Inspection on 21/02/07 for St Vincents

This inspection was carried out on 21st February 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 Vincents 14/02/06

St Vincents 22/09/05

St Vincents 25/01/05

St Vincents 20/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Vincents 33/35 Leicester Street Southport Merseyside PR9 0EX Lead Inspector Mrs Claire Lee Key Unannounced Inspection 09:00 21 and 22nd February 2007 st 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 Vincents DS0000005292.V328259.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 Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincents Address 33/35 Leicester Street Southport Merseyside PR9 0EX 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) 01704 546386 01704 539 257 jayjobling@yahoo.co.uk The Daughters of Charity of St Vincent De Paul Ms Rose Lowry Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 13 OP The service should employ a suitably qualified and experienced manager who is registered with the CSCI 14th February 2006 Date of last inspection Brief Description of the Service: St Vincents is a care home providing personal care and support for up to thirteen retired sisters from the Community of St Vincent de Paul and sisters from other religious communities. The home is situated in Southport town centre overlooking the marine lake and with easy access to public transport. The home has four floors served by a passenger lift and chairlifts on the back stairs. The sisters have single accommodation and a number of rooms have an ensuite facility. Bathrooms are adapted to assist those who are less able and the home also has a Jacuzzi room. Recreational areas comprise of two lounges and a dining room. All areas are very clean and well maintained. The Registered Providers are The Daughters of Charity of St Vincent De Paul and the registered manager is Ms Rose Lowry. The weekly accommodation rate is £323.00. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days for duration of eleven hours and thirteen sisters were accommodated at this time. A site visit took place as part of the unannounced inspection and this included a partial tour of the premises. A number of the home’s care, staff and health and safety records were viewed and discussions took place with seven sisters, four staff, the home’s administrator, manager and Director of the Community. During the inspection three sisters were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other sisters who also took part in the inspection process. There were no visitors at the time of the visit. All the key standards were inspected and also the previous recommendation from the last inspection in February 2006 was discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of sisters for them to complete. The sisters’ comments from the survey forms and comments received during the site visit are included in the report. What the service does well: The sisters’ health care needs are assessed prior to arriving at the home and care files seen were organised easy to read and accessible for the sisters and staff. The care files contained a plan of care, which evidenced current health and social care. The sisters’ religious vocation is central to the way in which care is provided and the daily routine of the home is conducted. The majority of the sisters are very independent and their life long service to the community is ongoing. Staff were observed to be respectful of the sisters’ beliefs and wishes. The home had a very pleasant relaxed atmosphere and many of the sisters were out during the day socialising. The sisters take part in a very good range of social activities including keep fit, flower arranging and computer studies. A staff member drives the minibus and a recent excursion to a local beauty spot was very much enjoyed. A sister said, “I have enjoyed the activities very much and more the outings to the shops and elsewhere in the car”. Some sisters go away on holidays and religious retreats. The sisters were taking part in choir practice during the afternoon of the site visit and also the hairdressing was present. A sister referred to the staffs’ enthusiasm and dedication when planning events. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 6 The sisters confirmed that the food was excellent and the menu is displayed in the home for the sisters to view. Lunch was observed to be a relaxed social occasion; the dining room tables attractively laid. The main meal of the day is served at lunchtime and the sisters are served four courses with an alternative if preferred. A sister said, “The food is just wonderful, you could not get better in a hotel”. The sisters were complimentary regarding the care and support they receive. Comments include: “Very good care” “The staff are wonderful” The girls are so kind” “It could not be better” The building is kept in very good order and subject to an ongoing programme of decoration. Three bedrooms have been redecorated and refurbished since the last inspection and new flooring has been laid in the kitchen. The lounges and bedrooms are attractively decorated and the sisters have their own belongings, which make the rooms ‘homely’. The bathrooms are suitably adapted with equipment to assist the sisters who are less independent. Staff are recruited via robust recruitment procedures and there is a good training programme in place. Staff attend mandatory training in safe working practise to ensure they have the skills and knowledge to undertake the work. Staff are also encouraged to attend other courses relevant to the care of the older person and also medicine administration. Over 90 staff have an NVQ (National Vocational Qualification) in care. As part of evaluating the care and service, the sisters are given satisfaction survey forms to complete. Comments seen were complimentary regarding the home, the care and attitude of the staff. The home’s policies and procedures were reviewed in November 2006 and staff made aware of any changes to the documents. The sisters and staff attend regular separate meetings and an annual development plan for 2007 was available. Staff commented on the good organisation skills of the manager and her strong leadership. Staff receive regular supervision with their work and an annual staff appraisal. What has improved since the last inspection? St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 7 Fire doors seen were not wedged open. 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 Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 8 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 Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 9 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): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre admission assessments help ensure that the home can meet the needs of the sisters. EVIDENCE: Individual records are kept for each sister and the sisters have an assessment of need which is carried out by the manager prior to them arriving at the home. Many of the sisters are already known to the Community and have visited the home prior to taking up residency. The assessments seen had been completed in detail with regards to medical history, health, personal, social and spiritual care. A care file had been prepared for a sister who is joining the home at a later date. The assessment information is used to form the basis for the sisters’ plan of care and staff interviewed were aware of the importance of collating sufficient information during the initial assessment. The information to St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 10 be recorded for sisters who stay at the home for respite is discussed under Standard 7 of this report. Standard 6 is a key standard to be assessed however the home provides personal (residential care) for the sisters and therefore this standard is not relevant. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the sisters are understood and set out in an individual plan of care. Medicines were administered according to the home’s policy and procedure for safe administration. Sisters were observed to be treated respectfully. EVIDENCE: The sisters who live permanently at the home have a plan of care and two were viewed as part of the case tracking process. The care plans examined were structured, clearly written and gave instructions to staff on how to meet individual care needs. The information recorded is subject to review by the manager and key worker (a role given to staff that includes extra responsibilities for a number of sisters). The sisters at present are not however involved with the drawing up of the written plan or take part in its review. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 12 Their consent and agreement has been obtained in the past and this is again to be sought for the current care provision. The care plans include key areas, for example, mobility, health and well being, independence, hobbies, personal care and family contact. Staff interviewed discussed the level of support a number of sisters require and also the importance of maintaining their independence. The sisters’ moving and handling requirements are assessed and also details of their preferred diet and activities recorded. One sister was receiving a high level of care due to very poor physical health and the care file recorded the changes in her condition. Observation charts were in place to ensure her nutritional needs and care of her skin for pressure relief were monitored. All the sisters are registered with a GP and care files seen evidenced a record of their visits and also other health professionals including district nurse. The district nurse service is provided for the sisters who require some nursing input. The sisters are weighed to monitor weight gain or loss and they have access to dental, optical and chiropody services. If a sister cannot use the weighing scales then a girth or upper arm measurement can be recorded. Comments from the sisters regarding the care include: “Very good care” “The staff are wonderful” The girls are so kind” “The staff are wonderful so devoted and caring” “I couldn’t speak highly enough of the care, concern and patience of the staff” A care file for a sister who had come to the home for respite care was case tracked. Only limited information was available and the manager was unsure who has completed the record. When the sisters attend the home for respite care from another care home their care needs should still be recorded. The implementation of a ‘short term’ care plan was discussed with the manager. The staff record the care they give and the care files are updated by the key workers to report on any changes. A number of care records, for example care plans, were not dated or signed on completion and this is recorded under Standard 37 of this report. The medicine trolley was found to be locked when not in use and staff are responsible for administering a number of medications. The medicine charts viewed had been completed to a satisfactory standard and evidenced staff signatures following administration of prescribed medicines. A separate record with two staff signatures was seen for the medicine Temazepam; this is a medicine that is liable to misuse. A number of sisters administer their own medications. The sisters sign a disclaimer regarding this practice and the home also completes a risk assessment to ensure the sisters are able to administer their own medicines safely. The medicines to be self administered should be recorded by staff when completing the risk assessment. Safe storage facilities St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 13 are available in the sisters’ rooms for their medicines. A returns book evidenced medicines returned to pharmacy in accordance with the home’s policy. The staff were observed to interact well with the sisters and showed respect and understanding of their individual care needs. Emphasis is placed on respecting the sisters’ faith and religious needs. This is a very important part of the care provision. Staff were observed to assist the sisters with their meals in a sensitive manner and also were observed knocking on bedroom doors before entering. A sister said, “The staff are very polite, you could not have better”. St Vincents DS0000005292.V328259.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): Standards 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There was a very friendly relaxed atmosphere and the sisters have choice and control over their lives in harmony with their religious vows. The food was well presented and nutritious. EVIDENCE: The sisters follow the routines of their religious life and also confirmed that they take part in a very good range of social activities and hobbies. These may be undertaken independently or with the assistance of staff, friends, family and also within their religious community (both country wide and overseas). The home had a lovely relaxed atmosphere and the sisters appeared very happy. A number were out during the day and some of the sisters had chosen to stay at the home, they were observed to be sitting quietly in the lounge or in their rooms. The sisters’ preferred activities and social pursuits were recorded in their plan of care and this information is updated regularly. Activities on offer include computer studies, outings, keep fit, choir practice, shopping trips, boat St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 15 trips, theatre concerts, holidays and games. A sister reported, “The activities arranged are very varied, interesting and available for choice. We are asked ahead of time to make suggestions as to what we would like to have arranged through the year”. Choir practice took place in the lounge during the site visit and the hairdresser was also present. A sister interviewed was complimentary regarding the outings from the home and said, “The staff arrange lots of trips for us and we really enjoy everything”. One sister enjoys painting and her artwork is displayed in the home. Many of the sisters have their own computer and computer lessons have been arranged with Southport College. The sisters take part in religious retreats, events and celebrations. The sisters have served in various Communities within their professions and have undertaken missionary work. They continue to take an active part within the local parish and provide help and support for the homeless. The sisters stated that the staff respect their wishes regarding the routine in the home and understand the importance of their religious beliefs and values. It was evident that good communication exists between the staff and the sisters. The sisters commented on the fact that the staff are always around to help but they also enjoy the freedom and independence offered. The administrator brings her dog to work and a sister was enjoying a walk with the pet in the afternoon. Systems are in place for the sisters to manage their own finances and for the home to offer assistance when needed. The menu is based over four weeks and offers well balanced nutritious meals. A variety of meals are available and the sisters confirmed that they are always offered a choice. The menu is displayed for the sisters and the cook caters for religious events and celebrations. The dining room tables were attractively laid for lunch with flower arrangements on all the tables. The main meal of the day is served at lunchtime and the sisters have a choice of four courses with tea or coffee. The sisters stated that the food was excellent, comments include: “Superb” “Five star hotel” “Fresh fruit and choice of at least three vegetables each day” “Really good cooking” “Lovely home baking”. “The cook is an excellent cook and provides tasty and varied menus” Lunch was a very sociable occasion and silver service provided by the staff. Staff confirmed that special diets are also catered for and pureed meals prepared when needed. The kitchen was tidy and clean and environmental health records up to date. There was a very good supply of fresh, frozen and dry goods in store. The sisters are given survey forms to complete and comments received were complimentary regarding the choice, quality and presentation of the meals. The home offers tea and coffee making facilities in the small lounge on the top floor. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 16 St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear and accessible complaint procedure is in place and the sisters were confident that their concerns would be listened to and acted upon. The home has a vulnerable adults procedure to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaint procedure, which is made available to the sisters. The home maintains a complaint log however no complaints or concerns have been received. The sisters who were interviewed were pleased with all aspects of the home and were aware of whom to talk with should they need to. A sister said, “It would be hard to complain about anything here”. The home has an abuse policy and Sefton’s local guide/procedure. All staff receive abuse awareness training as part of the home’s training plan. A member of staff interviewed was aware of the procedure to be followed should an allegation of abuse occur. St Vincents DS0000005292.V328259.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): Standards 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. St Vincents presents as a beautifully decorated, clean and well maintained home. This ensures the sisters live in a safe environment that meets their needs and also contributes to their quality of life. EVIDENCE: St Vincents is a large house comprising of four floors. The main hall has a copy of the most recent inspection reports and other information regarding the home. The areas viewed were exceptionally clean and well maintained. The home was found to be bright, airy and warm and the sisters have a passenger lift and chair lifts to upper floors. There are tea and coffee making facilities on the top floor and sisters have daily worship in the chapel on the first floor. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 19 The home is subject to an ongoing programme of decoration and refurbishment and since the last inspection three bedrooms have been decoration. There are two lounges on the ground floor, one of which is also used as the dining room. The lounges have comfortable armchairs and coffee tables. There is a large screen television in one lounge and a computer in the other lounge. The décor of the home is of an excellent standard and bedrooms seen were attractively decorated. The bedrooms had personal items in accordance with the sister’s individual vocation and preference. Sisters described the accommodation as very ‘homely’ and pleasant to live in. The home has moving and handling equipment and a number of special beds/mattresses to provide extra pressure relief according to assessed need. These were seen in use. Bathrooms seen were clean and odourless. The temperature of the hot water is recorded to the baths to ensure it is delivered to a safe temperature. A check of the hot water to one bathroom confirmed this. Then sisters have the use of a Jacuzzi room, shower facilities, hoist and parker baths (baths especially designed to assist those who are less able). The bathrooms are pleasantly and easy to use. They are nicely decorated and do not look clinical in their appearance. Care staff carry out laundry duties and the laundry room was clean and personal items are returned to the sisters in individual baskets. The home follows infection control procedures and COSHH data is available on products in use. Staff receive infection control training and have access to gloves and aprons. These were seen in use. Some structural work is planned to the laundry later on in the year. The home has emergency lighting and this is subject to an in house safety check and also an annual maintenance contract. Records seen were current. There is a patio area at the rear however the home are looking to lay a garden in the summer months. There is a ramp to the front entrance to assist the sisters who are less independent. The home has some parking space on the front forecourt. The sisters interviewed all said that the location of the home was ideal as it was close to local amenities, on a main bus route and in walking distance of Lord Street. The home has CCTV cameras to view external areas only. Comments from the sisters regarding the accommodation include: “Lovely home” “Could not have better in a hotel” “So comfortable” “Just lovely bedrooms with views of the sea” “Kept so clean and tidy” St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 20 St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 21 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): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in plan to protect the residents and staff receive training to ensure they have the skills and knowledge to care for the sisters in a safe manner. The person undertaking the ‘sleep over’ shift at night must be a member of staff and be trained. EVIDENCE: The staffing rota for the month of February 2007 was viewed and this evidenced satisfactory numbers of staff to provide the necessary care and support to the sisters. Full names of staff should be identified on the staffing rota to ensure these records are accurate. A senior carer was in charge for the first day of the inspection, the manager was on duty on the second day. Three care staff are employed during the day with a cook, a domestic and administrator. By talking with the manager and examining the staffing rota it was evidenced that at night the home is not staffed in accordance with its’ registration. At night the home must be staffed with a member of the care staff who is awake and a member of staff who ‘sleeps in’ and is called when needed. The home currently employs a member of the care staff who is awake however it was evidenced that the person carrying out the ‘sleep is’ not a member of staff but a member of the Community. A member of staff must be employed for the ‘sleep in’ position and undertake training to ensure they have the skills St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 22 and knowledge to undertake the work. The person currently carrying out the ‘sleep in’ has a CRB (Criminal Record Bureau) disclosure on file. The home has a stable workforce, a number of staff have worked at the home for a long period of time. Thirteen sisters were resident and those interviewed were complimentary regarding the care provided by all the staff. The following comments were made regarding the staff: “The “The “The “The staff staff staff staff are very good” are kind” are very attentive” really care” NVQ (National Vocational Qualification) in Care has been obtained by approximately 90 staff and a number of staff files viewed evidenced certificates at Level 2 and Level 3. This is a very good percentage and demonstrates the staffs’ commitment to learning. Six staff files were viewed with regard to recruitment practices and these evidenced the necessary checks to protect the sisters. Staff had completed a job application form and two references had been obtained. Staff files contained a POVA (Protection of Vulnerable Adult) check and/or CRB (Criminal Record Bureau) disclosure at enhanced level. The necessary checks are in place prior to staff commencing work and the interviewer completes an interview checklist. Staff are given a health declaration form to complete and a contract of employment. The home provides very good training for the staff in safe working practices, including moving and handling, infection control, food hygiene, first aid and health and safety. Staff also attend palliative care courses at the hospice and medicine administration training. Certificates for courses attended are in the staff files and staff interviewed were pleased with the standard and frequency of the training on offer. The home offers a ‘rolling’ programme for all courses. New staff receive an induction and the manager or senior carer complete an induction manual with the new employee. Further information can be obtained from the Skills for Care to enable staff to enhance their knowledge of the induction standards. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 23 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): Standards 31,32,33,35,36,37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is qualified and creates an open, inclusive management of the home. The sisters feel valued and their opinions matter. Policies, practices and procedures are in place to safeguard the health, welfare and safety of the sisters and staff. EVIDENCE: The registered manager is Ms Lowry and she has completed NVQ Level 4 in Management. Ms Lowry also undertakes training in safe working practices with the staff. Staff and the sisters described Ms Lowry as being: St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 24 “Very fair” “Very approachable” “Very easy to talk with” “A very good manager” “Really nice person” Ms Lowry is supported in her role by senior management who are available when needed. Ms Lowry works closely with the Director and it was evident that they work well together to ensure the sisters are provided with good care. The Director was advised of the requirement regarding the employment of a staff member for the ‘sleep in’ (Standard 27) and this has been discussed further with the Commission since the site visit. The sisters hold weekly meetings and the manager also arranges staff meetings, which are well attended; the last one was held in January 2007. A senior sister from the Community who is also the line manager, conducts Regulation 26 visits; records of the last three months visits were seen and these recorded good detail regarding the overall service. As part of evaluating the care and service, the sisters are given satisfaction survey forms to complete. Survey forms seen for February 2006 were complimentary regarding all aspects of the home. Policies and procedures were reviewed in November 2006 and staff made aware of any changes to the documents. The annual development plan is in place for 2007 and the home has been proactive in implementing a relationship and sexuality policy. The plan also reported on staff training and engaging a garden designer. Sisters interviewed were aware of what is planned for the home for this year. A number of staff have responsibilities for other quality checks for certain areas, for example, the laundry, general stores and medicine administration. This demonstrates good practice to ensure good standards are maintained. A senior member of the Advisory Committee also visits to conduct a review of the sisters’ care files as part of the quality assurance for the home. A number of reviews were seen. When discussing the management of the home the following comments were made: “That this home is exceptional and is a credit to the people in charge” “It just an ideal place to live. All needs anticipated” The home maintains a number of financial records on behalf of three sisters. Two records were viewed and these evidenced expenditures and staff signatures where appropriate. The financial records were up to date and are audited by the administrator. Staff interviewed confirmed that they receive supervision and also an annual appraisal. They stated that they are well supported in their role and can approach the manager at any time. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 25 When examining care files and staff files it was noted that a number of records, for example, care plans and staff inductions were not signed or dated when completed by a staff member. All records should be dated and signed on completion to protect the sisters and to keep them up to date and accurate. The home’s pre inspection questionnaire gave details of service and maintenance contracts for equipment and safe working practices. A spot check of the gas, chairlifts and manual handling equipment and specialist baths were seen. These were in date. The home is aware of the changes to the fire regulations and recent visits by the fire service have taken place. The home is in the process of updating its fire risk assessment of the building. Staff files evidenced dates of fire prevention training and the fire logbook weekly tests of the fire alarms. The home’s external contractor was carrying out work on the fire prevention equipment at the time of the site visit. The annual inspection of the equipment was carried out in January 2007. Fire doors seen were not wedged open. The sisters should be reminded to sign in and out when they leave and return to the premises to ensure staff are aware of how many people are present in the building. Accidents affecting the welfare of the sisters are recorded in an accident book. Reports seen evidenced a record of the incident and any treatment needed. St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 26 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 X X 3 X X 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 4 3 4 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 x 3 3 3 3 St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15(1)(2c) Requirement The registered person shall after consultation with the sister prepare a written plan in respect of their health and welfare and consult with them regarding its review. The registered person must ensure that at all times suitably qualified, competent and experienced personas are working at the care home in such numbers as are appropriate for the health and welfare of the sisters (service users). This refers to the position of a staff member for the ‘sleep in’. The registered person must ensure that persons employed at the care home receive training in moving and handling, first aid, infection control, food hygiene and fire safety. This refers to the position of a staff member for the ‘sleep in’. Timescale for action 21/04/07 2. OP27 18(1)(a) 21/04/07 3. OP30 18(1)(c) 21/05/07 St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 28 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. 3. 4. 5. Refer to Standard OP7 OP8 Good Practice Recommendations The home should ensure the care needs of sisters who require respite care are recorded. The provision of a short term care plan would be beneficial. The home should monitor weight gain or loss by recording a sister’s girth or upper arm measurement if weighing scales cannot be used. The home should ensure medicines to be self administered are recorded on the risk assessment. The home should ensure full names of staff are recorded on the staffing rota. The home should gain further information from Skills for Care on induction standards. The home should ensure all records are signed and dated on completion OP9 OP27 OP30 OP37 St Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Vincents DS0000005292.V328259.R01.S.doc Version 5.2 Page 30 - 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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