Latest Inspection
This is the latest available inspection report for this service, carried out on 5th May 2010. CQC found this care home to be providing an Excellent service.
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.
For extracts, read the latest CQC inspection for Cross And Passion Convent.
What the care home does well The spiritual needs of people living at the home is given up most consideration. This enables the chosen routines and lifestyle of the Sister`s to continue and provides very important continuity and familiarity. Health and personal care needs are extremely well met by a well qualified, caring and competent staff team. One sister told us in a Care Quality Commission (CQC) survey, "I feel we are very well blessed to have a wonderful home and wonderful staff". Another Sister said that there was, "Very caring staff and community". A third person commented, "I am very happy here and very well looked after". There is a very good relationship between people living at the home and members of staff that was relaxed and supportive. This helps people to feel comfortable and well cared for. There are good systems in place to protect people living at the home. All staff receive regular, mandatory adult protection training. What the care home could do better: The Cross and Passion Convent delivers a very high standard of care. Excellent systems are in place to make sure that the individual needs of each person living at the home are known and addressed. However although there is a very good system in place in respect of medication, it was noted that hand written entries in the drug administration recordwere not signed or countersigned. It has been recommended that all hand written entries are signed and dated by the person making the entry and checked and countersigned by a second person to confirm accuracy of the recording. This would help to protect people living at the home. Random inspection report
Care homes for older people
Name: Address: Cross And Passion Convent 19 East Beach Lytham Lancashire FY8 5EU three star excellent service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Denise Upton Date: 0 5 0 5 2 0 1 0 Information about the care home
Name of care home: Address: Cross And Passion Convent 19 East Beach Lytham Lancashire FY8 5EU 01253736913 01253732623 susandonegan@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Sisters Of The Cross & Passion Josephine Donnelly also known as Sister Catherine Laboure CP Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Conditions of registration: The registered person may provide the following category of service only: Care Home with Nursing - Code N To Service Users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling wihtin any other category - Code OP The maximum number of service users who can be accommodated is: 16 Date of last inspection Brief description of the care home The Sisters of Cross and Passion Care Home offers residential and nursing care for up to sixteen patients who are sixty-five and older. Most of the patients belong to the same religious order. The home is situated on the front at Lytham overlooking the green and is in close proximity to the local shops, library and public transport network.
Care Homes for Older People Page 2 of 10 care home 16 Over 65 16 0 Brief description of the care home Accommodation is provided in single bedrooms all of which have adapted shower ensuite facilities. There is one assisted bathroom, a lounge and large dining room. An additional seating area is also provided in the reception area of the home. The nursing home is situated within a convent in a large detached Victorian building. The Cross and Passion Convent is staffed with trained nurses and care assistants from the local area, the Matron of the home is from the Sisters of the Cross and Passion. Each person living at the home is provided with an individual copy of the homes Service User Guide. This important booklet tells residents about the home and the services and facilities provided. The Sisters receive all their living expenses from the Sisters of the Cross and Passion, who also provide for all their medical expenses. Care Homes for Older People Page 3 of 10 What we found:
This short random inspection did not look at all the minimum standards identified in the National Minimum Standards - Care Homes for Older People but focused on the health and personal care delivered and the systems in place for managing issues relating to complaints and the protection of people living at the home. These are important issues that directly affect the quality of care delivered and whether positive outcomes for the Sisters living at the home has been achieved. Individual care plans were in place for each of the Sisters that were detailed and informative, two of these were viewed. A separate care plan was written for each area of need that included spiritual needs, social and cultural needs, medication, moving and handling and mobility, mental and physical health needs, communication, hygiene, and dietary requirements. There was evidence of monthly reviews of the individual care plans taking place, with on-going amendments made as necessary. This helped to make sure that a clear and up to date record was maintained of each Sisters current strengths and needs so that staff were aware of any changes that needed to be made to the level of support and assistance required. The very person centred care plans gave clear and detailed instruction in order to guide and direct staff. This enabled staff to provide a very individualised service that was delivered in a consistent way. This also helped to make sure that the Sisters living at the home were encouraged to do what they could for themselves and promote independence whilst ensuring that all staff were giving the same amount of help when required. There was also clear evidence in the individual care plans that individual risks been identified and action taken to minimise those risks. Good risk assessments were in place. There was good evidence from documentation and discussion that physical and mental health care needs are very well met. Strategies were in place to ensure that the Sisters living at the home always got the medical care and support that they needed when they needed it. A local General Practitioner (G.P.) routinely visits the home each week. Every two weeks each Sister sees the G.P. during one of these visits. The G.P. also visits when requested. There was also clear evidence that any mental health concerns are quickly addressed that includes the involvement of local mental health services. There is a very good relationship with medical staff to ensure that as far as possible, the optimum health of each Sister is maintained. The relationship observed between the Sisters living at the home and staff group was relaxed and caring. This comfortable relationship enables staff get to know people well and any changes in health and well being are quickly noted and speedily addressed. There is a designated member of staff who is a moving and handling assessor and trainer. This person is very enthusiastic about maintaining best practice and has responsibility for updating moving and handling training on an annual basis and for advising staff on demand. All the Sisters have their own individual moving and handling equipment that is specifically obtained to address their individual requirements. As part of the visit, we checked how medicines were being handled. We checked a sample of medicines stocks and medicines records. Overall we found the handling of medication to be very well managed that helps protect the health and wellbeing of people who live in the home. There is a good system in place to make sure that medication is administered
Care Homes for Older People Page 4 of 10 safely and as prescribed. Only qualified members of staff administer medication. The medication administration records of two people were viewed. These had been completed correctly and a photograph of the person was available, this is good practice and helps prevent mistakes being made. Medicines stock was seen to be well organised, records were clearly presented and spare stock was stored securely. Records of medicines received into the home, given to people and disposed of were signed and up to date. We were informed that regular recorded checks are carried out to make sure staff were giving and recording medicines correctly. If any mistakes were found action was taken immediately to help prevent them happening again. It was noted that the individual drug administration records were all hand written. Although the records seen appeared to be the exact replica of the prescription label, the handwritten entries, outlining the name of the drug and directions for use, was not signed or countersigned by a second person. It is recommended that who ever writes a hand written entry in the drug administration record signs and dates the document to take ownership of the recording. Checking and countersigning a hand written entry in the drug administration record is considered good practice so as to ensure that the hand written entry is correct. This is for the protection of residents. Alternatively it may be possible to obtain pre printed prescription labels from the community pharmacist that could then be stuck on to the individual drug administration record. There is a homely remedies policy in place and protocols in respect of when required medication. This is medication that is not taken on a regular basis. This ensures consistency of use. Recent updated medication training has taken place in respect of all qualified and care staff. We were told that staff are always verbally informed of any changes to medication and advised what the new medication has been prescribed for. Privacy and dignity is well respected at the home. A member of staff gave a good account of how she respected the Sisters privacy and dignity when assistance with personal or health care was required. The health and personal care that people receive is based on their individual needs so they receive personal care in the way they prefer and in a way that shows respect for their privacy and dignity. All care staff receive training in respect of maintaining privacy and dignity during induction training and National Vocational Qualification (NVQ) training. A privacy and dignity policy is also available to advise and guide staff and this issue is also discussed through formal and informal day to day supervision arrangements. The Sister individually spoken with stated that she felt, Very well looked after and that the convent was, Very restful, very homely, we are like a family. The spiritual needs of the Sisters is extremely important and given priority. The convent chapel is in the same building and we were told, We have our spiritual life here and Mass every day, we have Mass at home. The Sisters have lived most of their lives in a convent and are used to order and regulation and like things well planned. Living at the home enables the Sisters to continue with the order and continuity of their religious life that is extremely important. A member of staff spoken with confirmed that a very high quality of care was consistently provided. We were told that excellent standards are maintained in respect of basic care and health and personal care needs. We were also told that there was a very person centred approach adopted by all staff and that everything was personalised for the
Care Homes for Older People Page 5 of 10 individual including time to sit and talk to the Sisters every day. The Cross and Passion Convent has a structured complaint policy and procedure in place, which includes details that any complaint would be responded to within a maximum of 28 days. From discussion with the registered manager, it is understood that a record of any complaint would be kept that included details of any action or investigation undertaken and outcome. Written details of the complaint procedure is incorporated in the Service User Guide, a copy of which is provided to each resident. Since the last Annual Service Review inspection, no complaints have been received either by the home or by the Commission. The Sisters that completed a CQC survey all said that they knew how to make a formal complaint and who they should speak with. There continues to be a variety of policies and procedures in place for the protection of residents. This includes an adult protection policy and a whistle blowing policy that helps to protect people living at the home from abuse or discrimination. All staff receive mandatory training regarding protection and abuse that is regularly updated. Care staff also receive guidance in respect of adult protection as part of their National Vocational Qualification training (NVQ). Opportunity is also provided for this topic to be discussion during one to one supervision and at team meetings. This helps to remind staff of the importance of protecting residents and the responsibility of the staff group in this matter. Since the last inspection there have been no safeguarding issues regarding the home. What the care home does well: What they could do better:
The Cross and Passion Convent delivers a very high standard of care. Excellent systems are in place to make sure that the individual needs of each person living at the home are known and addressed. However although there is a very good system in place in respect of medication, it was noted that hand written entries in the drug administration record
Care Homes for Older People Page 6 of 10 were not signed or countersigned. It has been recommended that all hand written entries are signed and dated by the person making the entry and checked and countersigned by a second person to confirm accuracy of the recording. This would help to protect people living at the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 10 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 9 It is recommended that all hand written entries in the drug administration record be signed and dated by the person making the entry and checked and countersigned by a second person to confirm accuracy of the recording. Alternatively it may be possible to obtain pre printed prescription labels from the community pharmacist. This would help to keep people safe. Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 10 of 10 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
