Inspection on 06/09/07 for St Raphaels Nursing Home

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Raphaels Nursing Home 09/08/06

St Raphaels Nursing Home 09/01/06

St Raphaels Nursing Home 05/07/05

St Raphaels Nursing Home 01/02/05

St Raphaels Nursing Home 15/07/04

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

CARE HOMES FOR OLDER PEOPLE St Raphaels Nursing Home Danehurst Danehill East Sussex RH17 7EZ Lead Inspector Chris Woolf Key Unannounced Inspection 6th September 2007 09:40 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 Raphaels Nursing Home DS0000014049.V348191.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 Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Raphaels Nursing Home Address Danehurst Danehill East Sussex RH17 7EZ 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) 01825-790485 01825 790715 www.anh.org.uk The Trustees of the Order of St Augustine of the Mercy of Jesus Sister Mary Basil (aka Catherine Rath) Care Home 58 Category(ies) of Dementia - over 65 years of age (58) registration, with number of places St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is fifty eight (58). That only adults with a dementia type illness are to be accommodated. That service users must be sixty five (65) years or over on admission. That a maximum of eight (8) service users with a learning disability can be accommodated, who can be aged below sixty five (65) years. That service users between the age of fifty five (55) and sixty four (64) years with a dementia type illness can be accommodated. 9th August 2006 Date of last inspection Brief Description of the Service: St Raphaels is a care home providing nursing and social care for up to fiftyeight people suffering with dementia. Within this number they are able to accommodate eight residents with a learning disability under the age of 65 who need care and support. The Trustees of the Order of St Augustine of the Mercy of Jesus are the owners. The organisation has other home’s in East Sussex. St Raphaels is situated in extensive grounds near to the hamlet of Danehill. The nearest towns are Haywards Heath and Burgess Hill. The home provides twenty-eight single rooms and fifteen shared rooms. There are several lounges and dining areas. The chapel attached to the home is open to local residents. Set in landscaped grounds, there are attractive enclosed gardens as well as lakes and woodlands. Residents can access these safely. The home’s literature states that one of its main aims is to provide unique high quality care, which enables individuals to lead valued and fulfilled lives with freedom to make choices. The home provides nursing care and support to residents who are both privately funded and those who are funded by Social Services The current fees for the service at the time of the visit range from £605 to £625 per week. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is sr.basil@anh.org.uk St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 5 St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. When reading this report it should be noted that where the word ‘residents’ is used this refers to the people who use the service. The information for this report has been gained from an annual quality assurance assessment carried out by the home; questionnaires received from 10 residents, 8 relatives, and 1 health care professional; and an unannounced site visit to the home lasting just under 7 hours. This means that people at the home including the staff did not know the inspection was going to take place. The Deputy Manager made herself available to assist throughout the inspection site visit in the absence of the manager. The site visit focused on talking with the majority of residents, the majority of the staff on duty, the Chaplin, a visiting health care professional, 9 visitors, and the deputy manager in order to gain their views on the service. A tour of the home took place. Observations were made of daily life in the home including activities that were taking place, a meal being served, and the interaction between the staff and the residents. A variety of records were looked at including care plans, staff files, activities records, medication records, accident records, and a variety of policies and procedures. The inspector would like to thank the Deputy Manager and all of the residents, staff, and visitors for their help during the site visit. What the service does well: This service offers a well managed home with high quality care, by well trained staff, in pleasant and comfortable surroundings. Residents’ privacy and dignity is respected, interesting activities are organised for them and they receive good quality meals. This is best described in comments received from residents, staff and visitors. The quotes come from comments made during the visit shown “...” and on comment cards received shown ‘…’. “Its superb”. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 7 “I don’t think she could be in a better place. … She has quality of life here, the best she could have” ‘St. Raphael’s provides a loving and caring environment which embraces not only the patient but his family and friends as well. Nothing is ever too much trouble for them’ ‘xxx appears happy and well looked after. The sisters are very kind and she seems to genuinely look on them as her friends. The care home gives off an aura of calm and quiet and its very homely. They are very attentive to visitors and seem to really know what is going on with all the people in their care. The staff seem to be very good, partly down to the great leadership from the sisters who always seem to be on the ball’. ‘ St. Raphael’s provides for the individuals specific needs; Treats the person with respect and great care; Looks after the needs of visitors, such as family members who have travelled large distances (tea & cakes etc!!); Always calm and sisters are always willing to talk and provide information; and trains staff well’. ‘St. Raphael’s offers a wonderfully caring and loving environment - the staff are always smiling and cheerful which makes such a difference when visiting’. ‘Trouble is always taken to maintain, to the highest level, my mother’s dignity and well-being. Although she can no longer communicate it is obvious that she is very well cared for’. “The activities are fantastic”. “The meals are good, they respect our choices” What has improved since the last inspection? The home’s Statement of Purpose has been updated to reflect the home’s approach to equality and diversity Additional information has been included in care plans. Individual risk assessments are now more comprehensive. The home has changed to use of the Monitored Dosage System for medication. Some bedrooms have been redecorated; new carpets have been laid in the 1st floor corridors; and a new built in fridge & freezer has been installed. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 8 The organisation has recently updated its induction programme. More comprehensive risk assessments have been introduced for all areas of the home 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 Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 9 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 Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 10 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. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that they will receive sufficient information to make a decision about admission to the home and that their needs will be assessed to ensure that the home is able to meet these needs. EVIDENCE: The home’s Statement of Purpose has been updated since the last inspection to reflect their approach to equality and diversity. Resident comment cards received confirmed that they received enough information about the home before moving in so that they could decide if it was the right place for them. One said, ‘I have been coming here for mass and I have also expressed to my St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 11 wife that if it were to come to the point that I needed help I would like to be placed here, as I know sisters, priest and people are friendly to me’ Each resident is issued with a contract (or statement of terms and conditions) when they move into the home. A qualified nurse from the home visits all prospective residents and their family, and any appropriate advocate or professional, to complete a preadmission assessment form covering the 12 activities of daily living, and any equality and diversity needs of the resident. The information received during this assessment enables the home to assess whether they can fully meet the needs of the prospective resident. Where residents are care managed or in hospital or another home assessments are also obtained from these sources. Relatives commented, “I waited 6 months for a place, its excellent”, “Mum came here for an assessment and mass”, and “I visited 15-20 places, this is head and shoulders above them all”. This home does not offer the facility of intermediate care, which is a specific service to enable residents to receive intensive rehabilitation in order for them to be able to return to their own home’s St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. The staff of the home, supported by a multi-disciplinary health care team, meet residents’ health, personal and social care needs. Residents’ privacy, dignity and independence are promoted. Safe systems of medication management help to protect residents. EVIDENCE: An individual, holistic, plan of care is in place for each resident. These care plans are based on the information gained during the pre-admission assessment and include any equality and diversity needs. Care plans are reviewed and updated monthly or more frequently if the needs of a resident St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 13 change. Residents or their representatives are involved in the formation and review of the care plans. Since the last inspection the home has introduced a more comprehensive form of risk assessments, they also now include information when needed on bruising and on challenging behaviour to help them to more easily monitor the frequency of such episodes The sisters, staff nurses, and care staff give high quality care to meet the needs of the residents. Where the risk of pressure areas is identified preventative measures are taken. The trained nurses deal with any pressure areas that may develop. At the time of the inspection site visit there were no incidences of pressure sores in the home. Nutritional screening takes place for all residents, they are weighed monthly and any significant changes are investigated. On the day of the site visit an optician was visiting the home to check on resident’s sight. Other services include G.P., continence advisor, and access to hearing tests and other NHS services. Visitors commented, “They took her to the dentist”, “The Doctor came to visit”, and “She had her eyes tested recently and has new glasses”. A visiting professional commented, “I have been coming a couple of months, never had any problems. I think the care is excellent”. Residents comments included, “We get well looked after” “They look after you night and day”, “They meet our health care needs”, ‘I receive good medical support from Sr. Basil and the staff nurse on duty and the G.P. visits once a week and is available for me to see if required’, and ‘I receive very good support and care here, the sisters, the nurses, the care assistants and also priest are always available when I need them’ Visitor comments included, “The care is superb”, “They answer the buzzers quickly”, “She is wonderfully looked after”, “The care is excellent”, ‘Since mum has stayed here her needs and her requirements have been exceeded by the loving care she receives from the staff’ Since the last inspection the home has changed to a monitored dosage system of medication. Medication policies and procedures in the home are sound and protect the residents. All of the residents in St. Raphael’s are treated with respect, their dignity is respected and their privacy is upheld. Residents’ comments included, “We are treated very nicely and politely, we are treated like ladies”, and ‘We all have a wonderful time here and are treated with dignity and respect at all times’. Visitor comments included, “They treat them with utter respect”, and ‘My mother is fully supported by nursing and care staff in a dignified and polite manner’. A resident comment card included, St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to lead a life that meets their needs and expectations with choices in all aspects of their daily lives; they are supported to maintain links with the family and friends; and they receive a healthy and nutritious diet. EVIDENCE: The home organises a good variety of activities for the residents, and employs a dedicated activities co-ordinator. Resident comments included, ‘There are lots of activities, I am taken on holiday once a year with the other residents by sister Basil to Butlins for 6 days; Art class once a week; O.T. twice a week; Bar-b-ques; strawberry tea party; and taken shopping once a week in the mini bus to Burgess Hill, a member of staff comes with us’, ‘ I am taken out for St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 15 walks in the garden frequently’, ‘I like singing, dancing, being involved in a variety of activities especially I like musical entertainment which are provided here at home’, and “We have a strawberry cream tea party here this afternoon”. A relative commented, ‘The staff make every effort to ensure that my mother is provided with every opportunity to participate in activities e.g. barbeque, singsongs and other entertainments, thus ensuring a good quality of life’. Residents’ religious needs are supported by the home. There is a chapel in the home and the chaplain holds daily services, which are also open to the local community. A Church of England vicar visits regularly and other denominations are made welcome. Residents’ said, “I have just been to chapel”, “the priest supports us”, and “I do not practice any faith”. Visitors are always made welcome in the home and can visit at any time to suit the needs of the resident. Visitors commented, “I am always offered tea and homemade cakes”, “They give me so much support too”, and “We had our golden wedding service here, it was lovely”. Staff said, “We always offer visitors tea and take them to the parlour or the residents room”, “Some visitors come for lunch”, and “The sisters put up some visitors, if they come from a distance”. Residents are given choices in all aspects of their daily lives. They are encouraged to look after their own financial affairs as far as they are able. They are encouraged to bring some of their own personal possessions into the home to personalise their rooms. Meals at the home are all freshly prepared to a high standard. Meals are nutritious, balanced and attractively served. Menu cards are placed on the tables giving the days choice of lunch and supper, and the meal is served from heated trolleys once they have made their choice. Where residents need to have pureed food this is served in separate portions to look like a regular meal. A vegetarian option is served at each meal. Currently the home does not have any residents with ethnic food requirements. Residents are able to have their meals where they wish whether this be in one of the dining rooms or in their own bedrooms. Appropriate help is given if a resident assistance with eating or drinking. Residents’ comments included, “The food is lovely”, “I like the food”, ‘I like the food, they respect our choices’, and ‘I am always given an alternative at mealtime if I do not like the meal on the menu. I do get a fairly good choice’. Visitors comments included, “I have eaten here, it’s very good”, “xxx says the food is a very high standard and she is fussy”, and “The food is fantastic, really, really lovely”. Staff said, “they get a good selection of food”, and “The meals look nice”. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 16 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 can be confident that their concerns and complaints will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a clear complaints policy and procedure and a copy is on display in the hallway for all to see. There have been six complaints during the past year but these have all be very minor and have all been resolved to the satisfaction of the complainant. Resident and visitor comment cards confirmed that they knew who to speak to if they had a concern and how to make a complaint. Resident comments included, ‘I can go to sister Basil or the nurses and the carers if I have a complaint’, and ‘I go to the staff and make a complaint and they will deal with it’. Visitor comments included ‘I am perfectly happy with the care my husband receives and have never had cause for complaint’, ‘We always feel that any concerns we have can be discussed openly with the staff and it will be taken St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 17 seriously and dealt with’, everything perfect”. “I have nothing but praise for it”, and “You will find In addition to the complaints register the home also maintain a compliments folder. Some of the comments from letters in this folder include, ‘He could not have been better cared for and loved by your staff and nurses’, ‘… how deeply appreciative we are for the very professional and generous care you are giving them - and for the unfailing welcome and time you give us …’, ‘We are full of admiration for St. Raphael’s and for the care xxx are receiving’, and ‘We observed the conscientiousness and dedication of the staff in the way they treated all the residents as individuals …’. Residents are protected from abuse by the home’s policies and procedures. All staff are trained in Adult Protection and staff spoken to all knew how to report any suspected abuse. No new member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults register has been received. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is pleasant, comfortable, clean and well maintained, with attractive gardens and bedrooms that meet their needs. EVIDENCE: St Raphael’s is located in an attractive country house, which adjoins a convent. The home has been extensively upgraded and adapted for its present use and is very well maintained. There is a passenger lift available for access to the upper floors, and level access is available to the grounds. The gardens are well used and there are attractive seating areas and a courtyard area with a St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 19 bird aviary. On the day of the site visit there was a strawberry cream tea party in the rear garden which was enjoyed by residents and their visitors. For security all external doors are accessed by security keypads. Visitors commented, “It’s a lovely home”, “The grounds are nice”, and “There is a wonderful feeling to the building”. There are a variety of communal spaces available including a lounge, a visitor lounge/parlour, a spacious dining room, an art/activities/training room, a chapel, and a hairdressing salon on the ground floor, and a lounge/dining room on the first floor. All rooms are comfortable, homely, and furnished to meet the needs of the residents. The home has 28 single and 15 shared rooms and all are attractively decorated and personalised to the residents’ choices. All rooms have wash hand basins and an accessible nurse call system. Residents are encouraged to bring in some of their belongings to further personalise their own rooms. Where rooms are shared this has been agreed by the resident or their representative. All shared rooms have curtaining to enable personal care tasks to be able to be carried out in private. A resident commented, “I have a nice bedroom”. The home is clean and free from offensive odours throughout. All comment cards confirmed that the home is always kept clean and odour free. A visitor said, “It’s always kept clean”, and a residents comment card said, ‘The home is always very clean and my room is always clean and tidy’. The sluices and the laundry facilities are clean and well maintained. The laundry has tiled flooring and is fitted with washing machines with the specified programmes to meet disinfection standards. Infection control policies and procedures are sound and personal protective clothing and hand-washing facilities are available wherever needed. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 20 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. A staff team who have been through robust recruitment procedures, receive sufficient training, and are employed in sufficient numbers, meet the needs of the residents. EVIDENCE: The home has sufficient staff on duty at all times to meet the needs of the residents. Separate teams, each led by a level 1 nurse, are allocated for the two floors. The manager and deputy manager each carry out the role of matron for the one of the floors. Dedicated cleaners, laundry assistants, and cooks are on duty each day. The home have the advantage of being able to call on trained nurses who live in the convent to help out at times of holidays and sickness. Residents comments included, “The staff are very good to us”, “The staff, nurse, and sisters are very good”, ‘There is always a member of staff present St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 21 in the lounge at all times and when I’m in my room they answer my call bell promptly’, ‘I am extremely happy here, I am looked after by all the sisters, staff nurses and staff very well. I would not like to leave here’. And ‘I am very content in St. Raphael’s nursing home, I am well looked after by all the home’s staff, treated with respect, always listened when I am asking about something, receive support and reassurance when I need it. I feel safe here’. A visitor comment card included, ‘All St. Raphael’s staff are excellent communicators …’, Currently 42.85 of care staff have attained NVQ at Level 2 or above. However a further 5 staff have started the training and when they qualify this will bring the percentage up to over 50 . Staff said, “I have NVQ Level 2”, and “I have NVQ Level 3” The home operates a robust recruitment procedure. No member of staff is employed until the home has received a satisfactory check of the Protection of Vulnerable Adults register and 2 satisfactory references. All trained nurses are checked against the Nursing and Midwifery Council register. The home explores any gaps in employment history during interview. All staff are issued with terms and conditions, and a copy of the General Social Care Council code of conduct. New staff undertake induction training to comply with Skills for Care specifications, and one member of staff said, “I am doing my induction at present”. Each member of staff has a training and development programme. All staff are up to date in the mandatory subjects, and in adult protection, and dementia, and staff spoken to all confirmed that they have done this training. It is planned for all staff to undertake Equality and Diversity training in the near future. Visitor comments included, ‘All the staff seem well trained, friendly and professional. It appears that the staff receive training whilst they are here via the excellent leadership of the two sisters in charge’, and ‘The training seems to be of a high quality, from what I have seen/heard about’. Other general comments from visitors regarding the staff included, “The carers are so courteous so nice, and so good with the residents”, “The staff are wonderful”, and “All the staff are lovely and friendly. I am never met by anything but a smile and a friendly face” Staff said, “Most staff have been here a long time”, “We are all happy here”, and “I’m new here and everyone has made me welcome”. St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 22 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, 35, & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has positive management and is run in the best interests of the residents. The health, safety, and welfare of residents and staff is promoted. EVIDENCE: The registered manager, Sister Basil, is an experienced Level 1 nurse, who has completed her NVQ 4 in Management since the last inspection. Another nun who is her deputy supports her. The management approach of the home St Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 23 creates an open, positive and inclusive atmosphere. Both the manager and her deputy have attended Equality and Diversity and Mental Capacity training. Residents’ comments included, ‘I receive lots of support from Sr. Basil and the staff nurses’, and ‘The sisters and the staff find time to listen to me’. Family comments included, ‘as far as we know mum has no religious convictions but the sisters do not seem to mind this and appear to really like her. They certainly don’t impose their personal convictions onto the residents’, ‘St. Raphael’s provides a loving and caring environment, which embraces not only the patient but his family and friends as well. Nothing is ever too much trouble for them’, and ‘The caring attitude of all the staff comes from the leadership of the nuns in charge which is genuine and unconditional. We feel very lucky to have discovered such a nice home as St. Raphael’s for mum’ Staff commented, “The sisters show they appreciate what we do”, and “The nuns are very calm”, and visitors commented, “Mum says its so peaceful”, “There is a good atmosphere”, and “The ethos of being able to go to chapel, and of the sisters and is lovely”. The home has developed its quality assurance systems. Questionnaires are circulated annually to relatives, visiting professionals and staff. An analysis is produced of the results of the questionnaires, and this is available on request. The home holds monthly Residents meetings, and monthly staff meetings. A resident said, “We have a residents meeting once a month”. Regular audits include Quality of care, accidents, medication, Health and safety, and Care Plans. Relatives and advocates are invited to attend Care Plan reviews. Residents or their families or powers of attorney are encouraged to manage their own finances where they are able and if not the home has financial procedures in place to protect the resident. Written records are maintained of any transactions undertaken on behalf of the resident. Individual records are kept of residents’ personal allowances. Lockable storage is provided for the safekeeping of residents’ valuables and money. The home protects the health, safety and welfare of residents and staff. and relevant health and safety legislation is complied with. All staff are up to date with mandatory training. All equipment is regularly maintained. Accidents are recorded and analysed. Fire safety procedures are up to date and relevant. St Raphaels Nursing Home DS0000014049.V348191.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 X X 3 St Raphaels Nursing Home DS0000014049.V348191.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 Home’s 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 Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 26 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 Raphaels Nursing Home DS0000014049.V348191.R01.S.doc Version 5.2 Page 27 - 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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