Archived: Cross and Passion Convent

People who live at Sisters of the Cross and Passion Convent are known as, Sister, followed by their religious name. The convent provides personal care to Sisters of the Cross and Passion but has offered respite care to people outside of the order.

We found the following examples of good practice.

• Visiting the Convent was restricted. All visitors were temperature checked and had to complete a health declaration form before admission. Visitors were required to follow best practice guidance and wear appropriate PPE. The convents visiting policy was discussed with the Sisters, their families and friends.

• Admissions into the Convent were risk assessed and followed government guidance. This included Sisters having to isolate in their bedroom for 14 days.

• Testing for Covid-19 for all Sisters and staff had occurred and was ongoing on a regular basis. The registered manager had processes to initiate to keep everyone safe should a positive test occur.

• People received support to maintain their relationships with family, friends and to meet their spiritual needs. This was achieved through telephone calls, video calls, socially distanced visits and online recorded spiritual services played in the chapel.

• Staff said the registered manager was very aware of what precautions needed to be in place and was very protective of the Sisters and the staff. We saw up to date coronavirus management, and infection control policies that contained current guidance.

• We observed prominent signage to guide staff on the use of protective personal equipment (PPE). There were separate rooms for staff to put on and take off their PPE. All staff had received training on how to wear, when to wear and how to dispose of PPE.

• We observed staff wearing PPE appropriately. Staff were observed socially distancing while spending time with the Sisters and engaging in activities.

• We observed the Convent looked clean and hygienic. Housekeeping staff followed a cleaning schedule that included regular cleaning of high touch areas such as door handles and switches.

Further information is in the detailed findings below.

People who live at Sisters of the Cross and Passion Convent are known as, Sister, followed by their religious name. The convent provides personal care to Sisters of the Cross and Passion but has offered respite care to people outside of the order.

Rating at last inspection.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service Good. We found the registered provider continued to provide a good standard of care to Sisters who lived at the Convent.

Why the service is rated Good

At this inspection we found the registered manager had systems to record safeguarding concerns, accidents and incidents and acted as required. The service carefully monitored and analysed such events to learn from them and improve the service.

Staff had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices. The registered manager had reported incidents to the Care Quality Commission when required.

Sisters we spoke with told us staff were exceptionally caring and respectful towards them. Staff we spoke with understood the importance of providing high standards of care and enabled Sisters to lead meaningful lives.

There was a chapel onsite and Sisters had the opportunity to attend daily mass delivered by a visiting priest or via a service filmed at another chapel and broadcast as it happens on the internet.

We observed only positive interactions between staff and Sisters who lived at Cross and Passion Convent. There was a culture of promoting dignity and respect towards people. We saw staff spent time and actively listened to Sisters as they completed routine tasks.

We found there were sufficient numbers of staff during our inspection visit. They were effectively deployed, trained and able to deliver care in a compassionate and patient manner.

Staff we spoke with confirmed they did not commence in post until the management team completed relevant checks. We checked staff records and noted employees received induction and training appropriate to their roles.

Risk assessments had been developed to minimise the potential risk of harm to Sisters during the delivery of their care. Care records showed they people’s needs had been reviewed and any changes had been recorded.

The Convent was clean and a safe place for Sisters to live. We found equipment had been serviced and maintained as required. Staff wore protective clothing such as gloves and aprons when needed. This reduced the risk of cross infection.

Medication records provided staff with a good understanding about specific support needs of each Sister who lived at the Cross and Passion Convent.

Sisters were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice.

Sisters told us they had plenty of food and drink with the option of additional snacks and drinks between meals.

There was a complaints procedure which was made available to Sisters and this was visible within the Convent. Sisters we spoke with, and visiting relatives and friends, told us they were happy and had no complaints.

The management team used a variety of methods to assess and monitor the quality of the service. These included regular audits, staff meetings and daily discussions with Sisters who lived at the Convent to seek their views about the service provided.

Sisters were supported with activities and social interaction but the registered manager also respected people’s right to not participate and engage in valued activities. The daily routine was structured to allow religious observances to be followed.

The registered manager offered Sisters a dignified end of life support that extended after their passing. People’s preferences related to end of life care were recorded, respected and honoured.

Further information is in the detailed findings below.

The service was last inspected 29 October 2013. At that inspection we found the service was meeting the legal requirements in force at the time.

The service was formerly known as Sisters of the Cross and Passion. In July 2015 the provider requested to cancel their registration with the Care Quality Commission (CQC) in error. This was because they believed the service no longer met the requirements to be registered. However, as some people receive public funding the service does fall within the scope of registration. The provider was re-registered in September 2015 and the service was renamed Cross and Passion Convent.

Cross and Passion Convent offers nursing care for up to sixteen people. All the people belong to the same religious order. The home is situated overlooking Lytham Green and close to community facilities. Communal accommodation is spacious and individual bedrooms are provided with an adapted en-suite facility. The residential and nursing unit is purpose built and based on the ground floor of the building. There is a chapel on the ground floor and an outer building used for activities and a craft centre. There is a passenger lift and staircase providing access to the upper floors where people who do not receive personal care live. There are two cottages adjacent to the forecourt used to accommodate visitors and relatives who wish to stay overnight. Comfortable communal areas, such as lounges and a dining room are available. A limited number of car parking spaces are available to the front and back of the building on a private forecourt, but on road parking is also permitted however this is limited.

The registered manager was present throughout our inspection. 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.

At the time of this inspection there were eleven people who lived at Cross and Passion Convent. People told us that they felt safe, blessed and content living at the home.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found that staff had received training in safeguarding adults and demonstrated a good understanding about what abuse meant.

The provider had recorded accidents and incidents and documented the support people were getting after experiencing falls. We found evidence staff had sought advice from health professionals. We have made a recommendation about improving analysis of incidents.

We found people’s medication had been managed safely. People had care plans for ‘as and when’ medication (PRN). Staff had received appropriate medication training and had been competence tested to ensure they were administering the medication as recommended.

There was a building fire risk assessment on the premises and emergency plans were in place in case people needed to be evacuated from the premises urgently. People had personal emergency evacuation plans (PEEPS) to enable safe evacuation in case of emergency.

We found there were effective infection control measures in place and high standards of hygiene had been maintained throughout the premises.

Staff had been safely recruited and there were enough staff to ensure that people's needs were met. There was scope within the staffing levels to keep checks on people's welfare and, where necessary, to provide extra care and support using bank staff or agency staff.

We found care planning was done in line with Mental Capacity Act 2005. Some staff showed awareness of the Mental Capacity Act 2005 and how to support people who lacked capacity to make particular decisions. However we found the knowledge of Mental Capacity among staff needed some improvement. We made a recommendation about this.

Appropriate applications for Deprivation of Liberty Safeguards had been made and authorised.

People using the service had access to healthcare professionals as required to meet their needs.

Consent was sought from people however we recommended the registered manager to ensure their paperwork clearly showing this. Best interest decisions were considered where care provision included restrictive practice and where people lacked the ability to make their own decisions. People were involved people in decisions made around the care they received. Care plans demonstrated people’s involvement. People and their relatives told us they were consulted about their care.

We made a recommendation about this.

The service demonstrated how they sought people’s opinions on the quality of care and service being provided. People informed us they were asked about their opinions.

We found evidence of robust management systems in the home. There were quality assurance systems in place. These were used to identify areas that needed improvement. We found audits had been undertaken for areas such as medication, care plans, kitchen and the premises.

People felt they received a good service and spoke highly of their staff and the registered manager. They told us the staff were kind, caring and respectful.

Staff were provided with effective support, supervision, appraisal and training. Staff were positive and we observed a positive culture within the staff team.

We found the service had a policy on how people could raise complaints about care and treatment and complaints had been made aware of how to complain.