Inspection on 03/05/07 for St Peters Convent

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Peters Convent 02/05/08

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 Paul Stibbons Key Unannounced Inspection 3rd May 2007 12:00 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.V338293.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.V338293.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.V338293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 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. St Peters Convent DS0000023549.V338293.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 and was conducted over a four hour period. A tour of the building was carried out and the inspector spoke with residents and staff members including catering and maintenance workers. A variety of records and documents were examined and discussions held with the homes manager and bursar. What the service does well: What has improved since the last inspection? What they could do better: Although the home has comprehensive information as to the needs of individuals, a more workable support plan to be used on a daily basis would benefit care staff in their duties. Workers have received training on dealing with medication but there are still errors in recording the administration of medicines. These errors could place residents at risk and must be addressed through further training/supervision processes. The home’s manager is in contact with workers on a daily basis but there is still the need to formalise supervision of staff to a minimum of six times per year to comply with the NMS. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 6 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.V338293.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.V338293.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): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents or their representatives are provided with sufficient information on which to base an informed decision on whether the home will meet their needs. EVIDENCE: The home’s statement of purpose and service user guide is in the process of being updated, as the management structure is about to change. The current manager is moving to Head of Care and a new home manager has been appointed. Residents contracts viewed have been updated to comply with the requirements of the previous report. A discussion with the home’s manager and feedback from residents and staff confirms that requirements and recommendations from the home’s last report are being met or implemented. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 9 Care plans viewed evidence that pre-admission assessments have taken place prior to admission of residents. Two residents confirmed that they had a trial stay at the home prior to accepting a permanent placement. A discussion with residents demonstrated a good understanding of the routines and opportunities within the home. The home does not provide for intermediate care. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive in their assessments but workers and residents would benefit from a more workable supplementary support plan. Residents are supported in accessing a range of healthcare services but are put at risk from poor recording practices when dealing with medication. EVIDENCE: St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 11 Four resident care plans were examined that are comprehensive in their assessment of personal, health and social care needs. Risk assessments have taken place and are documented clearly with evidence of review. Records examined evidence that residents are supported in accessing a range of healthcare services inclusive of GP, hospitals, opticians, physiotherapy etc. Although there is a great deal of evidence within the care plans they would be better supplemented with a more workable support plan detailing individual routines and likes and dislikes for care staff to work from. This was discussed with the home manager who agreed to implement a more holistic support plan for residents. The storage and procedures for dealing with medication were examined. Storage of medication is in compliance with current guidelines and legislation. It is recommended that the home acquires a purpose made book to record controlled drugs rather than the book in current use. There are several omissions on medication recording sheets and although the home uses the Monitored Dosage System, current practice is open to confusion. Staff members designated to administer medication have received training and are booked for more advanced training. A discussion with the manager followed about these findings and it is agreed that the home will consult with Boots pharmacy about reviewing the system in place. It was also agreed that the manager would address the shortcomings in recording as a matter of urgency through the supervision process. Residents spoken with expressed total satisfaction with the care provided, interaction observed between workers and residents was mutually respectful. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle residents experience in the home satisfies their social, cultural, religious and recreational interests and needs. Residents enjoy a nutritious diet of their choosing. EVIDENCE: Residents spoken with during the visit explained how they kept occupied during the day and this included going out either unaccompanied or supported by staff, reading from an extensive library, television, musical entertainment both within the home and the community, exercising, videos and visiting clothing shop. Residents were observed freely moving around the home and stated that routines were flexible. There are no restrictions on visiting times and many residents said they went out for days with relatives and friends. Residents spoke highly of the quality of food provided and confirmed they had choices of what to eat and where they would like to eat their meals. Menus viewed were seen to be varied and nutritious. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 13 St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their complaints will be listened to and acted upon and they are protected from abuse. EVIDENCE: Following recommendations from a previous report the home has reviewed the complaints policy and residents are aware they have the right to contact the CSCI directly if they so wish. Residents spoken with had no complaints and state they have no issues about approaching staff or management with concerns. The staff team responsible for dealing with medication have all received training and further advanced training is planned. Staff members have received training around adult protection issues and are familiar with reporting procedures. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment with ample personal and communal space to meet their needs. Residents have the specialist equipment they require to maximise their independence. EVIDENCE: The property is well maintained and furnished to a good standard. Bedrooms viewed were of a good size and personalised reflecting the individual’s interests and lifestyles. All bedrooms viewed were en-suite with large secure windows and views out to sea. Residents spoken with said how much they liked their rooms and the pleasant views. The home has a range of specialist equipment St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 16 to maximise the independence of residents. There are various communal areas that residents have access to, and lift shafts are provided to enable residents with mobility difficulties to move around the home. Health and safety records viewed were up to date and there is a dedicated maintenance person on site. The home has a laundry with washing machine and sluicing facility with dedicated personnel. The kitchen area is maintained to a hygienic standard with written cleaning procedures and staff that have been appropriately trained. Residents have access to a well-maintained garden area with seating. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well-trained staff team and are protected by the home’s recruitment procedures. EVIDENCE: Staff records viewed evidence that robust recruitment procedures are in place. There is evidence of CRB and POVA checks having been made, two references obtained and employment history checks undertaken. There is an induction package that each new employee has to complete and ongoing training to meet statutory requirements and other relevant knowledge. Over 50 of staff members have attained a minimum of NVQ at level 2. Staff members spoken with felt that they received adequate training to provide them with the skills and knowledge to competently fulfil their roles. Adequate numbers of staff were observed to be on duty to meet the needs of residents. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is well run by a competent and qualified manager. The health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 19 Residents spoken with feel that their views are taken into account and that they hold group meetings to express any wishes. The home has reviewed policies and procedures to update information relating to the CSCI change of address and contact details. Following a recommendation of the previous report a development plan for the current year is in place. Health and safety records viewed evidence that residents health, safety and welfare is promoted and protected. Residents have control over their own money and the homes bursar maintains a ledger for any petty cash transactions giving a clear audit trail. Staff members confirm supervision takes place but formal structures do not appear to be in place, the manager is however in daily contact with staff. A new manager has been appointed and a handover process is currently taking place. Staff members spoke well of the leadership and management approach of the home. St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 20 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 X 18 3 4 4 4 3 3 4 3 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 3 3 3 3 2 3 4 St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 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 systems and recording procedures for dealing with medication should be reviewed 2. OP9 St Peters Convent DS0000023549.V338293.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local 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.V338293.R01.S.doc Version 5.2 Page 23 - 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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