Inspection on 16/09/05 for The Infirmary

This inspection was carried out on 16th 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 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 Infirmary 03/01/07

The Infirmary 05/01/06

The Infirmary 25/02/05

The Infirmary 02/07/04

Similar services:

Henry Nihill House

Birchwood

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Spring Lane Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Infirmary Suttons Hospital in Charterhouse Charterhouse Square London EC1M 6AN Lead Inspector Pippa Treadwell-Smith Unannounced 16 September 2005 th 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. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Infirmary Address Suttons Hospital in Charterhouse, Charterhouse Square, London, EC1M 6AN 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) 0207 253 9521 0207 490 4445 chaterhouseecl@aol.com The Governors of Suttons Hospital in Charterhouse Ms Geraldine Ann Hales Care Home with Nursing 10 Category(ies) of OP Old age registration, with number of places The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Nursing procedures must be confined to residents admitted to the 10 beds within the registered Care Home - The Infirmary. Date of last inspection 25th February 2005 Brief Description of the Service: The Infirmary is registered as a care home with nursing for up to 10 people. It is located within the historic site known as The Charterhouse. Access is through the Gatehouse located in Charterhouse Square; this is manned and provides a secure entry into the whole site. The Infirmary provides contemporary and purpose built accommodation all on one level. It is located on the first floor and there is access via a shaft lift. Generally all the service users are male and have been living as Brothers, the term used by the organisation, within Suttons Hospital in Chaterhouse prior to admission. The Infirmary provides personal care to those Brothers who are not able to be supported in their on-site flats. Short unplanned admissions to The Infirmary would occur following disacharge from hospital and on the recommendation of the GP for an acute illness. In addition the staff of the Infirmary have a watching brief in relation to the health and personal care needs of the Brothers living in their flats. Of the ten single bedrooms in The Infirmary, eight have ensuite, assisted showers; the remaining two rooms have access to an adjacent bathroom with assisted bath. Although The Infirmary is self-contained with a small kitchen, dining-cum-sitting room and the quiet area of St Brunos Chapel, the service users have access to a large lounge on the ground floor and can take their meals in the Great Hall situated in the main building. Suttons Hospital In Charterhouse believes that every brother has the right to live their life with privacy and dignity, independence and choice. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one morning in September and lasted about three and a half hours. The manager was not available but the nurse-in-charge assisted with the inspection. A tour of the premises had been made at a pre-arranged visit a few weeks beforehand. A variety of records were looked at, including care plans, policies and procedures and health and safety documents. What the service does well: What has improved since the last inspection? The health and safety issues have been addressed since the last inspection. The unit is now equipped with clinical hand washing facilities and a sluice as well as a bed-pan washer. Staff have access to a training video in respect of adult protection and are now receiving regular support to discuss all aspects of their practice, career development and philosophy of care in the unit. Four areas in which the unit could improve are detailed in this report. The management team at The Infirmary are keen to work closely with the Commission for Social Care Inspection (CSCI) in order to raise standards further so that the Brothers have the best possible quality of life whilst resident in The Infirmary. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 6 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 Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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 The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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 (Standard 6 is not applicable) When a person moves into this accommodation, the manager works out what they want and need so that the staff are sure to meet these needs and wishes. This enables service users to be confident that The Infirmary is an appropriate place for them. EVIDENCE: Several of the service users were spoken to during both visits. They all said that they enjoyed living in The Infirmary and felt that their needs were being met. Four service users also responded by sending back comment cards. One recorded “The Infirmary provides an excellent standard of care with a friendly atmosphere at all times.” Two care files were looked at and each one contained appropriate assessments. The outcomes of the assessments had been translated into plans of care setting out how the person’s needs and wishes would be met. Risk assessments had also been completed in respect of nutritional screening, mobility and tissue viability. Any risk that had been identified was being effectively managed by the staff. A relative commented, “I am very happy with the standard of care which my father receives”. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 9 The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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, & 10 The service users in The Infirmary benefit from the close attention paid by staff to meeting their health needs. There is a clear and consistent care planning system in place to provide staff with the information they need to meet service users’ needs. Personal support in this home is offered in a way as to promote and protect service users’ privacy, dignity and independence. EVIDENCE: The records of two of the service users were looked at and showed that for each one there was a current plan of care, which set out the needs of the service users and how these were to be met. Service users are involved with their care plans as much as they want to be. There is evidence of regular evaluation. In addition areas of risk were also assessed using recognised nursing tools. Each area of risk showed how these risks were to deal with and reduced as far as possible. Feedback from the service users and discussions with staff was positive about the commitment to keeping the service users as well as possible. All the service users are registered with a GP who holds a weekly surgery in the home. There are clear indications of good working relationships between the staff in The Infirmary and the surgery. Records show referrals to outpatient’s The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 11 appointments and relevant health acre specialists. The service users also have access to alternative therapies including holistic massage, aromatherapy, lymphatic draining massage, reflexology, nutrition, Bach flower remedies and manicures. The services of a physiotherapist and acupuncturist are also available. All the service users commented that they were happy with the standard of care they receive. The statement of purpose clearly states that staff are not permitted to enter service users’ bedrooms unless permission is given or they are invited to do so. The comment cards from the service users recorded that their privacy is respected. Observation of the staff demonstrated appropriate interaction and positive relationships. Discussions with staff showed that they had a clear understanding of respecting service users’ rights, privacy and dignity. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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 & 14 The Infirmary is good at making the service users feel at home and comfortable and that they are well looked after. Service users’ relatives and friends are made to feel welcome. The service users are able to choose from a wide range of varied and stimulating activities and outings. EVIDENCE: A social and leisure calendar is on display in the foyer of The Infirmary. It outlines the programme of events from September 2005 to December 2005. It includes recitals, visits to places of interest, lectures and entertainment. The statement of purpose says that service users will be assisted to attend their own planned activities. The comment cards recorded that service users felt that suitable activities were organised for them. There is a visitor’s policy and all visits are recorded in the visitor’s book kept at the nurses/reception desk. This indicates that there are numerous visitors to the premises. Several visitors were seen over the two days that the inspector was present. Both relatives recorded that they are made to feel welcome at any time and can always visit their parent in private. The care plans include the likes and dislikes of the service users. They felt that their wishes are respected at all times. Discussion with staff indicate that service users are assisted fully in making life style choices. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 13 The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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) 16 & 18 The home has a satisfactory complaints system with some evidence that concerns are taken seriously and fully investigated. Service users are protected from abuse by the policies and procedures however further work is required to bring the adult protection procedure in line with that of the host authority. EVIDENCE: The complaint’s procedure is documented in the statement of purpose although the name of the current inspector requires updating. The inspector would recommend that no names are included but all concerns should be sent to the Regulation Manager of Camden CSCI. The pre-inspection information confirmed that The Infirmary had not received any complaints during the last twelve months. There is a system to record and monitor complaints and this showed that no concerns had been raised. Two relatives and a service user confirmed that they were not aware of the complaints procedure but had no call to raise any concerns. There is an indication that service users and their families may require reminding of the complaint’s procedure. A service user recorded in a comment card “We are very well off at Charterhouse. I have no complaints”. Since the last inspection staff have received training relating to adult protection through watching a video. There is a policy and procedure on adult protection however this is not linked to the local procedures agreed by London Borough of Islington. All allegations or incidents adult abuse must be reported outside the home and the host authority (Islington) will take the lead in The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 15 arranging strategy meetings and investigating any concerns unless it is clearly a police matter. The Infirmary does not have a copy of the local procedures and staff would benefit from training in relation to the local procedures. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 16 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) 19 & 26 The service users living in The Infirmary enjoy a very attractive and comfortable living environment. There is an excellent standard of cleanliness and hygiene that adds considerably to their quality of life. EVIDENCE: The service users’ rooms are spacious and well appointed. Most have good views and there is access to well-maintained grounds. The location of The Infirmary offers a secure and tranquil environment however there is access to community amenities and shopping areas. Service users are able to personalise their own rooms as well as take advantage of communal facilities. Throughout both visits the premises were found to be clean and hygienic. Staff are supported by sound policies and procedures relating to cross infection and have the necessary equipment and facilities to deal with contaminated material. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27, 28, 29 & 30 Staff have a clear understanding of their roles and are deployed in sufficient numbers to meet the needs of the service users. Service users benefit from a committed staff team. Records were not available for inspection because the manager was not on site due to annual leave. EVIDENCE: One nurse and two health care assistants were on shift during the inspection. Discussions with staff revealed that they have access to relevant training courses. A number of training events were on display on the notice board. These included manual handling, wound care programmes and the use of nutritional tools. A staff training and development programme or individual training records were not available. The pre-inspection information showed that 8 health care assistants are employed; one with NVQ2 and four on training. Confirmation will be required as to whether 50 of the staff will have achieved NVQ Level 2 and the manager has completed a relevant management qualification by the end of 2005. Job descriptions are available but those inspected were not dated therefore it is not possible to assess whether they reflect the current roles of the staff. At a previous visit the inspector left the manager staff forms to complete. These are to be available instead of staff personnel files. The pre-inspection information showed that staff are subject to a CRB check and these have been returned. The registered nurses PIN numbers are recorded and checked. Three were noted to have expired in August 2005 and confirmation will be needed that PIN numbers these three nurses have been renewed. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 18 A supervision structure and policy is in place and staff confirmed that they are receiving appraisals and regular support either through team meetings or individual sessions. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 38 The Infirmary is good at making sure that the service users are kept safe and secure whilst living in the unit. EVIDENCE: A range of records and documents were looked at. These were detailed, upto-date and confirmed that the unit is being run responsibly with checks being made and acted upon. The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 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 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 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 x COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 3 The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 21 Yes 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. 2. Standard 16 18 Regulation 22(1) 18(1)[c]i) Requirement Timescale for action 31.12.05 3. 28 & 30 18(1)[c] 4. 29 19 & 17 The complaints procedure must be made known to all service users and their relatives The adult protection policies and 31.12.05 procedures must be linked to the local agreement of the London Borough of Islington. Staff will require training in the local authority adult protection policies and procedures. (This is being partially re-stated) A staff training and development 30.10.05 programme must be available for inspection. The registered person must confirm in writing whether 50 of care staff will be trained to NVQ Level 2 standard and whether the Manager has achieved a relevant management qualification. (This is being partially re-stated) The registered person must 31.12.05 ensure that the staff forms left by the inspector on 06.09.05 are completed and available for inspection at all times. Confirmation is also required that the three staff whose PIN number have expired, have renewed them. Version 1.40 The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Page 22 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 Good Practice Recommendations The Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Centro 4 20-23 Mandela Street London NW1 0DU 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 Infirmary DG58 s32213 Sutton v183269 160905 Stage 4.doc Version 1.40 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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