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Inspection on 18/10/05 for St Wilfrid`s Care Home

Also see our care home review for St Wilfrid`s Care Home for more information

This inspection was carried out on 18th October 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People who live in the home said they were happy with the quality of care they received. Visitors spoken to during the inspection were also positive about care in the home and the level of activities available. Both residents and relatives said that they felt able to talk to the manager or staff if they had any concerns, and a number of them had done so. Staff spoken to were generally positive in their opinions of the quality of services provided.

What has improved since the last inspection?

What the care home could do better:

It has been stated in previous reports that service users care and daily recordings were well maintained, but the care planning systems did not accurately identify service user needs or the intervention required by staff to address these needs. The format used is also considered by the inspector to be time consuming to complete and to glean information from. Staff continue to identify unrealistic objectives which still do not adequately identify service users needs, or describe staff intervention. Some time therefore was spent in discussion with the staff on duty to ensure staff are aware of an appropriate care plan format and focus. Requirements for staff to identify and record service users needs accurately, and undertake training in care planning are made.

CARE HOMES FOR OLDER PEOPLE St Wilfrid`s Convent 29 Tite Street London SW3 4JX Lead Inspector Peter Montgomery Unannounced Inspection 18th October 2005 10:30 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 Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 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 Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Wilfrid`s Convent Address 29 Tite Street London SW3 4JX 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) 020 7351 5339 020 7376 5539 The Congregation of the Daughters of the Cross of Liege Mr Michael Burns Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2005 Brief Description of the Service: St. Wilfrid’s Convent is a large purpose built residential home for up to 44 older people located in an atttractive area of Chelsea. The proprietors are The Congregation of the Daughters of the Cross of Liege, Sisters of the order live in an attached annex. The home comprises of five floors, the lower ground floor provides a lounge/conservatory and a dining area, the main kitchen and laundry. The first floor main entrance leads to the reception area, this floor comprises of a communal lounge, the managers office, several meetings rooms and administration areas. The upper floors provide single bedroom accommodation, and all are provided with ensuite facilities. Small lounges are located on each floor, as are specialist bathing and toilet facilities. Two passenger lifts and an internal staircase provide access to the upper floor of the home.To the front are well landscaped and maintained gardens. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on Tuesday 18th. October 2005. Communal areas were viewed, the people who live in the home, visitors and staff on duty were spoken to in the lounges and in private. Individual and communal records were reviewed, including service users records, daily records and written feed back from service users, and this was used to inform the report. What the service does well: What has improved since the last inspection? What they could do better: It has been stated in previous reports that service users care and daily recordings were well maintained, but the care planning systems did not accurately identify service user needs or the intervention required by staff to address these needs. The format used is also considered by the inspector to be time consuming to complete and to glean information from. Staff continue to identify unrealistic objectives which still do not adequately identify service users needs, or describe staff intervention. Some time therefore was spent in discussion with the staff on duty to ensure staff are aware of an appropriate care plan format and focus. Requirements for staff to identify and record service users needs accurately, and undertake training in care planning are made. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 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. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 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 Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 The homes Statement of Purpose and Service user Guide is adequate and provides sufficient information for prospective users to be aware of the services available. People who use the service have their needs appropriately assessed. EVIDENCE: The homes Statement of Purpose and Service User Guide are fairly detailed and state the core objectives clearly. Records and individual assessment information demonstrated staff apply the aims consistently, and that service users have been admitted into the home with an assessment of how their needs can or may be met in compliance with this objective. People from the resident groups were spoken to, and most commented positively, saying they enjoyed living in the home and thought their needs were being met. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The information contained within the care planning system currently in place does not adequately provide staff with the information they need to satisfactorily address the needs of service users. EVIDENCE: Individual files were reviewed, and each contained a plan of care which set out the needs of the service user and how they were to be met by staff. Service users are also supported to make decisions as part of the independent lifestyle encouraged in the home. Each persons file also contained information on areas where there was considered to be a risk and how these risks were to be addressed. Whilst there was some evidence care plans were being reviewed in consultation with appropriate care professionals, it was considered the intervention and agreed goals in the plans did not address the apparent needs of the service user, nor were realistic objectives identified. E.g. one service users care needs refered to staff “maintaining mobility”, but did not state how, or if why there was a need for staff intervention. Care plan formats have been improved since the last inspection - where similar comments were made however staff appear to be experiencing the same problems in identifying care needs. To help facilitate improvements in care planning, the manager should consider the use of external training staff. This is a Requirement. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The meals in the home are good, offering both choice and variety and catering for special needs. People using the service are able to exercise choice and control over their nutritional needs. EVIDENCE: There is evidence of a varied programme of activities, and that staff accompany service users on outings where appropriate. Feedback from service users indicated that most considered activities good, particularly for those with specialised needs, and, although there are seasonal events such as barbeques etc. the inspector considers more individual activities, such as visits to the shops etc. could be facilitated. Catering staff provide meals for residents and many of the residents spoken to said how much they enjoyed the food in the home. The variety and quality of the meals provided are imaginative and include both vegetarian and ethnic choices. The home is commended for the quality of meals provided. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a complaints system, there is some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: All service users are given copies of the complaints procedure (in the service user guide) when they are admitted into the home, and a record of all complaints made in the home is retained on file by the manager. Service users spoken to are generally aware of the complaints process and all stated they feel able to discuss concerns with staff. A number of minor complaints have been recorded at the home and these concerns were satisfactorily concluded. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 There have been significant changes to the décor and furnishings in a number of areas in the home in the last year, service users live in a pleasant environment. EVIDENCE: Facilities, furnishings, décor and standards of cleanliness throughout the home are all appropriate and well maintained. The home is modern, with accommodation arranged over the first and second floors. Each floor has a small lounge, although many service users use the large ground floor dining area and conservatory. Resident’s bedrooms are all provided with en suite facilities, and are individually decorated with personal memorabilia. Service users comments demonstrated they were satisfied with the standard of accommodation and their rooms in particular. Communal areas are all well decorated and maintained, a new television room and quiet room have been created and both are decorated, equipped and furnished to a high standard. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users benefit from an experienced team of staff at the home who have the opportunity to access training and develop skills to meet their needs. EVIDENCE: Many of the staff at the home have worked there for a number of years and have built up a good knowledge and understanding of the needs of service users, ensuring residents’ needs continue to be met consistently, however it has been noted a high level of agency staff continue to be employed, due to continued vacancies. From previous comments made by the manager, the inspector is aware recruitment is an issue in the home, however vacancies should continue to be addressed as a priority. All staff have a personal appraisal/development plan, and records demonstrated staff had completed training in essential areas, such as food hygiene, health and safety, administering medication and first aid. It is however a Requirement that care plan training is added to the list of core training available to staff. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.35.38 The manager has a development plan for the home and is well supported by senior staff. All staff are aware of their roles and responsibilities. EVIDENCE: The manager and staff team strive to achieve appropriate standards for the home and feedback from users of the service was positive. Staff on duty stated regular meetings with residents are sheduled to determine their views, and access to external advocates is provided as required. A number of records were looked at, including care plans, risk assessments, staff rosters etc. These records were generaly detailed and and accurate, and – with the exception of care plans - record keeping overall demonstrated the home is being run responsibly with essential checks being made and acted upon. St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 15 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? 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 2 Standard 15 30 Regulation 7 18 [c][i] Requirement Care plans must be improved to ensure the format accurately reflects service users needs. The provider must ensure training programmes are appropriate to enable staff develop care planning skills to meet the needs of service users. Timescale for action 16/12/05 16/12/05 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 Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Wilfrid`s Convent DS0000010850.V259603.R01.S.doc Version 5.0 Page 18 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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