This was an unannounced inspection which took place on 14 January 2015. The service was last inspected in January 2014 when it was found to be meeting all the regulations we reviewed.
The Franciscan Convent is a home caring for the elderly Sisters of the congregation of the Franciscan Missionary of Saint Joseph. The service also accommodates females from other religious denominations. The service is registered to provide accommodation and personal care for up to 13 people. There were 9 people living at the service at the time of our inspection.
The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.
People who used the service told us they felt safe living at the Franciscan Convent. Relatives we spoke with confirmed they had no concerns about the safety of their family members.
All the people we spoke with gave very positive feedback about the caring attitude and approach of staff. People who used the service told us they considered staff knew them well and always respected their choices and preferences about the way they wished their care to be delivered. Although the ethos of the service was Catholic, people who used the service who were not of this faith told us they were treated equally and their views respected.
Care records we looked at showed people’s needs, wishes and preferences were recorded and regularly reviewed. Records provided good information for staff about how to promote people’s independence and ensure they were supporting people to achieve their goals.
Risk assessments and risk management plans were completed and regularly reviewed to help ensure people were protected against the risk of falls, pressure ulcers or poor nutrition and hydration.
We found the systems to ensure the safe administration of medicines in the service were not sufficiently robust to ensure people who used the service were adequately protected.
Staff were able to tell us of the correct procedure to follow should they have any concerns about the safety of a person who used the service. Staff also knew how to report any poor practice they might observe in the service. They told us they were confident they would be listened to by the managers in the service if they were to raise any concerns.
Some improvements needed to be made to ensure that recruitment processes in the service were sufficiently robust to protect people from the risks of unsuitable staff. We found staffing levels were appropriate to meet the needs of people who used the service.
Staff had received appropriate training for their role, including moving and handling, the administration of medicines and dementia awareness. However we found improvements needed to be made to the supervision and appraisal systems in the service to ensure staff were supported to continue their learning and development.
Staff we spoke with were aware of the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. The assistant manager on duty during the inspection demonstrated their knowledge about the process to follow should it be necessary to place any restrictions on a person who used the service in their best interests.
Staff told us they enjoyed working in the service and received good support from their colleagues and managers. They told us they felt valued in their role and appreciated being able to spend time with people who used the service.
People told us they were aware when they chose the service that limited activities were provided although they were supported to attend the daily religious services if they so wished. None of the people we spoke with expressed any concerns about the lack of activities and told us they enjoyed spending time in their own rooms. We were told Sisters living at the Franciscan Convent would spend time with people who used the service on a daily basis.
Some improvements needed to be made to the quality assurance systems in the service to ensure that the health, safety and welfare of people who used the service were always protected. This included the need for more robust health and safety checks.
All the people we spoke with told us the registered manager of the service was very approachable and would always listen and respond if any concerns were raised.