Inspection on 21/02/06 for St Wilfrid`s Care Home

This inspection was carried out on 21st February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Wilfrid`s Care Home 06/09/07

St Wilfrid`s Care Home 25/09/06

St Wilfrid`s Care Home 18/10/05

St Wilfrid`s Care Home 15/03/05

St Wilfrid`s Care Home 19/07/04

St Wilfrid`s Care Home 23/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Wilfrid`s Convent 29 Tite Street London SW3 4JX Lead Inspector Peter Montgomery Unannounced Inspection 21st February 2006 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.V284237.R01.S.doc Version 5.1 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.V284237.R01.S.doc Version 5.1 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.V284237.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 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.V284237.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on Tuesday 21st. February 2006. Communal areas were viewed, and the people who live in the home, staff on duty and visitors to the home were spoken to. Individual and communal records were reviewed, these included service users records and daily records, and this information was used to inform the report. What the service does well: What has improved since the last inspection? What they could do better: Care plans continue to identify unrealistic, or unnecessary objectives which still do not adequately identify service users needs, or describe staff intervention. E.g. a care plan was written for an individual who did not require staff intervention in the area of need described, in another a care plan described an individuals symptoms arising from their health needs– rather than how the persons needs should be met by staff. Some time therefore was spent in discussion with the senior care staff on duty to ensure support staff are aware of an appropriate care plan focus. A Requirements for staff to identify and record service users needs accurately is made in this report. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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.V284237.R01.S.doc Version 5.1 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.V284237.R01.S.doc Version 5.1 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): x EVIDENCE: This Standard was not assessed at this inspection. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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): 7,8,9,10,11 Individual plans of care for each resident are maintained. Service users and their advocates are encouraged to participate in care plan development, so that plans reflect the needs and wishes of the residents themselves. EVIDENCE: Records for service users demonstrated there was a plan of care for each person in place, describing how their needs were to be met by staff. Some improvements to the format and assessment process were evident from the last inspection, and staff have made good progress in developing a more appropriate format and reviewing needs. In all instances service users and, where appropriate advocates, have been involved in the development of the care plans, and risk assessments. However it is evident staff have some way to go in accurately (and succinctly) identifying care planning objectives, and these will be reviewed again at the next inspection. Care planns are again therefore identified as a Requirement in this report. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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 Community links have been established to support and enrich service users social and cultural needs. Service users have access to a varied range of activities and outings facilitated by the home. EVIDENCE: Both service users and relatives have previously confirmed they considered the support from staff for communal, or group activities to be good. It is noted staff are very familiar with the needs of service users - a number of whom have lived in the home for some considerable time - and are responsive to their needs and preferences. Service users were complimentary of the meals available, and an improved consultation process has resulted in a well balanced and attractive menu, with both the quality and variety of all meals taken in the home much appreciated by service users. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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): x EVIDENCE: This Standard was not assessed at this inspection St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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 The standard of the décor within the home is good with evidence of continued maintenance and improvement throughout. Overall the home provides a comfortable environment for service users. EVIDENCE: Service users rooms and communal areas were visited, and facilities and décor throughout the home were considered to be good. Service users bedrooms are generally attractive, and individual taste and choice is evident in furnishings and equipment, both in their rooms and throughout the home. Décor in many areas of the home has been improved, including new furnishings and decoration in the t.v. and quiet rooms. Service users comments demonstrated they were satisfied with the standard of accommodation in the home, and in their rooms particularly. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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 Residents 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: Staff roles and responsibilities are clearly stated, and a wide range of training opportunities are available. Many staff have worked in the home for some time, and they have been able to develop a good level of knowledge and understanding of the needs of service users. Whilst staffing levels are appropriate, and residents’ needs continue to be met, it was noted the home continue to operate with fairly high numbers of agency staff. It is recommended staff recruitment should be prioritised to resolve this issue. Staff have undertaken training in essential areas, such as food hygiene, health and safety, medication, mental health, first aid and most recently care planning. NVQ Level 2 training uptake by care staff is dissapointingly rather slow (23 currently)S however training staff assured the inspector training uptake for new staff will be improved, and this will be reviewed in subsequent inspections. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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): 31,32,33,34,35,36,37,38 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.V284237.R01.S.doc Version 5.1 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 3 St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 15 Regulation 7 Requirement Staff must continue to improve care planning to ensure systems accurately reflect service users needs. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 28 Good Practice Recommendations Staff recruitment should be improved to ensure a more appropriate balance of experienced and temporary staff is achieved. St Wilfrid`s Convent DS0000010850.V284237.R01.S.doc Version 5.1 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.V284237.R01.S.doc Version 5.1 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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