Inspection on 14/03/06 for The Franciscan Convent

This inspection was carried out on 14th March 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

The Franciscan Convent 10/03/09

The Franciscan Convent 24/01/07

The Franciscan Convent 20/09/05

The Franciscan Convent 15/03/05

The Franciscan Convent 16/08/04

The Franciscan Convent 04/02/04

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 The Franciscan Convent 26 East Park Road Blackburn Lancs BB1 8BB Lead Inspector Jane Craig Unannounced Inspection 14th March 2006 09:00 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 The Franciscan Convent DS0000005822.V280477.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. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Franciscan Convent Address 26 East Park Road Blackburn Lancs BB1 8BB 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) 01254 53962 0161 7946420 fmsj@aol.com Franciscan Missionaries of St Joseph Mrs Jennifer Sturgess Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection 20th September 2005 Date of last inspection Brief Description of the Service: Franciscan Convent is a registered charity, run by the Franciscan Missionary of St. Joseph. The Roman Catholic faith underpins the life of the home, and many of the routines are those of Convent life. Franciscan Convent is a home caring for the elderly Sisters of the Congregation; there are also places for lay people. The house is a detached property set in its own grounds in a quiet residential area of Blackburn. There is level access to the lawned gardens and flowerbeds surrounding the house, and garden furniture is provided. There is ample car parking space. There are local shops within walking distance and a bus service near to the gates of the house. Accommodation is provided for thirteen people in 9 single and 2 shared bedrooms, some bedrooms are en-suite. Bedrooms are situated on the first floor. A passenger lift enables ease of access. There is ample communal space in 3 lounges and 1 large dining room. The convent also has its own chapel on the ground floor and services are held daily. Offices are situated on both ground and first floor. The kitchen is on the ground floor and the laundry at basement level. Various aids and adaptations are provided throughout the home. Bathrooms and toilets are well equipped with appropriate aids to help independence. Residents’ en-suites are equipped with seats in the shower and grab rails. There is ample space to ensure staff can offer assistance if necessary. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 1 day. The previous statutory inspection was done on 20th September 2005 and information on the findings of this can be obtained from the home or from www.csci.org.uk There had been no additional visits to the home. At the time of the inspection there were 9 residents living at the home. The inspector met with 5 residents who agreed to talk about their experiences of living in the home. Some of their views and comments are included in this report. The inspector held discussions with the registered manager and two other members of staff. A partial tour of the premises took place and a number of records and documents were viewed. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents said that staff were very caring and looked after them well. One resident said, “nobody could do more.” Another said, “the staff are always polite and respectful, I can’t think of one who isn’t excellent.” Residents were happy with their lifestyle and said the home lived up to expectations. Their comments included, “I couldn’t fault a thing about the place,” “it has a lot going for it, a beautiful place inside and out,” and “I am quite happy here, I feel as if I have come home.” Residents were more than satisfied with the food. They said there was plenty of variety and the food was delicious. One resident said, “the food’s an absolute bonus here,” and another said, “if I could say excellent plus I would.” The manager made sure that new staff had thorough background checks before they started work at the home. New staff were also supervised by experienced staff who assisted them to understand the needs of the residents. The staff spoken with said they liked working in the home and felt supported by the registered manager. Residents and staff said they were able to discuss any matters with her at anytime. One resident said, “we couldn’t have anyone better in charge.” The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. The Franciscan Convent DS0000005822.V280477.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 The Franciscan Convent DS0000005822.V280477.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): EVIDENCE: None of the above standards were assessed during this inspection. Standard 3 was assessed and met during the inspection of 20/09/05. The Franciscan Convent DS0000005822.V280477.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 and 10 Some care plans did not provide staff with enough information to understand and meet resident’s needs. Residents’ ongoing healthcare needs were met but inadequate risk assessments may result in new healthcare needs not being identified. Shortfalls in medication administration records may result in medication errors. Care was provided in such a way as to uphold residents’ rights. EVIDENCE: The manager was in the process of testing new care plan documentation but the new format did not allow for staff to write clear, individual care plans. Care plans for two, recently admitted residents, did not contain enough information about their personal, health and social care needs. There were insufficient instructions for staff to follow. Care plans written in the old format were very detailed and included comprehensive directions for staff. This ensured that care was provided in a consistent manner. There were also other systems in place to ensure continuity of care, such as regular verbal handovers and detailed progress notes. Plans were reviewed regularly. Residents could be as involved in care planning as they wished and some residents wrote their own plans. A relative had been involved in writing a personal history for another resident. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 10 As previously recommended, most care plans included risk assessments for moving and handling, nutrition, falls and pressure sore risk. However, the falls assessment for one resident was incomplete. Consequently the resident did not have a plan to minimise the risk. Another resident had been assessed as high risk of developing pressure sores. There was no plan in place but staff were able to discuss what care was provided to minimise the risk. There was evidence that residents’ ongoing healthcare needs were monitored and they were referred to other professionals when necessary. Residents said their health needs were met. Residents’ comments included, “they look after us all,” “nobody could do more,” and “they always get the doctor out, they are very quick off the mark.” Despite a previous requirement, the Medication Administration Record (MAR) charts did not always provide an accurate record of external medications administered. Several MAR charts had handwritten amendments that were not signed and witnessed. Dose changes were not always dated, which meant that the records of medication given was not auditable. A number of residents were prescribed variable dose or when required medicines. Although staff had attempted to define the criteria for when the medication should be given, these would benefit from further development. Staff received training in care values during their induction. They gave examples of how they maintained residents’ privacy and dignity whilst providing personal care. Some residents had been involved in drawing up a charter of rights which was included in the service users guide. Residents confirmed that they were treated with respect. One said, “the staff are always polite and respectful, I can’t think of one who isn’t excellent.” Another said, “they are very polite to people under their care.” Residents also said staff respected their rights to privacy, independence and choice. One said, “we’re very independent.” The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 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): 12 and 15 Residents’ social, recreational and religious needs were met. The standard of meals was high and residents received a varied and nutritious diet. EVIDENCE: All the residents spoken with said they were very happy living at the home. One resident said she, “came for a week and didn’t want to go home.” Other comments included, “I couldn’t fault a thing about the place,” “it has a lot going for it, a beautiful place inside and out,” and “I am quite happy here, I feel as if I have come home.” Residents were satisfied with the routines in the home and said they had plenty of choice as to how they spent their time. A number of residents had activities and occupation outside the home and did not rely on staff to meet their social and recreational needs. Others had information on their plans about their interests and their social needs were met on a one to one basis. One resident said, “I enjoy the Mass every morning and don’t really want anything else.” Another said, “I go out every week, they give me a carer.” Records showed that residents had a varied and nutritious diet. Although there was a set menu every day the residents and staff said that they could have anything they wanted at any time. All the residents were very complimentary about the meals and their comments included, “delicious,” “plentiful,” “always beautifully cooked,” “the food’s an absolute bonus here,” The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 12 “remarkable,” “plenty of greens,” and “if I could say excellent plus I would.” Residents could choose whether to have their meals in the main dining room or in their rooms. Mealtimes were social occasions and residents were served at the table so they could choose exactly what they wanted and how much. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 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): EVIDENCE: None of the above standards were assessed during this inspection. Standards 16 and 18 were assessed and met during the inspection of 20/09/05. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 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): EVIDENCE: None of the above standards were assessed during this inspection. Standards 19 and 26 were assessed and met during the inspection of 20/09/05. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 15 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): 29 Recruitment policies and practices provided safeguards for residents. EVIDENCE: Robust recruitment policies were in place. The files of two new employees were viewed. Pre-employment checks had been carried out and the required information and documents were retained on file. There was a very low turnover of staff and most of the current team had worked at the home for a number of years. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 16 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 and 38 The home is well run by a competent and qualified manager. Regular training in health and safety topics provided safeguards for residents and staff. EVIDENCE: The registered manager had many years experience of working with the resident group. The manager had attained the NVQ level 4 in care and the Registered Managers Award and also held an advanced management qualification. The manager updated her knowledge and skills through attending short courses, self-directed study and networking with other managers. Staff and residents were very positive about the management of the home. One resident said, “we couldn’t have anyone better in charge.” Staff said they enjoyed working at the home and found the manager approachable and supportive. Following a previous recommendation all staff had received updated fire safety training. Training in other safe working practice topics was up to date. Water The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 17 temperatures in bathrooms were being monitored regularly to minimise the risk of scalding. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 18 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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 19 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. 2. 3. Standard OP7 OP8 OP9 Regulation 15(1) 15(1) 13(2) Requirement Care plans must outline how residents’ personal, health and social care needs are to be met. Care plans must identify health risks and how they are to be minimised. Accurate records must be kept of all medication administered. This includes creams and other topical preparations. (Timescale of 30/09/05 not met) Timescale for action 30/04/06 30/04/06 20/03/06 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. 2. 3. Refer to Standard OP7 OP8 OP9 Good Practice Recommendations Care plans should provide detailed directions for staff as to how care is to be provided. Healthcare risks should be assessed and monitored. Handwritten amendments to MAR charts should be signed and dated. Dose changes should be clearly documented on MAR charts. The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 The Franciscan Convent DS0000005822.V280477.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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