Archived: The Infirmary

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.

The Infirmary is registered to provide residential care for up to ten older people. The service is provided for sisters of St Hilda’s Priory. On the day of inspection there were five sisters living at the service. There is a passenger lift to assist sisters to the upper floors and the service is set in spacious and pleasant grounds.

During the inspection planning process we identified that there was two managers registered against this location. A registered manager is a person who has registered with the CQC 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. We discussed this with the provider during the inspection. One of the managers had retired in March 2011 and was no longer employed by the service. This manager was also the Nominated Individual (NI). A NI is a person who has the responsibility for supervising the management of the regulated activity. We have asked the provider to take action regarding this outside of the inspection process.

At the last comprehensive inspection in April 2015 we rated the service Good in all domains.

At this inspection, we found that some improvements were required. Quality assurance processes were not in place to monitor and improve the service. Records were not always kept to monitor positional changes or safety checks and staff did not record handover information at the end of their shift.

We judged this to be a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

You can see what action we told the provider to take at the back of the full version of the report.

The Sisters told us they felt safe. We found that people were protected from the risk of avoidable harm or abuse because the registered provider had effective systems in place to manage any safeguarding concerns. Staff received training on safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm.

Risk assessments had been developed and contained relevant information. We found that these were in place when required and had been regularly reviewed. Accidents and incidents had been thoroughly recorded and appropriate action had been taken to reduce the risk of reoccurrence although they were not analysed to identify trends.

Medicines were stored securely and assessments had been completed on staff that ensured they were competent completing this activity. We found gaps in the recordings of medicines that should have been administered. As and when required medicines had not always been managed appropriately and there was no guidance in place for staff to identify when these medicines should be administered.

Safe recruitment processes were in place and had been followed. Pre-employment checks on employees were completed that helped to minimise the risk of unsuitable people from working with adults at risk. Records confirmed staff received induction training when they were new in post.

Training records confirmed staff had received a wide variety of training through practical face to face sessions as well as online. Staff told us they were happy with the training provided.

We checked and found the provider was working within the principles of the MCA. There was no one currently living at the service that required a DoLS authorisation. The manager was clear about the process they needed to follow if the need occurred.

The Sisters were supported to maintain a balanced diet. The Sisters spoke positively about the meals on offer and all staff were aware of the Sisters specific dietary needs.

Care records contained evidence of close working relationships with other professionals to maintain and promote the Sisters health. Sisters confirmed staff were proactive in seeking professional advice and had regular visits from the district nursing team and GP’s.

Care plans were produced to meet the Sisters individual support needs and were reviewed on a regular basis. They focused on what was important to the Sisters and how they wished for support to be provided.

The Sisters were aware of how to make a complaint and told us staff listened to concerns raised. A copy of the registered provider’s complaints policy was available.

There was information on advocacy services available and although none of the Sisters were using an advocate, staff were aware of how to make a referral should this be needed.

The Sisters lived a structured day to day life which was self-directed and in accordance with the Sisters religious beliefs. Staff supported the Sisters with religious activities and respected their wishes.

Staff told us they did not feel supported by the registered manager and that they didn’t spend enough time at the service. They were not confident their opinions were valued or listened to. The Sisters told us they did not see the registered manager on a regular basis.

Satisfaction surveys had been distributed to the Sisters of the service to gain their views. Action had been taken when areas for improvement had been identified.

Notifications had been submitted to CQC as required by legislation.

The sisters told us they were contented with their lives in The infirmary. One sister told us "I have been helped to attend hospital appointments. The staff are all excellent and kind."

Staff told us that they were supported to give good care. They had plenty of time to help and to chat with the sisters.

We found that the sisters were consulted and involved in their care and that they were treated with respect. Their care needs were met by staff who understood their needs and who had taken risks into consideration. We saw that specialists had been consulted so that the sisters had the benefit of expert health and medical advice.

Medication was handled safely.

Staff were safely recruited.

The Infirmary had a system in place to monitor and improve the quality of care.

We saw that The Infirmary had a consent policy and staff told us that their training had included the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). This meant that the staff had training to ensure the SIsters did not have decisions made on their behalf when they had the capacity to do so for themselves and that they were not unlawfully deprived of their liberty.

Staff had received training in all core areas including medication and safeguarding to make sure they had the skills to offer the right care for the Sister's assessed needs. We saw care assessments, care plans and risk assessments which were kept up to date in line with changing needs.

Staff told us they had supervision to ensure they were supported to develop their skills for the benefit of the Sisters in their care.

We saw that The Infirmary had a complaints policy and procedure. When we spoke with the Sisters they told us that any concerns and complaints were dealt with to their satisfaction.