Archived: The Infirmary

Updated 24 August 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection site visit took place on 2 August 2018 and was unannounced. This meant the provider did not know we would be visiting.

The inspection was conducted by one adult social care inspector and an expert by experience. An expert by experience is someone who has personal experience of using or caring for someone who uses this type of service. The expert by experience who supported this inspection had extensive knowledge of caring for older people and people living with dementia.

As part of planning our inspection, we contacted Healthwatch and local authority safeguarding and quality performance teams to obtain their views about the service. Healthwatch is an independent consumer group, which gathers and represents the views of the public about health and social care services in England. We reviewed information we held about the service, including the notifications we had received from the provider. Notifications are changes, events or incidents the provider is legally obliged to tell us about within required timescales.

The provider sent us their Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We used this information to help plan for the inspection.

During the inspection, we reviewed a range of records. These included three Sisters care records containing care planning documentation, daily records and medicine records. We completed a tour of the service and looked at communal areas, bathrooms and Sisters bedrooms, with their permission.

We looked at five staff files relating to their supervision, appraisal and training. We reviewed records relating to the management of the service and a wide variety of policies and procedures.

During the inspection we spoke with five Sisters who used the service to gain their views on the service provided. We also spoke with four members of staff including the deputy manager and the provider.

Updated 24 August 2018

Inspection site visit activity took place on 2 August 2018 and was unannounced.

At our last inspection the provider was found to be in breach of Regulation 17 Good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of: Is the service Safe? and Is the service Well-led? to at least good.

At this inspection we found that sufficient improvement had been made to say that the breach of regulation had been met.

The Infirmary is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Infirmary provides accommodation for up to 10 Sisters of the Chapter of the Order of the Holy Paraclete, in one adapted building. At the time of this inspection there was five Sisters living at the service.

There was a manager in post who had registered with CQC. 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 2008 and associated Regulations about how the service is run.’ At the time of this inspection the registered manager was on planned leave. The deputy manager assisted throughout.

Effective quality assurance processes were now in place to monitor and improve the service. When shortfalls had been found, the registered manager had taken swift action to implement improvements.

Improvements had been made to the management of medicines. Regular audits were now in place to ensure staff had administered, recorded and checked stock balances of medicines each day.

Risks to the Sisters had been assessed and appropriate control measure were put in place. There was a safeguarding policy and procedure which staff were familiar with and confident any concerns would be managed appropriately.

Regular maintenance checks had been conducted and required servicing certificates were in place. The service was clean and tidy throughout and staff had access to appropriate personal protective equipment to promote good infection control and prevention practices.

Staff had received regular training to ensure they had the skills and knowledge to support the Sisters. Staff were supported through a regular system of one to one supervisions where their personal development was promoted. Annual appraisals had also taken place.

The Sisters were provided with support which help them maintain a balanced diet. They were encouraged to remain as independent as possible and their choices were respected by staff.

The Sisters were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Where the Sisters had made advanced decisions with regards to care and treatment, this was clearly recorded and their wishes were respected.

The Sisters received support from other professionals where required. Care records contained details of people who were important to the Sisters and how staff could encourage these personal relationships.

Care plans were person-centred and focused on what was important to the Sisters. Activities were promoted which reflected the Sisters religious beliefs and wishes.

Feedback was sought by the registered manager to continuously improve the service. Whilst there had been no complaints made in the past 12 months, a clear complaints policy was in place that the Sisters were familiar with.

Regular staff meetings had taken place to provide staff with the opportunity to contribute to the service. The Sisters were encouraged to attend regular meetings at the Priory and to engage with other Sisters.