Inspection on 02/05/08 for St Peters Convent

This inspection was carried out on 2nd May 2008.

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 03/05/07

St Peters Convent 16/10/06

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 Eamonn Kelly Unannounced Inspection 09:30 2nd May 2008 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.V363089.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.V363089.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 Name of registered manager Type of registration No. of places registered (if applicable) 01227 744000 Sisters of the Sacred Hearts of Jesus and Mary 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.V363089.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 Brief Description of the Service: St. Peter’s Convent, owned and operated by a religious order, provides accommodation and support for older people. Support is, in accordance with the aims of the organisation, provided exclusively for female residents. Sisters of the order retain occupancy of the 3rd floor and some other parts of the premises as part of their convent. Resident’s bedrooms are on the 1st and 2nd floors; a passenger lift operates from the basement to third floor. All residents have single bedrooms with ensuite facilities. The premises are on the seafront and have enclosed gardens at the rear. Weekly fees are £484 with some additional charges to be met by residents. Details of admission procedures, weekly fees and additional charges are contained in written pre-admission information available to prospective residents and their supporters. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that people who use the service experience good quality outcomes. The inspection took place on 2nd May 2008. The methodology used to produce the report included discussion of the AQAA (annual quality assurance assessment) currently in draft form at the home, meetings with members of the manager/Sisters of the order/residents/members of staff, checks of the parts of the premises used by residents and staff and review of records used in the care and support of residents. The outcomes of the previous inspection report were checked. Checks were also made of information known to the Commission about the service. Support is provided, in accordance with the aims of the organisation, exclusively for female residents. The previous report contained no requirements but recommended improvements in care plans and medication administration. This report contains no requirements or recommendations. In keeping with the Commission’s policy of looking closely at specific regulations and standards from time to time, some emphasis was placed on this occasion on how well the home meets Standard 18 and 29 (protection and recruitment). These standards are being met which means that the interests of residents are further protected. What the service does well: What has improved since the last inspection? The manager has introduced several improvements. These include new written pre-admission information, better individual care plans and risk assessments and increase in activities for the physical and mental stimulation of residents. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 6 Procedures for administering medication have been reviewed and updated. The induction procedure has been brought into line with “Skills for Care” standards. Staff files have been updated to make sure that the relevant employment checks are carried out. Formal staff supervision has been reviewed and improved. Over the past year, the manager has reviewed and improved many of the home’s procedures so that residents are protected and members of staff are clearer as to their responsibilities in meeting the support needs of residents. 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 Peters Convent DS0000023549.V363089.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.V363089.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, 6. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Prospective residents and their representatives are encouraged to visit the premises to see if their support needs are likely to be met. They receive the advice and guidance they need at this stage. EVIDENCE: The manager carries out pre-admission assessments that involves visiting prospective residents in hospital or other locations, meeting with relatives and discussions with health service and Local Authority care staff if appropriate. The individual care plan is begun at the point of assessment and admission. All steps necessary to enable prospective residents to make a decision about taking up residential accommodation are taken. All new residents receive a personal contract. These outline the weekly fees, additional charges and other information useful to residents and their advocates. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 9 There is a separate fee list for residents requiring respite care support and such residents receive the same pre-admission assessment as those requiring permanent occupancy. St Peters Convent DS0000023549.V363089.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): 7-11. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Resident’s health, personal and social care needs are met. EVIDENCE: Examples of four care plan records seen indicate that residents support needs are identified. Their needs are kept under review and their changing conditions are addressed. Members of staff observe any changing needs of residents and arrangements are made to address these. Relevant changes in social care or health needs are noted in individual care plans. Residents have good access to GP and district nurse services. A district nurse was at the premises during this inspection visit. Residents have good access to dentists, opticians and chiropodists. Where a resident needed help with hearing difficulties this was provided. There is also contact in individual cases with community psycho-geriatrician services. Members of staff maintain a weight chart for residents when the need for this is recognised. Nutritional charts are St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 11 raised automatically for residents with diabetes and following review for those with significant weight loss or gain. The previous inspection report requested a thorough review of medication procedures. A senior carer demonstrated how this was carried out. Medicines are stored securely, administered safely and unused stocks disposed of properly. The method of storing controlled drugs complies with current required practices. Residents are treated with understanding and respect by staff. Members of staff have experience in helping people who are seriously ill and those who are receiving terminal care. There is also support available from the Sisters of the order and from availability of church services within the premises. St Peters Convent DS0000023549.V363089.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): 12-15. People who use the service experience excellent quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents receive support to keep physically and mentally active. This support matches their expectations and preferences. EVIDENCE: Members of staff help residents to remain physically and mentally active. This support is enhanced by the individual and group attention to residents given by the activities co-ordinator. This member of staff also contributes care hours in addition to the allocated 24 hours a week for resident encouragement in remaining active. The activities co-ordinator maintains extensive records about the success of initiatives and involves residents in the planning of events and activities. During the inspection visit, many residents had copies of the home’s newsletter that contained photographs of residents and details of outings and activities. Relatives and visitors provide good support and they may visit at any time. There are several kitchenettes throughout the premises for visitors and staff to avail of informal arrangements. Residents and staff have reasonable access to St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 13 the Sister’s minibus for occasional outings. Residents spoke positively about the events arranged and of how they are involved in selecting events and venues. Residents are encouraged to continue the patterns of their former lives as far as possible within their changing circumstances and to exercise control over longer and shorter-term decisions. The manager is enhancing the importance of having relevant biographical details of each resident included in care plans. This is to enable staff to more fully appreciate and understand the nature of resident’s previous lives and occupations. Weight charts and nutritional assessments are maintained. Residents are able to have their meal over an extended period and members of staff give them assistance as needed. They are encouraged to choose from different meals options available at around noon and late evening and have their meals in very congenial surroundings. St Peters Convent DS0000023549.V363089.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. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents are protected from abusive practices. Good recruitment and training procedures are in place for the protection of residents. EVIDENCE: There have been no complaints about the service since the previous inspection visit. People connected to the service are encouraged to make their views known to the manager and members of staff and note is taken of these comments or views. Written surveys are also used for this purpose. The activities organiser also carries out regular surveys during which she helps residents where necessary to reflect on how to respond to the questions raised. The service has a complaints procedure. Residents and members of staff are aware of this procedure. The manager is updating policies and procedures for safeguarding people and is making these readily available for staff. Members of staff receive POVA (protection of vulnerable adults) training. The manager advises social services and the commission of issues affecting resident’s health. Members of staff are aware of how they should report concerns to the relevant local authority. Care plan records indicate that care managers carry out frequent reviews of social services funded residents. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 15 Staff files indicate that references are taken up and new members of staff receive induction that meets the requirements of the relevant care-sector organisation (Skills for Care). The draft AQAA (annual quality assurance self-assessment) indicates that the manager plans to provide staff with training on working with residents with the on-set of challenging behaviours to enable them to work confidently and effectively when problems and new situations arise. A member of staff also indicated that consideration is being given to this issue as the home continues to support people as their aging problems increase. St Peters Convent DS0000023549.V363089.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26. People who use the service experience excellent quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents have the benefit of living in premises that meet their accommodation and support needs. EVIDENCE: Bedrooms are situated on the 1st and 2nd floors and residents have the additional benefit of access to a passenger lift. All bedrooms are single and are equipped with en-suite facilities. Some of the convent’s Sisters occupy bedrooms on the residential floors but most have their own accommodation on the 3rd floor. Handrails have been fitted throughout the premises for residents’ safety. Specialist equipment is provided throughout the premises (for example several Parker baths in bathrooms, bed sides, hoists, call bells in bedrooms and communal areas, electrically operated beds). St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 17 The draft AQAA (annual quality assurance self-assessment) states that the necessary safety checks have been completed and that, for example, fire safety checks are undertaken and recorded. The premises are kept clean and tidy and are in good condition. Lounge areas are comfortable as are dining room areas. The enclosed gardens are suitable for use by frail older people using them independently or accompanied. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 18 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): 27-30. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. The use of appropriate recruitment, selection and training procedures contributes to the safety, comfort and protection of residents. EVIDENCE: Three residents and two visitors said they have confidence in the staff that care for them. Rotas show well thought out ways of making sure that the home is staffed efficiently with attention given to the changing needs of the people who use the service. Staff files indicate that most members of care staff have achieved an NVQ qualification and all are encouraged to do so. Members of staff also undertake training in moving & handling, infection control, health and safety, and medication administration. The manager is looking at the possibility of enabling staff to undertake the RVQ Certificate in Dementia Care and intends to identify suitable providers. She is also moving towards having some staff undertake Moving & Handling Trainer Training so that this staff support can be provided in-house. Job descriptions and specifications define the roles and responsibilities of staff. People who use the service report that staff working with them are skilled in their role and are consistently able to meet their needs. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 19 The manager says that she is given sufficient funding to have enough staff available to meet the needs of the people using the service. The rota sheets examined evidenced this. Members of staff receive relevant training that is focussed on delivering improved outcomes for residents. The training matrix on view suggests that the home puts a high level of importance on training. Staff say that they are supported through training to meet the individual needs of people in a person centred way. There is a good recruitment procedure that defines the process to be followed. The relevant checks are carried out including CRB and POVA-first checks. The previous inspection report requested more emphasis on formal staff supervision and staff files indicate that this request has been addressed. There are clear contingency plans for cover for vacancies and sickness; there is little use of agency or temporary staff and a “bank” staff procedure is maintained to enable staff to be obtained when necessary. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 20 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, 33, 35, 38. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. The management and administration of the home is based on openness and respect and has effective quality assurance systems. EVIDENCE: Supported by the organisation’s strategic, financial and operational systems the manager conducts the home in the interests of residents. For example, she says that she is confident that the budget for staffing hours is sufficient for meeting the needs of residents. Discussion is taking place to ensure that everincreasing needs of residents are properly met. The manager has a clear understanding of the key principles and focus of the service. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 21 The providers aim for an increased quality of life for residents with a focus on equality and diversity issues. There is also a focus on person centred thinking with residents shaping service delivery. There is a strong ethos of being open and transparent in all areas of running of the home. At the time of the inspection visit, the manager was completing the AQAA (annual quality assurance assessment). This document lets the commission know about changes providers have made and where they still need to make improvements. The manager showed how this is being completed and, for example, how she will be able to make a declaration that all necessary safety checks and associated certificates are in place. The service has good policies and procedures that the manager reviews and updates in line with current thinking and practice. She ensures that all members of staff follow the policies and procedures of the home. Over the past year the manager has improved many of the home’s important procedures. The home has a clear health and safety policy. The manager is confident that all members of staff are aware of the policy and are trained to put theory into practice. She says that regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. The manager and registered responsible person for the service deliver good business planning and effective financial controls. The manager will submit an application within the coming weeks to be registered with the commission and intends to achieve the Registered Manager’s Award. Quality assurance and monitoring procedures are in place for efficient running of the home, to give value for money and deliver effective outcomes for the people who use the service. The examples of questionnaires used by the manager and activities organiser show that residents are centrally involved in having a say and being helped to give this feedback. People are supported to manage their own money where possible. Where this is not possible there is a clear reason why and they receive advice to obtain impartial legal and financial support. Individuals have access to their records whenever they wish. St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X X 4 X 4 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 Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations St Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Peters Convent DS0000023549.V363089.R01.S.doc Version 5.2 Page 25 - 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. 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