Care Home: St Paul`s Convent

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What the care home does well This is a random inspection and therefore not all the core standards were assessed. Sisters are supported to lead a comfortable and structured religious life based on their strengths and abilities. This is so that they are supported to live their lives pursuing what is important to them. Sisters are supported to keep in touch with their families and friends so that they canmaintain relationships that are important to them. Sisters have the information that they need to enable them to decide if they want to live at the home. Prior to coming to stay there Sisters can be confident that the home will be suitable to meet their needs. Sisters told us that they were happy with how the home support them to meet their personal hygiene needs. Sisters are involved in writing their care plan so that care and support can be provided in the way they prefer. Sisters can be confident that they receive their medication at the times they require. Sisters have access to a range of health and social care professionals and this ensures that the appropriate advice is sought to meet their health needs. Sisters are offered a variety of nutritious meals that meet any special dietary requirements. Sisters can be confident that their concerns are taken seriously and their views are acted upon. Sisters can be confident that there are systems in place to protect them from harm. Sisters benefit from being cared for by a staff team that are supported in their job roles. Sisters can be confident that they are supported by people who have received training in order to meet their individual and collective needs. Sisters have opportunities to be involved in the running of the home What the care home could do better: This is a random inspection and therefore not all the core standards were assessed. Care records must reflect the actual care provided. Medication must be stored securely at all times so that people are safe from harm. Food should always be safe for people to eat. Random inspection report Care homes for older people Name: Address: St Paul`s Convent The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL 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: Amanda Lyndon Date: 0 9 0 6 2 0 1 0 Information about the care home Name of care home: Address: St Paul`s Convent The Infirmary 94 Selly Park Road Selly Park Birmingham West Midlands B29 7LL 01214156100 01214720603 care@sellypark.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Sisters of Charity of St Paul the Apostle Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 36 Number of places (if applicable): Under 65 Over 65 0 36 dementia old age, not falling within any other category Conditions of registration: 36 0 The maximum number of service users who can be accommodated is: 36 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Female; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 36, Old age, not falling within any other category (OP) 36 Date of last inspection Care Homes for Older People Page 2 of 12 Brief description of the care home St Pauls Nursing Home provides 24 hour nursing care. It caters for up to 36 Religious Sisters of St Pauls and includes those who are in need of care for reasons of old age or dementia. This ranges from Sisters in need of short stay rehabilitation to those requiring long term nursing needs. The aim of the home is for Sisters to continue to lead a structured religious life within the limits of their strength. The home is located within the Convent of St Pauls, in a residential area of South Birmingham. It is close to local shops, amenities and public transport links. There is ample off road parking within the grounds of the convent. The home consists of a well maintained four storey building and is attached to the main convent. It is set in its own beautiful extensive grounds which are very well maintained and easily accessed by Sisters from home. The building is very spacious with a range of communal living rooms. Sisters have access to the convent chapel. Equipment is available so that all Sisters are able to participate in the daily religious services if they are not able to attend in person. All Sisters have a single bedroom that is equipped with a wash hand basin and call bell to summon assistance if required. Bedrooms are located on three floors and there is a passenger lift that gives access to all upper floors. There are assisted bathing facilities to meet the needs of Sisters. The home has hoisting and pressure relieving equipment for Sisters who require support in this area. Sisters living at the home are members of a Religious Congregation, a Registered Charity to which all earnings pensions etc are covenanted. The charity is responsible for all expenses attached to the upkeep and running of the home. Further information about this is available at the home. Care Homes for Older People Page 3 of 12 What we found: The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for Sisters who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. The last key inspection of this service was completed on 20th July 2007. At that time we awarded the service a three stars rating. This meant that Sisters living at the home experienced excellent quality outcomes. We completed an Annual Service Review about the service provided at the home on 11th May 2009. The outcome of this did not change our opinion of the quality of service provided. This random visit was undertaken by one inspector over one day. There were thirty six Sisters living at the home and two of these were in hospital. The home did not know that we would be visiting. Prior to the visit taking place, we looked at all of the information we had received or asked for. This included any notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law. We received an Annual Quality Assurance Assessment (AQAA). This tells us how the home think they are performing in order to meet the needs of the people living there. It also gives us some numerical information about staff and Sisters living at the home. This was completed by the manager in good detail and returned to us within the deadline. We sent out surveys to ten Sisters who live at the home and ten staff members, in order to obtain their views about the service provided. Ten Sisters who live at the home and nine staff members returned surveys to us. Their comments are included in this report. The care of two people was casetracked. This involves talking to them and discovering their experiences of living at the home. We focus on the outcomes for these Sisters. We also spent time observing care practices and speaking to four staff members about the care and support they provided to these people. We sampled care, staffing and health and safety records. We looked around the areas of the home used by the Sisters case tracked to make sure it was warm, clean and comfortable for them. We gave all Sisters living at the home the opportunity to be involved in the inspection. We spoke with four Sisters and one health professional who was visiting the home. These are our findings: The statement of purpose and service user guide had recently been updated and were available within the home for people to read. These included information about the services and facilities provided there. We saw that these had been produced in a large print format so that more people could access the information. The nursing home is an integral part of the Convent. As a result of this the vast majority of people who come to stay there are already familiar with the facilities and services provided. We spoke with a Sister who had recently come to stay at the home. We saw that Care Homes for Older People Page 4 of 12 comprehensive information had been obtained about her care needs prior to admission. This is to ensure that her needs could be met at the home. She told us that as she had travelled a long distance to get to the home she had not had an opportunity to view the home prior to this admission. She did however state that she was already familiar with the home as she had previously stayed there for a short time. She said I have stayed at the home before. My room was made ready. I was very poorly when I came here but I cannot believe my progress. I am at home here and the care is wonderful. We saw that comprehensive assessments of peoples individual physical, religious, emotional and social care needs are undertaken on admission to the home. These are reviewed periodically throughout their time there. Care plans are written from this information. These are individual plans written with the involvement of Sisters and their representatives about what they can do for themselves and in what areas they require support. We found that the vast majority of care plans were personalised and included Sisters preferences regarding their daily lives. They identified what the Sisters could and couldnt do for themselves. They gave instructions for staff about the support to be provided. It was evident from our discussions with Sisters living at the home that they were involved in writing and reviewing these. This is important so that Sisters are encouraged to maintain their independence. It means that their preferred routines can be maintained whilst living at the home. From our discussions with the staff team it was evident that they had a good understanding of peoples individual care needs. However we did identify that on occasions information recorded on a Sisters repositioning chart did not always reflect the actual care to be provided, as outlined in their plan of care. This means that from the written record we were not able to determine whether pressure area care was provided at the times that the Sister required. This is in order to reduce the risk of the Sister developing sore skin. We brought this to the attention of the manager for investigation. Shortly following the visit the manager told us that the outcome of her investigation was that the Sister had received the support at the times that she required however the staff had on occasions failed to record this. She told us that she had taken the appropriate actions to address this for the benefit of the Sisters living at the home. We saw that the home complete risk assessments for Sisters so that consideration is given to supporting them to take responsible risks and promote their independence. We saw that moving and handling assessments identified the specific support and equipment required for each Sister. In addition the majority of staff had undertaken recent training in this area. This should mean that people are supported to transfer in a safe manner. Sisters told us that they were happy with the level of personal care provided by the home. We saw that Sisters were clean, hair was neatly styled and people were wearing clothing appropriate to their religion. One Sister met with during the visit told us You neednt worry about us. We are well looked after. Another person said We get a high standard of care and all our needs both spiritually and physically are seen to. Staff treat us with dignity and respect. We saw that Sisters can retain their own doctor on admission to the home, if the doctor is in agreement. In addition we saw that advice can be sought as needed from a range of other health and social care professionals. We spoke with a health professional who was visiting the home. He said that this was the first time that he had been there and that so far his visit had been positive. Care Homes for Older People Page 5 of 12 We looked at the system in place for the management of medication and found that there was a robust system in place for the management of this. This should mean that the Sisters receive their medication at the times they require. However it was of concern that we saw that a number of bottles of liquid medication and other prescription items had been left out at the bottom of one of the drug trolleys, in between medication rounds. The trolley was located within a treatment room and there was no lock on the door into this room. This meant that the medication was accessible to all people within the home placing them at risk of harm. From discussions with the staff team it was evident that this was regular practice, as the drug trolley was not large enough to store all of the medication. We discussed this with the manager who stated that she had identified a need to purchase a larger drug trolley and that plans were in place to do this. As an immediate response to our concerns we saw that as an interim measure the medication was locked away in a medication cupboard. Sisters told us that they are encouraged to be as involved as possible in the life of St Pauls Convent and the wider Congregation. The home offers opportunities for Sisters to participate in daily prayers and religious services celebrated by the wider community of the Sisters of St Paul. Sisters able and wishing to attend religious services are assisted by staff to attend the specially adapted gallery of the Convent Chapel. Sisters who are unable to get to the Chapel but wish to follow the services can do so through an intercom system in their bedrooms. From records sampled and from our discussions with staff and Sisters living at the home, it was evident that there was also a range of other activities to join in with. This included trips outside of the home. One Sister told us that she particularly enjoyed the weekly movement and music session. Sisters are encouraged to maintain contact with their family and other people important to them. They told us that there is an open visiting policy and that they can meet with their visitors in private if they wish. One Sister who completed a survey told us The care home is a very friendly place which offers hospitality to all visitors. Menus identified a variety of nutritious meals and special diets are prepared for reasons of health and personal preference. A choice of meals is always available and Sisters told us that they are made aware of these on a daily basis. They told us that the Chef attends the Sisters meetings so that they are involved in deciding what meals are being prepared. We saw that lunchtime was relaxed and that Sisters were being assisted by staff in a respectful manner. One Sister met with during the visit told us We are spoilt here but we are thriving on it. There is a kitchenette containing food items located on each of the three floors. This is so that Sisters have the option of choosing snacks at other times. We did however identify that a number of refrigerated food items located within one of the kitchenettes were past their use by date. This does not uphold the health and safety of Sisters who may eat these items. This was brought to the attention of the deputy manager and the items were removed straight away. Since our last visit we have not received any complaints about the service provided at the home. This includes any incidents of a safeguarding nature. From records held at the home reviewed during our visit we found that they had not received any complaints since Care Homes for Older People Page 6 of 12 2008. They had recorded one low level concern about the quality of food on one occasion. This included a comprehensive record of actions taken in response to this for the benefit of the Sisters living at the home. One Sister who completed a survey told us I am entirely satisfied with this home. The staff training matrix identified that all staff had undertaken training about safeguarding. Care staff met with during the visit had a good knowledge about this. This should protect the Sisters living at the home from harm. In addition to nursing and care staff, administration, cleaning, maintenance and catering staff are employed. This means that the Sisters living at the home receive some support in these areas. The laundry service is provided to the nursing home by the main Convent. Sisters living at the home and the staff team told us that there were enough staff on duty to meet Sisters needs. One Sister said When I use my buzzer the staff come on the dot. The efficiency of staff is great. One care staff member said There are plenty of staff. We are absolutely supported by the nurses. We get on great. The gender of all staff employed at the home reflected that of the Sisters. This is so that support can be provided in an understanding and sensitive manner. It was evident that staff turnover was very low. We saw that on the few occasions that agency staff were required, efforts were made to ensure that the same individuals come to the home. This is to promote continuity of care for the Sisters living at the home. We saw evidence that agency staff undertake an induction into working at the home and that the Sisters have an opportunity to be introduced to new agency staff during group meetings. This means that they have a say about who is supporting them at the home. We reviewed two staff files of people who had recently come to work at the home. These included all information required. At least two references had been obtained for each of the new workers and we saw that staff do not start working at the home until satisfactory criminal records checks have been completed. This should mean that Sisters can be confident that people employed by the home are suitable to work with them. From discussions with the staff team and information on the staff training matrix, we identified that staff had recently undertaken a wide range of training. This included training in a number of heath and safety matters for example manual handling, COSHH and fire safety. Staff also told us that they had also undertaken recent training about a number of care topics specific to their job roles. This included tissue viability and end of life care. Other training was planned including dementia care, medicine management and falls prevention. This should mean that care and support is provided in a competent manner. One staff member met with during the visit said I think that the training we do is adequate. Another person said The care home does well in the training of staff. Staff have the opportunity to put forward their suggestions about the service provided. Evidence of actions being taken in response to these was identified within the minutes of recent staff meetings sampled. We also saw that staff are able to put their views forward via staff questionnaires. We saw that no issues had been raised recently as a result of the findings of these. Since our last visit the management structure within the home has changed. The previous home manager retired in 2009. The deputy manager who has worked at the home for the Care Homes for Older People Page 7 of 12 past 21years had been promoted and since 2009 has been working as the home manager. She has relevant and appropriate qualifications including the Registered Managers Award, however until this point she has not applied to us in order to become the registered manager at the home. This is required so that we as a regulatory body can assess whether she is a suitable person to manage the home for the benefit of the Sisters living there. Following discussion it would appear that there had been confusion about whose role it was to arrange for the application to be processed. During the visit the arrangements for this were clarified. Shortly after the visit the manager advised that she had sent all relevant information to us in order for her application to be processed. Positive comments were made by the Sisters living at the home and the staff team about her management style including The manager comes round every morning. She is approachable and The manager is always ready to see to our needs. The manager is supported by a deputy manager who also has relevant management qualifications and has worked at the home for a long period of time. She had a good understanding of the needs of individual Sisters and it was evident that there were clear lines of accountability between the management team. This is for the benefit of the Sisters living at the home. Prior to the visit the manager completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This included comprehensive details about the home, staff and Sisters who live there. It also included information about what the service hoped to achieve for the benefit of the Sisters living there. We found that the information included within this was consistent with the findings of our visit. This means that it gave us a reliable picture of the service provided at the home. There are systems in place to capture the view of Sisters living at the home. We saw that senior external managers undertake regular quality monitoring visits at the home and that Sisters are involved in these. We could not, however, sample the reports of the most recent three visits as they were not available at the home. Group meetings involving Sisters living at the home are held regularly and service satisfaction questionnaires are sent out to Sisters. This means that they have regular opportunities to put forward suggestions about the service provided. We saw that actions are taken in response to suggestions put forward and that Sisters are made aware of these. The manager had a good knowledge about accidents that had occurred involving Sisters living at the home. We saw that accident records were well maintained and regularly audited so that any trends or patterns in accidents can be identified. This means that measures can be put in place to reduce the risk of further accidents of a similar nature from occurring again. What the care home does well: This is a random inspection and therefore not all the core standards were assessed. Sisters are supported to lead a comfortable and structured religious life based on their strengths and abilities. This is so that they are supported to live their lives pursuing what is important to them. Sisters are supported to keep in touch with their families and friends so that they can Care Homes for Older People Page 8 of 12 maintain relationships that are important to them. Sisters have the information that they need to enable them to decide if they want to live at the home. Prior to coming to stay there Sisters can be confident that the home will be suitable to meet their needs. Sisters told us that they were happy with how the home support them to meet their personal hygiene needs. Sisters are involved in writing their care plan so that care and support can be provided in the way they prefer. Sisters can be confident that they receive their medication at the times they require. Sisters have access to a range of health and social care professionals and this ensures that the appropriate advice is sought to meet their health needs. Sisters are offered a variety of nutritious meals that meet any special dietary requirements. Sisters can be confident that their concerns are taken seriously and their views are acted upon. Sisters can be confident that there are systems in place to protect them from harm. Sisters benefit from being cared for by a staff team that are supported in their job roles. Sisters can be confident that they are supported by people who have received training in order to meet their individual and collective needs. Sisters have opportunities to be involved in the running of the home What they could do better: 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 9 of 12 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 10 of 12 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 1 8 12 Care records must be up to date and reflect the actual care provided. This is to ensure that care and support is provided at the required times. 19/07/2010 2 9 13 Arrangements must be made 19/07/2010 to ensure that medication is stored securely at all times. This is to maintain the health and safety of people living at the home. 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 32 Quality monitoring reports should be available at the home so that people can be confident that actions have been taken as a result of these. Systems should be in place to ensure that all food available for consumption is safe to do so. 2 38 Care Homes for Older People Page 11 of 12 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. 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