Inspection on 20/09/05 for The Franciscan Convent

This inspection was carried out on 20th September 2005.

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 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

The Franciscan Convent 10/03/09

The Franciscan Convent 24/01/07

The Franciscan Convent 14/03/06

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 Announced Inspection 20th September 2005 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 The Franciscan Convent DS0000005822.V251957.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. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 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 Missionary 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.V251957.R01.S.doc Version 5.0 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 15th March 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.V251957.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which meant that the residents and staff were told beforehand when the inspector would be arriving. The inspection took place over one day. At the time there were 8 residents accommodated in the home. The inspector met with all of the residents. Their views and comments are included in this report. Three residents also completed comment cards before the inspection. Discussions were held with the registered manager and two other members of staff. Four relatives or visitors had returned comment cards, indicating very positive experiences of the home. A partial tour of the premises took place and a number of documents and records were viewed. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents said they got on very well with the manager and staff, which contributed to the warm atmosphere in the home. They said that staff were caring, kind and polite. Residents were supported to make their own choices and maintain their independence. One resident said, “they give me help I ask for, they don’t try to take over.” Care plans were well written with clear directions for staff so that they knew exactly what residents needed and how they preferred to be helped. Residents could write their own plans if they wished. Residents said that staff looked after their health very well. Staff had lots of opportunities for training. 86 of the care staff were trained to at least NVQ level 2 and the registered manager held the recommended qualifications. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 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.V251957.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 The Franciscan Convent DS0000005822.V251957.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): 3 The admission process ensured that the resident’s needs were assessed and understood before they moved into the home. EVIDENCE: The registered manager assessed lay residents in their own home or in hospital before offering them a place at the home. The assessment took into account the resident’s needs and whether the lifestyle offered at the home was appropriate. The Mother General assessed the needs of Sisters who chose to live at the home, to ensure that the services and facilities could meet their needs. The assessment would be discussed with the registered manager who finalised the admission. The manager confirmed that extra staff and training would be provided where the need was identified. The Franciscan Convent DS0000005822.V251957.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): 7, 8 and 9 Care plans were detailed and provided staff with the information they needed to understand and meet residents’ needs. Staff met residents’ healthcare needs with support from outside agencies. There had been some improvements in medication practices. However, failure to keep accurate records of medicines administered may result in medication errors. EVIDENCE: 2 residents wrote their own care plans with additions from staff where appropriate. Other residents had opportunities to be involved if they wished. Care plans were very detailed and provided staff with clear directions as to how residents’ health, social and personal care needs were to be met. Care needs were evaluated every week and plans updated as changes occurred. A full care plan review was carried out every six months. Residents said staff looked after their health very well. One resident said, “staff are particularly good, there is a day and night service.” Another said “very good care, I have everything I need.” A relative wrote that her aunt “is very well cared for in all aspects of her life.” The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 10 Records showed that referrals were made to outside agencies as necessary and residents were always escorted to healthcare appointments outside the home. The registered manager had links with the falls collaborative. Falls risk assessments were conducted every three months and management plans were in place to minimise risk. There were no assessments to identify or monitor residents’ nutritional or pressure sore risk, to ensure timely referral to other agencies. However, residents already known to be at risk of developing pressure sores had appropriate equipment and pressure relieving care. Three previous recommendations relating to safe handling of medication had been actioned. 1 recommendation, regarding medicines to be given when required, remained outstanding. There was a complete set of policies to assist with medication management. All staff were undertaking advanced training. Medication was stored safely and records were kept of medicines received and disposed of. There were some gaps on Medication Administration Records (MAR) charts with regard to the administration of prescribed creams, which must be addressed. The Franciscan Convent DS0000005822.V251957.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): 13 and 14 The ethos of the home enabled residents to exercise choice in all aspects of their lives. Residents were supported to keep in contact with family and friends and to make full use of community facilities. EVIDENCE: There was an open visiting policy. The home could accommodate guests and two residents talked about having members of their family to stay. A visitor to the home commented that they always received a lovely welcome from residents and staff. Residents were supported to make full use of community facilities, either independently or with staff. Many residents attended various meetings in the community. One resident said staff were always available to take her into town. Several residents talked about trips out over the summer, which they had enjoyed. Residents had choice in all aspects of their daily lives, within the limits of their vows. Lay residents said they were able to choose whether or not to participate in the religious aspects of the home. One resident said, “there are no unpleasant rules.” Another said, “I do everything myself but it’s nice to know someone’s here if anything goes wrong.” The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 12 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 Residents were confident that any complaints would be acted upon. Members of staff had a clear understanding of adult protection issues, which safeguarded residents and meant that any alleged incidents would be dealt with appropriately. EVIDENCE: The complaints procedure was displayed in all bedrooms. Residents said they were very happy living at Franciscan Convent and had no complaints about their care. All residents spoken with said they could approach the manager or any of the staff if they had any concerns and they were confident they would be dealt with. One resident said, “I am not afraid to say anything if I did have a complaint.” The Commission had not received any complaints about the service. Staff had access to policies and written guidance on adult protection issues, including the Blackburn with Darwen Adult Protection Procedure. Staff had attended updated training provided by the local authority and those spoken with understood their roles and responsibilities in reporting. Residents said they felt safe and well cared for. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 13 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 was clean and well maintained. The standard of décor and furnishings provided residents with a safe, comfortable and homely place to live. EVIDENCE: The home was well maintained and the registered manager confirmed that any repairs were carried out quickly. There was an annual audit of the premises when areas for redecoration and refurbishment were identified. There was a good standard of décor and furnishings throughout. Residents were happy with the environment and their bedrooms. Several said they enjoyed sitting or going for walks in the grounds, which were well maintained. Residents talked about the standard of cleanliness in the home. One said, “I like my room very much, it’s bright and clean.” Another said “we have cleaners every day, they keep it nice.” There was a well equipped laundry in the basement. Residents were happy with the laundry service. One said, “the washing comes back quickly, I can send anything and it always looks lovely.” The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 14 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 There were sufficient staff on duty to meet the needs of the residents. Residents benefited from a stable and qualified staff team. Recruitment practices provided safeguards for residents. EVIDENCE: Residents said there were always enough staff on duty. One said, “the call bell is always answered quickly,” and another said that there was always a member of staff available to take her out if she wished. Residents all said they got on very well with the manager and staff. One said of the manager, “she is a wonderful person, who will do anything for anyone.” Others commented that the staff were polite, caring, kind and good at their jobs. The manager and staff confirmed that staffing levels were flexible. They gave examples of where they had been increased to meet the special needs of the residents. There was a low turnover of staff and only one new member had been employed since the last inspection. Records showed that pre-employment checks were conducted. The required documents and information were retained on file. The induction training programme met the national training organisation specifications. Care staff generally moved straight onto NVQ training and 87 had achieved level 2 or above. Staff said there were very good training opportunities and that they were given time, funding and extra staff to cover. They said they were encouraged to do any training they thought was relevant. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 15 One member of staff had gained a qualification to run a special exercise and massage group recommended by the falls collaborative, which the residents said was “good fun” and “good exercise.” The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 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): 33, 35 and 38 The home was run in accordance with the wishes and expectations of the residents. The way finances were managed suited the residents. Health and safety policies and practices usually provided safeguards but the lack of fire safety training may place residents and staff at risk. EVIDENCE: The home had retained the Blackburn with Darwen quality assurance award. There were no formal mechanisms for seeking residents’ views. The residents did not wish to complete surveys about their home and lifestyle. There were occasional residents meetings but most discussions took place informally on a day to day basis. Residents said they were consulted about anything of importance. The registered manager audited other systems such as care plans, medication and records. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 17 The convent managed the financial affairs of those residents who had taken a vow of poverty. They were provided with a personal allowance which most residents managed themselves. Others had detailed financial plans on file. Accurate records were kept of any transactions made on behalf of residents. Staff had received update training in safe working practice topics with the exception of fire safety training, which was overdue. Fire equipment and alarm systems were serviced and drills were held. The fire procedure was posted in all rooms and residents were aware of what to do and where to go in the event of fire. Servicing and maintenance of gas and electrical installations, appliances and equipment was up to date. Potentially hazardous substances were stored safely. Assessments and data sheets were available. The thermostatic valves on hot water taps were checked and adjusted annually but hot water temperatures were not monitored in between. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement Accurate records must be kept of all medication administered. This includes creams and other topical preparations. Staff must receive update training in fire prevention. Timescale for action 30/09/05 2 OP38 23(4)(d) 30/11/05 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 OP8 OP9 OP38 Good Practice Recommendations Healthcare risks should be assessed and monitored. Criteria fro the administration of when required and variable dose medication should be clearly defined and recorded for all residents. The temperature of hot water in the baths should be monitored on a regular basis. The Franciscan Convent DS0000005822.V251957.R01.S.doc Version 5.0 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.V251957.R01.S.doc Version 5.0 Page 21 - 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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