CARE HOMES FOR OLDER PEOPLE
Stella Matutina Convent 16 Clifton Drive Ansdell St Annes FY8 5RQ Lead Inspector
Lillian McMullen Unannounced 3rd June 2005 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 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 F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Stella Matutina Convent Address 16 Clifton Drive Ansdell St Annes Lancashire FY8 5RQ 01253 734834 01253 794424 pauline@cjsm.org Sisters Of Charity Of Jesus and Mary Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Pauline Louvain Calvert Care Home only 41 Category(ies) of Old Age (OP 41) registration, with number of places Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th February 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 F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10am and took place over 5 hours. The Inspector spoke to five staff members, eight residents, a relative and the manager. Part of the inspection was spent on looking at care documentation in relation to the care planning and assessment procedure. What the service does well: What has improved since the last inspection?
The recruitment procedures have improved, all staff and volunteers are now cleared through the Criminal Records Bureau prior to working in the home. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 standard(s) 3 There is a good assessment procedure in place, which ensures the needs of the residents can be met. EVIDENCE: The records of four residents were examined all had full assessment information. Also on file was information about the specialist needs required by residents all of which was acquired prior to admission. There was also evidence of social work assessments being carried out to supplement the homes assessment. In addition to the manager visiting prospective residents in their own home to carry out an assessment of need, prospective residents are invited to Stella Matutina with their relatives to meet the staff and view the facilities. A period of respite or short term care is also offered which allows the resident to establish if the home meets their expectations whilst providing staff with the opportunity to ensure the needs of the resident can be appropriately met. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 9 Staff members confirmed they had access to this information and could describe in detail the care needs of residents. Residents spoken to said they were happy that their needs were being met by the home. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 10 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 standard(s) 7,8 and 10 The care planning process ensures the assessed needs of the residents are met. EVIDENCE: Individual records are kept for each resident with a plan of care setting out in detail the action that needed to be taken by care staff to ensure all aspects of health, personal and social care needs of the residents were met. Significant events had been recorded and daily entries made setting out the care given. Evidence was seen to confirm that residents are involved in the care planning process, all care plans examined were signed by the resident, one resident spoken was able to inform the inspector that she knew the content of her care plan and that regular reviews take place. Risk assessments accompany the care plan and are reviewed also on a monthly basis. All residents spoken to were happy with the care they receive. One resident said “staff are always very thoughtful and I am extremely content”. A relative
Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 11 spoken to said she was “very pleased” with the care her sister receives and that staff work extremely hard and do all they can to please. Staff spoken to had a good understanding of the care needs of the residents and confirmed that they have good management support. The inspector observed staff assisting residents and was pleased to see they had good relationships with residents and carried out all tasks in a friendly and sensitive way. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 standard(s) 12,13 and 14 Social activities and meals are well managed to suit both the individual and group. Contact between residents and their families are encouraged to help them maintain relationships. EVIDENCE: An activity organiser is employed together with an assistant. A full programme of activities is arranged to meet all preferences and abilities. Outings are organised to shows and places of interest, in addition shopping outings take place either as a group activity or on a one to one basis. A new people carrier vehicle has recently been purchased for the benefit of al the residents and a number of staff has appropriate insurance cover to drive this car, residents are not charged for the fuel costs. In house activities are organised which include quizzes, handicrafts, gardening etc. A full weekly programme is displayed on the resident’s notice board. Residents spoken to said they enjoyed the activities provided especially the trips out. One resident said “staff do all they can to make each day different” and that “they will you take you out if you need to go to the doctors or go shopping”.
Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 13 Daily mass takes place in the home’s chapel for those wishing to take part. Visitors are welcome at anytime and residents are encouraged to retain relationships with family and friends. A relative spoken to at the time of the visit confirmed that she could visit at any time for as long as she wishes and that she is always made to feel welcome. Whilst Standard 15 (Meals and Mealtimes) was not fully assessed at this inspection the inspector observed the mid day meal being served and was pleased to see it was well presented and was being enjoyed by all the residents. A number of residents commented that they enjoyed their meals and that the standard of food served was consistently good. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 standard(s) EVIDENCE: None of the above standards were assessed at this inspection. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 standard(s) EVIDENCE: None of the above standards were assessed at this inspection. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the above standards were assessed at this inspection. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 33 The home is well managed and run in the best interests of residents. EVIDENCE: Residents and staff spoke well of the manager and the care and support that she gives. The manager has many years experience in caring for the elderly and is appropriately qualified. 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 should now be further
Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 18 developed by the implementation of a formal internal quality assurance system. This would provide the manager with the opportunity to gain the views and opinions of residents; staff and relatives to further enhance the service provided. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 3 x x x x x Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 20 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. 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. Refer to Standard 33 Good Practice Recommendations To develop a internal quality assurrance system. Stella Matutina Convent F57 F09 S9719 Stella Matutina V231370 030605 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Area Office, 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
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