Inspection on 25/09/06 for St Wilfrid`s Care Home

This inspection was carried out on 25th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 21/02/06

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 Ann Gavin Unannounced Inspection 25th September 2006 09:30 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.V311447.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 Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 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.V311447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 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 attractive 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 ground 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. Three passenger lifts and two internal staircases provide access to the upper floor of the home. To the front are well landscaped and maintained gardens. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on Tuesday 26th September from 10.15 am to 6 45 pm. It was unannounced. This report is made up of information gained from speaking with residents, staff, and managers as well as looking at records, tracking the care of four residents and a tour of the communal areas of the home. There were 5 residents, 16 relatives/visitors and 2 professional questionnaires returned. Following the inspection and an immediate requirement a local GP also contacted the inspector to express their support of the staff and the service they offer specifically in the care of the person who had fallen. ‘…In my view St Wilfrid’s is the best residential home I know’ What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas that need to be developed further. The key one is care planning ensuring that it is a reflection of the person and is drawn up together with their involvement. Medical advise must always be sought in the case of a fall where someone hits their head and the Commission should be kept informed of all falls and incidents involving residents. There needs to be risk assessments with clear action plans for people who fall. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 6 The manager must be sure that staff without a CRB check only start work in exceptional circumstances and with the POVA first check in place. 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.V311447.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The outcome for this area is good. St Wilfrid’s completes assessments on all people who are moving into the home. EVIDENCE: ‘ I knew two people in the home before I came’ The residents spoken with said they or their relatives had been given adequate information on St Wilfrid’s. The assessments of some residents were seen. They were carried out using St Wilfids own assessment form completed by the head of care on an initial assessment visit. Once the resident has moved into the home a further assessment is carried out and a care plan and risk assessments are completed. Residents spoken with said they or their relatives had visited St Wilfrid’s prior to moving in. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 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 outcome for this area is adequate. The care plans need further development to be more personal to residents. Action plans are required for residents who fall and guidelines are needed for people with mental health needs to make sure that their care is consistent. The risk assessments must be updated when circumstances change. EVIDENCE: The residents spoken with were generally happy with the care they received. Observation of the staff had shown that they were respectful and discreet in the support they offered residents. This was confirmed in speaking with residents. Residents did not appear to have seen their care plans. One care plan seen did not reflect the issues raised by the resident nor an updated, risk assessment. These matters were discussed with the head of care who will make sure that the issues are followed through and documented. A discussion was held with the head of care and three senior carers around care plans and the areas to be further developed. The head of care has St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 10 developed the care plans since the last inspection to include goals for every area of the plan. The four care plans seen highlighted the following areas: • Only one resident had signed their care plan and there was little evidence of residents being fully involved in the process of completing their plan of care. The staff said they do sit with residents and go through the plan but the care plans could be more personal and specify how the resident would like to be supported. The monthly reviews were not present on all. Those seen did not reflect any discussions with the residents or how support may be changed. The format of the care plan does not give an accessible picture of the resident and how they wish their care to be carried out. An easy to read brief profile of the resident with their preferences and their support needs would help, especially when agency staff support residents. There were no guidelines as to how to support residents with specific behaviour or mental health needs. These must be put in place and any necessary training undertaken. There were risk assessments for each resident but there was no evidence that when circumstances changed the risk assessment was updated and made relevant. For example one person had released the window restrictor in their room • • • • All these areas will all be addressed by the home. There were a number of people in the accident book who had falls, some repeatedly. People had been referred to the falls clinic and there was some involvement with a local health initiative to monitor falls. However there was no action plan in place to help identify the reasons and prevent recurrent falls. The head of care will discuss again with the district nurses and local general practitioner and the health initiative to agree a plan of action for all. All incidents affecting the care of the residents must also be sent to the Commission. The medication records for four people were looked at along with the medication storage. The system was generally good and clear. There does need to be a regular audit of all medication kept as one eye drop was found to be three days out of date. There were two droppers one without a labels and St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 11 the other had worn away. These were both eardrops but they need to be marked as such with the name of the resident and the date of opening. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The outcome for this area is good. There are a variety of social, cultural activities. There is good access for family and friends, contacts with the local community. The food is of a good standard. EVIDENCE: ‘Sister is a most enthusiastic organiser and appreciated by all…’ ‘ The food is excellent’ ‘I have every confidence in St Wilfrid’s – (relative) There are extensive social and cultural activities arranged by a religious sister who leads the events and activities. There is also a small team of volunteers who help with activities all of whom, the manager said, had been CRB checked. Speaking with Sister she described the social calendar how peoples ideas are acted upon. One of the resident spoke of wishing to have an exercise class and sister said she was looking into finding someone who could do this being mindful of any health and safety aspects. In September the events included cocktails, visit to the Physics Garden, visit by a Scottish group of dancers, a concert from St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 13 students at the royal college of music and a harvest festival. One relative feedback received after the inspection suggested more time could be spent with residents encouraging them in activities. All residents families are welcomed and residents spoke of an ease of contact with them. One resident spoke of how the phone in his room enabled easy contact with those members of their family far away. Residents spoke of the good environment but one was saddened by the new furniture, which they felt, lacked character. There was no evidence of any consultation with residents about décor or any other aspect of life at St Wilfred’s. There have been no residents meetings or forums. This aspect of involving residents in all areas of the home and their choice within it must be developed. A resident’s forum is planned for October and this should become a regular part of the life at St Wilfrid’s. The residents spoken with were happy with the food and the fact that there was a book where they can make suggestions and comments. The menus seen were varied and balanced. There is always a choice including a vegetarian option. One feedback form, received after the inspection, did mention that they thought the food was sometimes reheated rather than freshly cooked. One resident spoke of how obliging staff were in bringing breakfast in bed when they needed to get up early. Another of how on the whole it was healthy and appetising. One made a comment about the timing of lunch feeling that 12 o’clock was too early this was past onto the manager to review with residents. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The outcome for this area is adequate. There is a complaint system though it needs to be more accessible and monitored. All staff have been on adult protection training. The correct procedure for employing someone whilst awaiting CRB clearance must be followed. EVIDENCE: The complaints system is currently under review. At the moment complaint forms are at reception though they were not clearly displayed. There were not any notices describing what to do if you are unhappy or wish to compliment the home. The manager said that this is in the guide to the home available in each room. There were no complaints noted in the pre inspection questionnaire. This was discussed with the manager, the need to note all the times that people may approach him with ‘concerns ‘. All need to be written down with the action taken and a system set up in order for all to be monitored. Discussing recruitment and CRB (Criminal Record Checks) the manager said they have been employing people in before CRB checks are through. These staff only work supervised but they do need to have a POVA first check completed before starting. This has not been done to date. However the manager will apply immediately and ensure that the guidance is followed. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The outcome for this area is good. A tour of the communal areas showed that the home is well maintained with good décor and attention to detail. There is a choice of areas to relax which the residents were pleased with. The home was clean and fresh throughout. EVIDENCE: St Wifrid’s is a modern attractive home. Accommodation is arranged over the first and second floors. Each floor has a small lounge and kitchen. There is also a library, smoking and non-smoking lounge a conference/ activity room and a conservatory. A gardener maintains the attractive gardens. Resident’s bedrooms are all provided with en suite facilities, and are individually decorated. Resident’s rooms and communal areas were visited. They were clean and fresh and the facilities and décor throughout the home were good. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 16 Residents bedrooms display their personal taste with their own pieces of furniture paintings photos etc. There are a variety of areas that residents can choose to relax in. All were bright and fresh. St Wilfrid’s employ domestics to maintain all areas. One resident spoke of the difficulty they had with the strong smell of the cleaning products used. This was discussed with the head of care who will offer this person the choice of having their own cleaning products for their room. These will be locked away and risk assessed. St Wilfrid’s have appointed the domestic supervisor to take the lead in developing all the health and safety policies within the home. Speaking with her she talked through the five days training she undertook and how she is joint working with a health and safety consultant to update all the policies and procedures in the home. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The outcome for this area is good .St Wilfrid’s have a programme of training for staff. Staff observed showed a good understanding of the residents needs and offered support in a respectful and discreet manner. EVIDENCE: Four of the five questionnaires returned from residents said that staff usually are available when you need them and one said they were always available. A discussion was held with the head of care and with three of the senior care staff. They spoke of the training they have completed and are planning to do. All the senior staff are completing NVQ level 3. The junior staff are working on their NVQ level 2. Each spoke clearly of their roles and the ways they would support residents. The head of care supervises the care staff every two months they feel this is working well. Notes are kept of these sessions. There are now weekly care staff meetings held. One staff member was observed supporting a resident whose mood was challenging. The staff member showed understanding and respect throughout. The manager said they are trying to resolve the high level of agency staff and are looking at new ways to recruit staff. They are now using just two agencies to cover the vacant posts one for night staff and one for daytime. In this way it is hoped to have as much consistency as possible. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 18 St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 The outcome for this area is adequate. The manager together with the head of care and senior care staff look after the day to day running of the home. There is a new lead person for all aspects of health and safety in the home. EVIDENCE: All the feedback from the questionnaires from residents, their families and professionals said that they were satisfied with the overall care received at St Wilfrid’s. St Wilfrid’s has just recently sent out a quality assurance questionnaire to residents and friends. This asks whether residents would welcome a separate forum for friends and family. The residents forum does need to become a regular feature to be sure that residents are fully involved in developments and ideas for St Wilfrid’s. The home must make sure that there are regular unannounced visits by the person in control and a copy of their report should be sent to the Commission. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 20 The accident book was looked at and the manager must make sure that the Commission is kept informed of all accidents and incidents. A tour of the building highlighted that residents’ doors were being propped open with door wedges which contravene the fire regulations. An immediate requirement was made to remove them and make sure that an early date is set to fit approved doorstops. St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 21 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 17 X 18 2 3 X X X X X 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 3 X 2 X 3 3 X 2 St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Care plans need to be further developed to be more personal to the resident. The manager must ensure that residents are involved in planning their care and sign their care plans An easy to access profile of residents should be drawn up to make sure that agency staff are clear on the support needs of each resident The manager must report to the Commission an account of the incident of the service user who fell and where no medical advice was sought. Social services must be advised of this situation. Immediate requirement Guidelines must be in place for people with mental health needs The manager must ensure that a detailed risk assessment with action plan is completed for each resident who falls and professional advice is sought. Risk assessments for residents must be reviewed and updated A regular check of medication and expiry date must be carried DS0000010850.V311447.R01.S.doc Timescale for action 31/10/06 2 OP7 15 31/10/06 3 OP8 37 04/10/06 4 5 OP8 OP8 12 13 31/10/06 31/10/06 6 OP9 13 31/10/06 St Wilfrid`s Convent Version 5.2 Page 23 7 OP16 22 8 9 OP18 OP33 19 26 10 OP33 12 11 12 OP38 OP38 37 23 out. All medication must be marked The manager must further develop the complaints procedure accessible to all. A record of all complaints and action taken must be kept. All staff must have a CRB with POVA first checks prior to working unsupervised. Evidence of regular unannounced visits to the home by the person in control must be carried out and the report sent to the commission Regular forum for residents to be consulted on all aspects of the home must be set up. Views of Family and friends must also be sought on a regular basis. The manager must ensure that all accidents, incidents are reported to the commission All wedges must be removed from residents doors .The timescale for when approved door stops will be fitted to residents doors must be forwarded to the commission immediate requirement 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 04/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Wilfrid`s Convent DS0000010850.V311447.R01.S.doc Version 5.2 Page 24 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. 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