Care Home: St Angelas Convent

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What the care home does well The information available about the home is good however the Sisters must ensure that they only admit people into the home who come within the remit of the conditions of their registration. Care planning processes are person centred and people will receive the care and support that they need. Medication procedures have been improved to some extent but would benefit from further changes, to make things safer. Great emphasis is placed upon meeting individual`s religious and spiritual needs and this forms the basis of the day-to-day life for people who live in this home. They will receive nice meals. The procedures for dealing with any complaints that may be made will ensure that people who live in the home and their represenatives, will be listened to and the appropriate actions will be taken. People will be safeguarded from coming to harm.St Angela`s Convent is comfortable, well decorated and nicely furnished. It provides a safe and peaceful environment for the people who live there. Staffing levels are appropriate to meet people`s care needs, they will have been recruited following safe procedure to ensure that only suitable staff are employed and the staff training programme is satisfactory. This means that staff will have the right skills and experience to meet people`s individual needs. St Angela`s Convent is well managed and run in the best interest of the people who live there. They will be safeguarded by the home`s procedures. What has improved since the last inspection? There were two recommendations of good practice made after the last inspection in respects of medications. Both suggestions have been taken on board and this means that medication practices are safer. What the care home could do better: No requirements have been made following this inspection, however the manager must ensure that placement is not provided for people outside the category group and remit of their registration. This could have the potential to mean that the staff team would not have the necessary skills and knowledge to care for people with specific care needs (for example dementia). CARE HOMES FOR OLDER PEOPLE St Angelas Convent 5 Litfield Place Clifton Bristol BS8 3LU Lead Inspector Vanessa Carter Unannounced Inspection 5th January 2009 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 St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Angelas Convent Address 5 Litfield Place Clifton Bristol BS8 3LU 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) 0117 9735436 0117 9706844 stangelas@btconnect.com Sisters Of The Temple Sister Marie Louise Le Vern Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 23 9th January 2008 Date of last inspection Brief Description of the Service: St Angelas Clifton Down Convent is operated by The Sisters of The Temple, a Roman Catholic religious order. The manager and three of the senior care staff are sisters within the order. Additional lay staff are employed to fulfil care and ancillary responsibilities. It is registered by the Commission for Social Care Inspection to provide accommodation and personal care for up to 23 persons, aged 65 years and over. St Angelas is a large detached building in a suburb of North Bristol close to the countryside. Shops and community facilities are within 1/4 mile of the home. Accommodation is provided over three of four floors, in single rooms, all of which have en-suite facilities. There is a communal dining room on the ground floor, which is only used on special occasions by residents. There are no communal lounge facilities in the home. St Angelas home offers respite care when places are available. A shaft lift is in place to all floors. The top floor offers accommodation to independent guests of the Sisters of the Temple, and does not come within the remit of the registration. The fee’s and any extra charges made for things such as chiropody or hairdressing can be discussed with the home manager. Information about the home will be provided verbally to those people who enquire about living in the home and then confirmed in writing within the new resident’s contract. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over one day. A total of six hours were spent in the home. Evidence to form the report has been gathered from a number of sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the Home Manager • Talking with some of the care staff • Observations of staff practices and their interaction with the people who live in the home • A tour of the home • Case Tracking the care of a number of people • Talking with a number of the people who live in the home • Looking at some of the homes records • Information supplied in CSCI survey forms, completed by people who live in the home – we had nine returned. • Information supplied in two healthcare professional survey forms. What the service does well: The information available about the home is good however the Sisters must ensure that they only admit people into the home who come within the remit of the conditions of their registration. Care planning processes are person centred and people will receive the care and support that they need. Medication procedures have been improved to some extent but would benefit from further changes, to make things safer. Great emphasis is placed upon meeting individual’s religious and spiritual needs and this forms the basis of the day-to-day life for people who live in this home. They will receive nice meals. The procedures for dealing with any complaints that may be made will ensure that people who live in the home and their represenatives, will be listened to and the appropriate actions will be taken. People will be safeguarded from coming to harm. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 6 St Angela’s Convent is comfortable, well decorated and nicely furnished. It provides a safe and peaceful environment for the people who live there. Staffing levels are appropriate to meet people’s care needs, they will have been recruited following safe procedure to ensure that only suitable staff are employed and the staff training programme is satisfactory. This means that staff will have the right skills and experience to meet people’s individual needs. St Angela’s Convent is well managed and run in the best interest of the people who live there. They will be safeguarded by the home’s procedures. 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 summary of this inspection report can be made available in other formats on request. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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 St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available about the home is good however the Sisters must ensure that they only admit people into the home who come within the remit of the conditions of their registration. EVIDENCE: The Statement of Purpose and Service User’s’ Guide (referred to as the resident’s guide in this home) were both last reviewed and updated in July 2008. Both documents provide a full picture of the services and facilities on offer at St Angela’s Convent so people who live there will know what to expect. The service users guide is given to everyone who lives in the home. Eight people returned our survey forms and said that they had been provided with enough information about the home to make an informed decision about moving to St Angel’s Convent. “I chose St Angela’s because a friend used to live here. It was easy to make up my mind when I needed a care home” and “my family have known St Angela’s for years so this home was first choice for me” were comments included on the survey forms. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 9 The majority of people who are currently living in this home are self-funding – they will have been provided with a contract detailing the terms and conditions of their stay. When people are part funded by a local authority, they will be provided with a statement of terms and conditions too. Those people who completed our survey forms said that they had been provided with a contract. Prior to any admission being arranged, the home manager or another appointed person, will undertake an assessment of needs in order to make sure that the home is able to meet their care needs. We saw an ‘Assessment and Treatment Needs’ form completed for the most recently admitted person – it was detailed and comprehensive and covered personal care needs, social and spiritual needs, healthcare, and mobility and dietary needs. The home is registered to provide personal care for people whose primary care needs are within the old age category. St Angela’s Convent is not registered to provide placement for people whose primary healthcare needs are that of dementia or if they have significant healthcare and nursing care needs. They were currently looking after one person, on a short term respite care basis, who has mental health care needs, and whilst their needs were being met, this does not comply with their registration. The registered manager must always ensure that the care they provide is within the remit of their registration. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning processes are person centred and people will receive the care and support that they need. Medication procedures have been improved to some extent but would benefit from further changes, to make things safer. EVIDENCE: The care plans of three people were looked at to determine the processes involved in preparing individual personal plans for each person. The care planning documentation was clear and well formatted and the information is set out in a logical format. The plans correspond to the information recorded in the last assessment of care needs. Staff explained that a review assessment will be completed on a regular basis and these measures will ensure that care plans remain up to date and a true reflection of each person’s needs. One member of staff has been delegated the responsibility of ensuring that care plans are reviewed on a monthly basis and updated as necessary. Each of the three plans had been well prepared and set out the specific care needs of the individual person, and how those needs were to be met. Care staff spoken with during the inspection demonstrated a good awareness of St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 11 each person’s specific needs. The home manager must ensure placement at St Angela’s always falls within the remit of their conditions of registration, and that the staff team have the necessary skills and abilities to be able to meet each persons care needs. The primary care needs of one person had changed since admission and although referral has already been made to the appropriate healthcare professionals, the suitability of the placement must be reviewed. A number of other people have nursing care and end–of–life care needs – the community nurses and St Peter’s Hospice are involved and responsible for meeting healthcare needs. It is the ethos of the home “to look after people right up until the end” but the manager must always ensure that this is in the best interests for the individual involved. Records are kept of all visits by healthcare professional - such as GP’s, district nurses, occupational therapists and St Peter’s Hospice nurses. Daily running records are kept of the care given and are written in a kind and respectful manner. Both GP’s that returned completed survey forms to us stated that individuals health care needs are met, and the staff act upon the advice they seek and are given. Both described the staff team as being “very attentive”. Every person who was spoken with during the inspection said that they were very well looked after and the following comments were made – “I am very well looked after. The staff are very considerate and caring”, “I get all the help I need, everybody is so kind” and one relative said in out survey forms “When my mother went to live at St Angela’s she was very poorly. Due the wonderful Christian love and care, my mother enjoys her life now”. Medication procedures have marginally improved following two recommendations of good practice being made after the last inspection. A log of signatures for each staff member who administers medications is now kept, and the practice of hanging the medication cupboard keys ‘in a visible place’ has been amended. One staff member discussed the methods used for ordering, receipt, storage, administration and disposal of medications. Medication administration was not observed during this inspection. People who live in the home who were spoken with during the inspection, said that they received their tablets when they were due. From our observations and comments received from people we spoke with, it is very evident that people who live at St Angela’s are treated with respect and dignity. People’s privacy was respected and staff did not enter bedrooms until they were asked to do so. Daily running records were written in a respectful manner. It is the ethos of St Angela’s to care for people up until the end of their lives. Many of the people spoken with during the inspection hoped that St Angela’s would be their last home. District nurses and St Peter’s Hospice Nurses, will work with the care staff and oversee the healthcare support, when people have end-of-life care issues. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Great emphasis is placed upon meeting individual’s religious and spiritual needs and this forms the basis of the day-to-day life for people who live in this home. They will receive nice meals. EVIDENCE: In the annual quality assurance assessment provided for us prior to the inspection, the manager stated that St Angela’s provides “a haven of peace and security”. Activities arranged by the home are few and far between, however this is pointed out before admission arranged. A piano player visits One person said “this is why I chose St Angela’s I want a quiet life and I am not interested in playing bingo”. There is a daily Mass service held in the Chapel and coffee is served afterwards in the dining room. One person who said that they try and attend every day said “this is very important to me and why I live here”. There is a “corner club” each week at Clifton Cathedral where a midday meal is served but the manager said that only a few people go along at the moment. Although there is very little opportunity for social activities, it is apparent that people choose to live here because that is what they want, that their religious and spiritual needs are met and that this is very important to them. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 13 Visiting by friends and family is greatly encouraged and there is an open arrangement for visiting. One person said that their family visited each week and were always welcomed by the staff and the Nuns. It is evident that people are encouraged to make decisions and make choices about what they do and what they have to eat. The coffee mornings/resident meetings are used as a means of gathering people’s views and opinions. People spoken with were all “content”, “very satisfied” and “very happy”. All meals are served in people’s bedrooms and the dining room on the ground floor is only ever used on special occasions. Before people are offered placement at St Angela’s they will be informed of these arrangements, one person said “I’d prefer to eat in the privacy of my room”. A varied and well balanced diet is provided and people who returned our survey forms said that they “always or usually” liked the meals that were provided. Comments from people spoken with during the inspection included “I don’t like all the meals but in general the meals are very good”, “I am a fussy eater and the staff know what I like to eat” and “sometimes the portions are too large, but the staff don’t mind if I leave a little”. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures for dealing with any complaints that may be made will ensure that people who live in the home and their represenatives, will be listened to and the appropriate actions will be taken. People will be safeguarded from coming to harm. EVIDENCE: The complaints procedure is included in the statement of purpose, service users guide and a copy is displayed in the main reception area next to the visitor’s signing in book, and on each floor of the home. Residents spoken with during the inspection confirmed that they knew the procedure for making complaints and would approach the manager, or any of the other senior staff. All 11 people who completed our survey forms indicated that they knew who to talk to if they were not happy and how to make a complaint, and comments included the following very positive views – “I have no complaints”, “In the 11 years I have lived here I have had no reason to complain”, and “If I have anything I want to say, I just talk to the staff. But I am very contented with all the arrangements”. We have received one complaint since the last inspection and a visit was made to the home to follow up the issues raised. This has been concluded satisfactory. There is an Adult Protection policy and procedures in place in the home, which comply with the Local Authority Adult Protection Procedures (also known as St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 15 Safeguarding Adults). Staff spoken with during the inspection demonstrated an awareness of adult protection issues and also what action they would be expected to take if any abusive behaviour, or bad practice came to their attention. Staff training in the protection of vulnerable adults (POVA) is included in the induction-training programme and by regular updates. One staff member confirmed that they had attended recent training with Bristol Council. There is a whistle blowing policy in place in the home for staff to follow if they have any concerns about poor practice. One person wrote on the survey form that they returned to us “I feel very safe here at St Angela’s. The staff are all very considerate and caring”. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Angela’s Convent is comfortable, well decorated and nicely furnished. It provides a safe and peaceful environment for the people who live there. EVIDENCE: St Angela’s Convent is a large detached period property. It is located on the edges of Clifton Downs and within a short walk from local shops and other amenities. There are four floors but only three are used for communal areas and people’s bedrooms. There is a shaft lift between all floors therefore the home is fully accessible for people in wheelchairs. The main entrance to the left of the building has a number of steps up into the main reception area however there are ramps and disabled access to the right side of the building. There is car parking to the front of the home plus a small grassed area and established shrubbery. To the rear of the home, there is a paved area and seating and then steps down to a large lawn and walled garden. The gardens were well kept. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 17 In respect of communal space, on the ground floor there is one small sitting room, the chapel where daily Mass is held, and a dining room. On each floor there is a kitchenette from where drinks are made and meals are served. A coffee morning is held each day after Mass and served in the dining room. There are a number of toilets and bathrooms located throughout the home and some baths are fitted with hoists. All bedrooms have en-suite facilities of at the least a toilet and wash hand-basin, some with a bath as well. People will be provided with any equipment or adaptations that they need and we saw hospital type beds, grab rails, hoisting equipment and other moving and handling equipment. Each room is fitted with a call bell system. All bedrooms are for single occupation, are larger than the minimum special requirements, and have en-suite facilities. There are a few bedrooms on the ground floor but the majority are on the first and second floors. Most of the bedrooms were seen during the inspection and each was comfortably decorated and furnished. People are able to bring in small items of furniture from home, will be provided with a room key if requested and will have access to a lockable drawer for personal possessions. On the day of inspection, the home was warm and well lit. Radiators are guarded. The home was clean, tidy and had no unpleasant odours. People who completed our survey forms all said that the home was “Always” fresh and clean, and made the following comments about the home – “everything is spotless”, “the home and gardens are immaculately kept” and “my room is cleaned every day”. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate to meet people’s care needs, they will have been recruited following safe procedure to ensure that only suitable staff are employed and the staff training programme is satisfactory. This means that staff will have the right skills and experience to meet people’s individual needs. EVIDENCE: The home is currently looking after 21 people out of a maximum of 23. Staffing levels are arranged according to the care needs and dependency levels of the people living there and we were told that currently there are seven care staff each morning, five in the afternoons and evening, and then one waking staff member over-night, with one sleeping and on-call staff member between the hours of 11.30pm to 5.30am. The home manager lives in the Convent, which is part of the home, and is also available for any emergencies. There are two senior care staff who will be responsible for delegated management tasks such as care planning and reviewing, and in addition to the care staff there are catering, administrative, maintenance and housekeeping staff. People who returned our survey forms said that staff were “Always” available when they needed them, that they ”Always” received the care and support that they needed, and added the following comments – “staff are always near to hand” and “the staff couldn’t do any more for me, they are extremely St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 19 attentive”. Conversations with many of the people who live in the home during the course of the inspection, confirmed that they are looked after by staff who can meet their needs. All care staff will be expected to complete NVQ training to at least level 2. The minimum ratio of 50 trained members of staff is far exceeded with 18 of the 20 care staff (90 ) having already achieved the award, plus one other working towards this. This commitment to providing a well-trained staff team is commendable. A number of the staff team have been employed for 20 years plus and there have only been two new recruits since the last inspection. This means that people will be looked after by staff who are familiar with their specific needs – agency staff are not used. The staff files of these two staff members were looked at in order to determine the process the home goes through in recruiting new staff. Robust recruitment procedures are followed and preemployment checks are completed. This includes written application, interview and assessment, two written references, POVA1st checks and CRB disclosures. These measures will ensure that only suitable people are employed to work at the home. All mandatory training we were told is provided by an external training company. Staff spoken with during the course of the inspection confirmed that they have received training in fire safety, food hygiene, manual handling, infection control and dietary management. A record is kept for each person of the training they have received. New staff will receive an induction-training programme and the completed programmes for the two new recruits, were seen. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Angela’s Convent is well managed and run in the best interest of the people who live there. They will be safeguarded by the home’s procedures. EVIDENCE: Sister Marie Louise Le Vern has been the home manager at St Angela s for many years. She is a qualified nurse and is experienced in the care of the elderly. Those people who live in the home who were spoken with during the inspection, said that they saw the manager every day and that she was very approachable and arranged things in their best interests. The manager completed the annual quality assurance assessment and is aware of those areas where they still feel that they need to make some improvements. We were told that the next Customer Satisfaction survey will be completed by the Sisters of the Temple in the next couple of month. One St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 21 member of the senior staff have been delegated the task of ensuring that care planning documentation is kept up to date and reviewed on a regular basis. These measures will ensure that the care and support provided for each person remains a match to their care needs. The home has procedures in place to manage any monies they hold on behalf of people who live in the home. The records for three randomly selected people were checked and the records tallied with the amounts of money held. The home employs a maintenance person who works for three days each week. A number of environmental checks are completed including water temperature checks, fire alarm and equipment checks and the emergency lighting. All the necessary service contracts were up to date. No health and safety issues were noted during the tour of the property and the home was clean, tidy and well maintained. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 22 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 3 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP4 Good Practice Recommendations Placements for people with mental health care needs must be reviewed and the advice of healthcare professionals regarding ongoing support must be followed. St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 St Angelas Convent DS0000026518.V373540.R01.S.doc Version 5.2 Page 25 - 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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