Archived: Franciscan Convent Burnley

We found the following examples of good practice.

• The wellbeing of the sisters in the home had been most affected by the closure of the church. The registered manager had sought creative ways to link in with services via the internet. Further expansion of technology was being considered.

• Staff roles were maintained separately, there was no cross over between the care staff, domestic staff or kitchen staff. Separate areas had been provided for staff to take their breaks which allowed them to maintain correct social distancing.

• The registered manager had completed robust environmental audits and risk assessments and identified how to use available funding to improve the environment and minimise infection risks. This included; buying a powerful carpet cleaner, ordering new chairs which were easier to clean, foot operated soap/hand gel dispensers and bins.

At the last inspection on 22 and 23 May 2017, we found breaches of three of the regulations. These related to a failure to complete necessary checks when recruiting staff, a failure to comply with the Mental Capacity Act 2005 and a failure to apply for authorisation to deprive a person of their liberty. We also made recommendations about ensuring that safety checks were completed in a timely way and the need for the provider to monitor the quality of the service. Following the inspection we asked the provider to send us an action plan to show what they would do and by when, to make the necessary improvements. An action plan was provided as requested. During this inspection we found that the necessary improvements had been made and the provider was complying with all regulations reviewed.

Records showed that staff had been recruited safely and the staff we spoke with were aware of how to safeguard adults at risk. People told us there were always enough staff available to meet their needs.

People told us the staff who supported them were kind and caring. They told us staff provided them with support when they needed it. People told us staff respected their right to privacy and dignity and encouraged them to be as independent as they could be. We saw evidence of this during the inspection.

Staff received an effective induction and appropriate training. People who lived at the service felt that staff had the knowledge and skills to meet their needs.

People received appropriate support with eating and drinking and their healthcare needs were met. Appropriate referrals were made to community healthcare professionals, to ensure that people’s needs were met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way; the policies and systems at the service supported this practice. Where people lacked the capacity to make decisions about their care, the service had taken appropriate action in line with the Mental Capacity Act 2005.

People told us that they received care that reflected their individual needs and preferences and we found evidence of this. Staff told us they knew people well and gave examples of people’s routines and how people liked to be supported.

People who lived at the service spent much of their time in the chapel attending mass and prayers. They were happy to spend the remainder of their time reading, watching television and going out for walks.

Staff communicated effectively with people. They supported people sensitively and did not rush them when providing care. People’s communication needs were identified and appropriate support was provided.

People living at the service told us staff regularly asked them if they were happy with the support they received. They felt able to raise any concerns or make suggestions for improvement.

The service had a registered manager in post. People living at the service and staff were happy with how the service was being managed. They found the registered manager approachable and supportive.

A variety of audits of quality and safety were completed by the registered manager regularly. We found the audits completed were effective in ensuring that appropriate levels of quality and safety were maintained at the service.

The Franciscan Convent is a home caring for the Sisters of the congregation of the Franciscan Missionaries of Saint Joseph. The service is registered to provide accommodation and personal care for up to 25 people. There were nine people living in the home at the time of our inspection.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers ('the provider'), 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 our last inspection on 14 and 15 October 2015, we found the provider was not meeting all the relevant regulations. We therefore asked the provider to take action in relation to the notification of incidents and improve staff supervision and appraisal arrangements. Following the inspection, the provider sent us an action plan which set out the action they were taking to meet the regulations. During this inspection, we found the necessary improvements had been made. However, we also found there were shortfalls in the recruitment process of new staff and the implementation of the Mental Capacity Act 2005. You can see what action we told the provider to take at the back of the full version of the report. We also made two recommendations about ensuring all safety checks were carried out in a timely manner and ensuring the provider has carried out assessments to demonstrate the quality of the service.

People living in the home said they felt safe and staff treated them well. There were sufficient staff deployed in the home to meet people's care and support needs. However, we found appropriate checks had not been carried out during the recruitment of a new member of staff. Safeguarding adults’ procedures were in place and staff understood their responsibilities to safeguard people from abuse. Risks associated with people’s care were identified and assessed. People's medicines were managed appropriately and minor shortfalls in the record keeping were rectified during the inspection.

Systems were in place to carry out safety checks on the environment. However, we found the gas safety certificate had expired. Arrangements were made to check the gas installations during the inspection and we were sent a copy of the new certificate following our visit.

Staff received training which equipped them for their roles and supported them in providing safe care for people. Staff spoken with told us they were well supported through a system of regular supervisions and meetings. Arrangements were in place for any new staff member to undertake a structured induction.

We found there was no evidence to indicate people’s mental capacity to make their own decisions had been assessed and recorded in line the requirements of the Mental Capacity Act 2005. In addition, consideration had not been given to the appropriateness of Deprivation of Liberty Safeguard applications, in order to protect people’s rights and freedoms.

There were appropriate arrangements in place to support people to have a balanced and healthy diet. People had access to a GP and other health care professionals when they needed them.

Care plans and risk assessments had been completed to ensure people received appropriate care. Whilst all care plans and risk assessments had been updated on a monthly basis, some information was brief and lacked detail in line with the wishes of people living in the home. As the care plans were reviewed as a whole, we found information was difficult to locate. The registered manager assured us the care plans would be separated into sections according to people’s needs. Wherever possible people living in the home had been consulted about their care needs and had been involved in the care planning process.

Staff treated people in a respectful and dignified manner and people's privacy was respected. All people spoken with made complimentary comments about the caring nature of the staff and the registered manager. People were supported to remain as independent as possible.

People chose how to spend their time and the home had a calm, quiet and tranquil atmosphere. People attended the chapel on site for religious services throughout the day.

The registered manager was well respected and provided supportive leadership to her team. Systems were in place to monitor the quality of the service provided and ensure people received safe and effective care. However, we found some shortfalls in the operation of the service. The registered manager sent us an update following the inspection detailing the actions she intended to take to address these issues.

We spoke with a group of sisters who had lived at the convent for some time and we visited the first floor Infirmary where people who require close personal care were being looked after. We spoke with the registered manager and the assistant manager.

We looked in detail at the medication records for three people whose care needs had recently increased. The records were well maintained and the medication administered by suitably experienced and trained staff. Individually prescribed creams were stored in the person's own container held within the medicine trolley. We examined the Incident Record book and found detailed notes of a medication error that had occurred some months ago and saw that appropriate action had been taken to ensure the individual's well being and actions to prevent a re - occurrence were noted.

Other records were examined in relation to accidents within the home. These were generally well recorded and where a delay in recording an accident had occurred appropriate action had been taken by the registered manager to ensure that the staff recorded the details in a timely manner.

Three people who used the service told us, "It suits me here and I am happy at this home", "I am very happy here and very settled" and "I have no problems living here. It was a culture shock coming back from abroad but I am happy here". People told us they were happy at this care home.

Plans of care had been developed, where possible, with people who used the service and had been updated on a regular basis to enable staff to deliver effective care.

All the people we spoke with said the food was good and met their requirements.

The environment was homely and suitable for the people who lived there. Equipment was serviced to keep people safe. All the people we spoke with had personalised their bedrooms and were satisfied with the facilities they were provided with.

There were sufficient numbers of well trained staff to meet people's needs.

Records were stored safely and reviewed regularly to help keep staff up to date with information necessary to manage the home.

People said that staff listened to what they had to say and were confident their views would be acted upon. One person told us, "I've nothing to complain about but if I did I know they'd put it right ' they're all very approachable".

People told us they could choose how they spent their time and that they could have privacy when they wanted it. They said that staff knew their preferences about their daily routines, such as what time they liked to get up and go to bed, what food they preferred and how they liked to spend their time.

We found new staff were recruited safely and all staff received regular training to give them the skills and knowledge to look after people properly. We spoke with three staff. They told us they would feel confident to speak out against poor practice if needed. People living in the home said, 'I am treated very well' and 'Everyone is very kind and patient'.