Inspection on 24/10/05 for Stella Matutina Convent

This inspection was carried out on 24th 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.

Other inspections for this house

Stella Matutina Convent 06/07/06

Stella Matutina Convent 03/06/05

Stella Matutina Convent 18/02/05

Stella Matutina Convent 16/09/04

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 Stella Matutina Convent 16 Clifton Drive Ansdell Lytham St Annes Lancashire FY8 5RQ Lead Inspector Mrs Lillian McMullen Announced Inspection 24th October 2005 10:00 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 Stella Matutina Convent DS0000009719.V254953.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. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stella Matutina Convent Address 16 Clifton Drive Ansdell Lytham St Annes Lancashire FY8 5RQ 01253 734834 01253 794424 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) Sisters Of Charity Of Jesus And Mary Mrs Pauline Louvain Calvert Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd June 2005 Brief Description of the Service: Stella Matutina is owned and run by a religious order, which is a charitable organisation. The ethos of the home is to provide a good quality care service within a setting that allows service users the opportunity to live their lives in a secure environment, which meets their assessed needs. The building is situated over looking the sea, in its own grounds. Service users of all religious denominations are welcome, the home has a chapel and a priest is in attendance, church services are conducted and spiritual guidance offered. The home is registered to accommodate 41 service users. At present only female residents are cared for. Professional medical attention is sought from G.Ps., district nurses, chiropodists, and physiotherapists, CPNs etc. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was carried out by two inspectors. The inspection started at 10am and took place over five and a half hours. Present at the inspection was the registered manager and Mr M Barwick a management consultant who provides management guidance and support and who acts on behalf of Sister Helen the Responsible Individual. The Inspectors spoke to four staff members and six residents. In addition comment cards were received from residents, relatives and a number of doctors, in the main comments were positive and confirmed that a good standard of care is provided at Stella Matutina. Part of the inspection was spent on looking at the home’s policies and procedures together with the recruitment procedures. What the service does well: What has improved since the last inspection? Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 6 Since the previous inspection the registered manager has implemented a internal quality assurance system. This provides residents, relatives and visiting professionals the opportunity to comment on the care provided and the attitude of the staff. 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. Stella Matutina Convent DS0000009719.V254953.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 Stella Matutina Convent DS0000009719.V254953.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): EVIDENCE: Standard 3 was assessed at the previous inspection. Intermediate care is not provided at Stella Matutina. Stella Matutina Convent DS0000009719.V254953.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): 9 The medication procedures are robust and consistently followed. EVIDENCE: The recording of medication was examined and found to be generally correct, however it was noted that there were medication strengths omitted on hand written records and clear definition as to why medication was not taken was not always recorded.. All medication received into the home together with medication returned to the pharmacy is recorded. Medication is stored in a secure facility and training is provided to all staff. At present all staff with the exception of two night staff have received training. The registered manager gave her assurance that these two staff will receive training in the near future. Staff signatures were recorded for day staff, however night staff signatures are required. Residents who wish to administer their own medication can do so upon the completion of a successful risk assessment. A secure facility is provided in Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 10 every bedroom for the safe storage of medication. All seven residents who currently self medicate have signed disclaimers. The inspectors observed the administration of medication during the mid day meal. Practice observed revealed that medication was given directly to the resident, the staff member then waited whilst the resident took their medication and then medication administration record was signed. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 11 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): 15 The meals are of a consistently good standard. EVIDENCE: A dedicated chef makes meals on the premises. From discussion with the chef it was evident that he prefers to make all meals from fresh produce and enjoys home baking. The menus were inspected and found to provide a varied and balanced diet. The chef was able to confirm he had information about residents with special diets and personal preferences. Meal times are set although flexible enough to accommodate preferences. The inspectors ate a lunch with the residents, during the inspection, which was appetizing and enjoyable. Residents spoken to all confirmed that they enjoyed their meals and said that the meals were always well presented and that if they wish they could have a glass of wine with their meal. Staff, were observed assisting the more frail residents. This task was carried out in a sensitive and unhurried manner. It was pleasing to note that residents Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 12 requiring a blended diet had their meal presented in a way that retained colour and texture. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 13 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 and 18 Good practices and policies are in place to enable concerns to be raised and responded to and to protect residents from abuse. EVIDENCE: The home has a comprehensive complaints procedure, which is contained in the Service User Guide and provided to residents and their relatives upon admission. The home has received no complaints since the last inspection. The Commission for Social Care Inspection has received no complaints within the last year and there have been no vulnerable adult referrals to Social Services. Comment cards received from residents, relatives and professionals all confirmed that people were well informed in respect of the home’s complaint procedure. In the main residents spoken to said that if they had any concerns they would approach the registered manager. However, one resident spoken to felt that her concerns would not be taken seriously, saying, that she is seen as difficult and challenging. The home has an abuse policy in place, which includes guidance on whistle blowing, abuse of residents and advice for staff on what could be perceived as abusive practice. This policy is easily accessible by staff. Criminal Records Bureau clearances were checked. The home maintains records of details of staff applications and clearances received and liaise well with the Commission in respect of POVA (Protection of Vulnerable Adults) clearance. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 14 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 and 26 The home is decorated and furnished to a excellent standard. EVIDENCE: The Inspector toured the home and found that the physical standards are consistently good through out the building. A refurbishment programme has recently been completed which has resulted in an excellent standard of decoration. All radiators were guarded and fail-safe devices are fitted to all hot water outlets, the water temperature is checked monthly and the findings recorded. The communal rooms are spacious, comfortable and furnished appropriately to meet the needs of the residents. The residents’ bedrooms were all individual, reflecting their preferences and containing personal possessions. Specialist equipment was seen around the home ensuring individual needs are met whilst promoting independence. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 15 The laundry room is situated in the basement and the facilities ensure that laundry is washed at the appropriate temperatures. Walls and floors are impermeable that minimises the risk of cross infection. The grounds of the home are extensive and well maintained. To ensure residents can move safely ramps are situated both inside and outside the home. A maintenance man is employed who will carry out minor repairs and ensure the home is maintained to a safe standard. Staff are encouraged to record any areas that require attention, this record is then viewed by the maintenance man and he dates and signs the record once remedial action has been taken. The home was found to be warm, thoroughly clean and free from any offensive odours. All staff receive training in infection control. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 16 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 and 30 The policies and procedures for the recruitment of staff are robust and provide safeguards for the protection of residents. Staffing levels and skills mix are determined in accordance with the assessed needs of the residents. EVIDENCE: There is a clear commitment to the training and development of all staff at Stella Matutina and staff have worked hard to achieve their NVQ qualifications. Currently 80 of the care staff employed at the home has successfully achieved a National Vocational Qualification (NVQ) award in care at level 2 or above. The manager ensures that, all staff attends mandatory training. A training matrix is maintained which provided evidence of courses attended and when refresher courses are due. Induction training is provided and staff are provided with a mentor until the registered manager is satisfied that the new staff member is competent to carry out their duties unsupervised. Whilst induction training is recorded by the means of a checklist the inspector advised that the ‘tick’ that says the subject matter has been covered should be replaced by the date the training was provided and the signatures of both the trainer and the trainee. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 17 The home operates a thorough recruitment process in order to protect service users. Since the last inspection, some new members of staff have been appointed. From observation of three staff member’s personnel files, it was evident that the home’s policy and procedures in respect of staff recruitment had been followed. An application form, formal interview, references and a Criminal Records Bureau clearance had been obtained prior to the applicants actually taking up post at the home. Advice was offered to improve on the application form. The inspector suggested that greater health details of prospective employees should be requested and prospective employees should be asked to declare any cautions received in addition to criminal convictions. Staffing levels were sufficient for the number of residents living at the home. Residents said they were happy with the care they receive from the home and were well treated by the staff. Staff spoken to said they were clear about their role and work well as a team to ensure the individual and collective needs of residents are met. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 18 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): The management and staff at the home are competent and the health, safety and welfare of residents are strongly promoted. EVIDENCE: Good systems are in place to ensure that a safe environment is maintained. Records are kept of routine maintenance and servicing of equipment. COSHH regulations are adhered to and substances hazardous to health are stored securely. All staff are made aware of their responsibilities for health and safety. Training in health and safety and fire safety is provided through the induction of all new staff and refresher courses are held at regular intervals. The home has comprehensive policies and procedures in relation to health and safety these Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 19 take the form of individual policies in relation to safe working practices. However at the time of the inspection the homes generic health and safety policy could not be located and the inspector advised that the Health and Safety Executive be contacted who will supply the necessary document. Risk assessments are in place, which, ensures that the health, safety and welfare of the residents and staff are promoted and protected. The inspector advised that risk assessment in relation to safe working practices should be extended to ensure that action to minimise the risk is recorded for all identified hazards. In addition, staff should sign all risk assessments once they have read and understood the content. A excellent procedure for the safe use of oxygen was seen to be place. To prevent the risk of scalding a record is maintained of hot water temperatures in all bathrooms and hot water outlets used by residents. Systems are also in place to reduce the risk of Legionella, the storage of water is regulated by the means of valves in addition a external company regularly takes water samples for testing. However at the time of the inspection the records to confirm these tests were up to date was not available due to the maintenance man having left the building. The registered manager was asked to forward copies of the records to The Commission for Social Care Inspection. The manger is supported in her role by an external management team; in addition the home employs an administrator and a deputy manager. All senior staff has delegated areas of responsibilities and good systems are in place to ensure that resident’s rights are safeguarded. The home is well run and this was further endorsed when the home was awarded 5 stars, 3 crowns and 2 wheelchairs by the RDB Quality Benchmark Company in December 2004. This achievement has now been further endorsed by the implementation of an internal quality assurance system. This provides the manager with the opportunity to gain the views and opinions of residents, relative’s and visiting professionals. The system for recording resident’s personal money held by the home was examined, this was found to be satisfactory and documented all money received and all expenditure. In addition receipts are retained together with the balance held. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 20 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 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 X X X X 3 X X 3 Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 21 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 Refer to Standard OP29 OP30 OP38 OP38 OP38 Good Practice Recommendations The application should be developed to include greater health details and any cautions the prospective employee may have received. All induction training should be signed and dated by the trainer and the trainee, A generic Health and Safety policy should be in place. All risk assessments should include the steps taken to minimise all identified hazards. The records relating to the testing of Legionella and the maintenance of safe water temperatures should be forwarded to The Commission for Social Care Inspection. Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Stella Matutina Convent DS0000009719.V254953.R01.S.doc Version 5.0 Page 23 - 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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