat, fruit and vegetables feature every day. The lunchtime meal options were sampled, and were judged tasty, well presented. The residents confirmed that they had a choice of menu options (usually at least two choices for each meal) and that they could change their minds and have snacks in between meals. There is a choice of dining area and each is furnished and decorated in a homely, congenial way. The pace of the meal was unhurried. Staff were observed assisting residents to eat in a respectful way. The home provides some adapted cutlery and crockery (e.g. plate guards). There are kitchenettes on each floor, which residents can use for breakfasts or snacks, and records confirm that their ability to use these facilities safely is risk assessed in each case. St Peters Convent DS0000023549.V312500.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 16. There is a complaints procedure readily available, and residents feel that any complaints they had would be listened to and acted on. 18. Residents feel well cared for and safe, and there is a policy on adult protection, underpinned by training. EVIDENCE: This home has a policy on concerns and complaints, which properly commits the home to try to resolve complaints within a specified timeframe, to record all complaints in the home’s register, and includes the complainant’s option to refer their complaint to the Commission at any stage if that is their preference. However, prospective complainants who wish to pursue the option of referring their complaint to the Commission are also requested to involve the Trustees via the manager or deputy manager. The inspector judged this would effectively rule out the scope for any anonymous complaints / whistle-blowing. Complainants who wish to take their complaints further are also requested to put their complaints in writing. The inspector judged this could prove offputting for anyone with a visual or literacy impairment. The inspector also noted contact details for the Commission will require updating to take into St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 15 account its Maidstone location and requires telephone, e-mail address etc. to facilitate access. There was only one complaint logged in the home’s register, dating from September 2005. This is not judged a realistic reflection of communal living, even where there is a generally high level of satisfaction expressed by residents, and the challenge will be to better evidence how the home resolves any day-to-day expressions of dissatisfaction in its complaints register. The home also has a range of policies to safeguard the residents against abuse: on service users’ rights, protection, whistle blowing, restraint, investigations. Staff confirmed their commitment to challenge and report any instances, should they occur, and residents said they felt safe. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 16 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, 23, 24, 26 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. 19. The layout of this home is generally suitable for its stated purpose and is very well maintained. 20. Residents have a choice of communal areas, and furnishings tend to be domestic in character. There are homely touches throughout. 21. Lavatories and washing facilities are accessible to bedrooms and communal areas 22. There is a range of equipment and adaptations but periodic assessment of the premises by an Occupational Therapist are recommended to ensure the home maintains its capacity to meet the needs of the residents. 23. All the residents have access to the privacy of their own bedrooms and each bedroom is personalised. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 17 26. The home is generally well maintained and all areas inspected were free of any unpleasant odours. EVIDENCE: This home is located on the seafront in Herne Bay. It is within easy reach of the local shops, amenities and public transport. The inspector noted that no matters were raised for attention in respect of the environment at the last inspection, and that the last inspection reported that there were no outstanding requirements from the local fire safety officer or local authority environmental health officer. This is judged a good use of the regulatory frameworks. There has been no overall periodic assessment of the premises by an Occupational Therapist, but the inspector understands there are problems accessing this kind of resource across the region. However, individual residents are assessed by OTs and physiotherapists, as part of the admission and care planning processes, to ensure the home maintains its capacity to meet their needs. There is a generally adequate range of equipment and adaptation available in this home. Residents have access to wheelchairs, Zimmer frames and other mobility equipment, and the inspector noted that these were being stored discreetly i.e. not cluttering communal areas. There are hand / grab rails throughout the property. There is a shaft lift providing access to all floors, and a platform lift on each floor (i.e. 3) for small flights of stairs. The garden areas are also accessible to residents with mobility impairment. A number of residents wear hearing aids, but the home only has one Loop system (linked to the television) in its lounge. Residents have a choice of communal areas, and furnishings tend to be domestic in character. There are homely touches throughout, and the home was clean, adequately lit and centrally heated at comfortable temperatures throughout. There is a communal phone booth in a lobby, which is wheelchair accessible and has a seat. It is used a lot. It has a flashing light on the outside to signal an incoming call and it also rings in the lounge. There is also a communal phone on the 1st Floor. All bedrooms have telephone sockets. Residents can have phones installed at their own expense or, more usually, use their own mobile phones. All the current residents have access to the privacy of single bedrooms. Four bedrooms were selected for assessment against the National Minimum Standards on this occasion. They were found to be generally compliant with St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 18 the National Minimum Standards, well maintained and personalised. All the bedrooms have en-suite WCs and hand-basins, and a large number have baths and/or shower facilities, so that privacy and their availability are assured. Records confirm that where some facilities were withheld (e.g. locks on cupboard doors or windows) this was properly subject to individual risk assessment. The siting of electrical sockets three feet from the floor was judged good practice, as it means residents can operate them independently, without having to stoop or seek staff assistance. This home has sufficient communal baths, WC and shower facilities i.e. reasonably accessible to almost all the bedrooms and communal areas. All the bedrooms, moreover, have en-suite WCs and many have full en-suite facilities. The standard of cleanliness and layout of the catering area were judged of a good standard. All surfaces were continuous, impermeable and easily cleanable. Fridge and freezer temperatures were compliant with food safety standards, and food safety hygiene features regularly in staff training. Continence is managed very effectively. The laundry has a washing machine with a sluicing facility and dedicated laundry personnel. There were no unpleasant odours anywhere in the home. All the maintenance and health and safety records inspected were up to date and systematically stored. The home clearly benefits from having its own cleaning staff and maintenance man. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 27,28. There was compliance with the staffing levels as described, on the day of this inspection site visit, and feedback from residents and relatives confirmed that they were generally very satisfied with the care given. 29. The home’s recruitment process is systematic, to safeguard the residents 30. There is a rolling cycle of training to ensure staff competence in a range of health and safety related practice, including NVQ accreditation. EVIDENCE: The inspector understands the following staffing arrangements apply: • • • • • • • 7am till 3pm – Manager plus 3-4 carers 12-8pm = 2nd shift – 2 carers and I other carer from 4-8pm 7.45pm till 7.45am – 2 carers (both of whom are waking night staff) There is a cleaner for each floor from 8.00am till 2.00 – this is applied flexibly so individuals may, for example, start and finish earlier There are two dedicated laundry staff who alternate There is a Head cook, plus a deputy and three kitchen assistants – one of whom covers for him There is a caretaker / driver who comes on duty every day DS0000023549.V312500.R01.S.doc Version 5.2 Page 20 St Peters Convent Although some staff said that having more staff available at busy times of the day would be appreciated, this has been judged adequate staffing provision given the number and dependency levels of the residents (11/17 residents are low dependency), as well as the layout of the home. Any day-to-day shortfalls are covered by existing staff or agency staff. Staff and records confirmed a generally systematic recruitment process, which was subject to satisfactory references (though in one case this only amounted to one), identification checks, POVA First checks by the home, and CRB checks (though CRB checks are maintained by an umbrella organisation and stored separately). Records and staff also confirmed induction is provided for new appointments, and that is a rolling cycle of mandatory training on issues such as manual handling, Food hygiene / nutrition, infection control, First Aid, health and safety, medication (with more advanced training booked for November), adult protection and fire safety training etc. Almost half the staff (45 ) have undertaken NVQ Level 2 training or above (with four more in close prospect – the estimated completion date is February 2007). Further training is planned in dementia care, record keeping and foundation training. This was judged an appropriate level of investment. Feedback confirms that this manager has an open, accessible management style and that she is supportive to staff. However, see section on “Management and Administration” in respect of future plans. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 21 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, 32, 33, 34, 35, 36, 37 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 31, 32. The home has generally been able to demonstrate good use of the inspection and regulatory processes. 32, 33. There is evidence of some formal as well as day-to-day informal dialogue with residents and their relatives to maintain an open and inclusive ethos; and to ensure the home is run in their best interests. But this needs to link conspicuously with a Quality Assurance system and an annual development plan. 35. There are robust procedures in place for accounting for and safeguarding residents’ finances. 36. Staff who give direct care are given supervision, but the frequency of this needs to comply with the elements of this standard. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 22 38. All property maintenance records and health and safety checks seen were judged well maintained. EVIDENCE: Patricia Tweedie has been managing this home for the past three years, having previously managed another home and worked for the NHS. She is a 1st level nurse and has a Diploma in Social Policy / Psychology. She is also an NVQ Assessor and reports having successfully completed the Registered Manager’s Award. However, Ms Tweedie has not in that time submitted her application for registration by the Commission. The inspector was advised that the organisation is currently undergoing changes, and that she will become the care co-ordinator (i.e. taking over the direct care side of the home) before going back to university next year. Another manager is scheduled to join the home in the near future. There are clear lines of accountability within the home and within the organisation. Records and care staff confirmed having received supervision from line management, though the frequency of this varied from between 1-4 months, and there were gaps. The reader is advised that the standard for care staff is at least six times a year. These sessions are said to usefully review performance since the last session; and were also used to discuss operational matters as well as identify training and support needs. Supervision for support and ancillary staff involves a more needs led approach as part of continuous management. All staff said they found line management approachable on a day-to-day basis. Records confirm that there is good provision for the health and safety of people who live and work at this home. All maintenance records seen were up to date and filed systematically. And the caretaker is to be commended for the diligence with which he carries out health and safety related quality control checks and staff training. There are policies and procedures governing practice (though some of these will require updating to take the Commission’s new title and contact details into account), and these are usefully underpinned by staff training. See section on “staffing” in respect of supervision, however. There was good evidence of residents’ participation in informal day-to-day choices, and in larger group meetings (one was planned for the day of this inspection visit). But there was no systematic quality assurance system in place other than that operated by the Commission. Nor was there an annual St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 23 financial or development plan available for inspection for the current year. These will be required. The registered manager ensures that residents have good control over their own money. And safeguards are in place to protect the interests of the residents – the home’s bursar maintains a ledger for any petty cash transactions with the residents, and they are required to countersign and dayday transactions. Receipts are kept to provide an audit trail. The manager does not, as a matter of policy moreover, act as Appointee for any residents. St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 4 St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1)(c) 5(1) Requirement The home’s Statement of Purpose and Service User Guide will require attention to obtain full compliance with all the elements of this standard The home’s contract will require attention to obtain full compliance with all the elements of this standard There needs to be a systematic quality assurance system, which combines with financial planning processes to produce an annual development plan for the home. The views of all stakeholders should be central to these processes, to properly measure the home’s success in meeting its aims, objectives and statement of purpose. Care staff need to receive formal supervision at least six times a year Timescale for action 31/12/06 2 OP2 5(b)(c) & Schedule 4 24 31/12/06 3 OP33 31/12/06 4 OP36 18 30/11/06 St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 26 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 OP7 OP12 OP33 OP16 Good Practice Recommendations Care plans should be used to translate objectives into practical staff instructions and to more conspicuously address the aspirational, social care needs of residents The home should consider setting up a dedicated activities co-ordinator and activities programme. The plans to build on the work already undertaken should be progressed. The home’s complaints procedure. Three matters are raised for attention: • Access to the Commission should not have to be subject to the involvement of line management personnel. • Prospective complainants should not be required to put their complaints in writing. • The challenge will be to better evidence how the home resolves any day-to-day expressions of dissatisfaction in its complaints register One resident would like to be able to raise the foot end of her bed and may benefit by an adapted armchair. 5 OP24 St Peters Convent DS0000023549.V312500.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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