Inspection on 12/10/07 for St Luke`s Hospital

This is the latest available inspection report for this service, carried out on 12th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Luke`s Hospital 15/11/05

St Luke`s Hospital 26/07/05

St Luke`s Hospital 29/03/05

St Luke`s Hospital 21/09/04

St Luke`s Hospital 02/03/04

St Luke`s Hospital 08/10/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Luke`s Hospital 4 Latimer Road Headington Oxford Oxfordshire OX3 7PF Lead Inspector Delia Styles Unannounced Inspection 12th October 2007 10:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Hospital Address 4 Latimer Road Headington Oxford Oxfordshire OX3 7PF 01865 228800 01865 228899 admin@stlukeshosp.co.uk www.stlukeshosp.co.uk St Luke’s Hospital, Oxford Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Zannifer Mason Care Home 51 Category(ies) of Dementia (51), Old age, not falling within any registration, with number other category (51), Physical disability (7), of places Physical disability over 65 years of age (51), Terminally ill (3), Terminally ill over 65 years of age (3) St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of people to be cared for, at any one time, must not exceed 51 Older people may be admitted from the age of 60 years Up to 7 people with physical disabilities may be cared for, at any one time, aged between 18 and 65 years on admission Up to 3 people may be admitted for terminal care, at any one time, aged 40 years and over 8th January 2007 Date of last inspection Brief Description of the Service: St Lukes Hospital is a care home with nursing registered with the Commission for Social Care Inspection and is not a hospital in the traditional meaning of the word. The home is managed by a non-profit making Christian charitable trust, the Council of St Luke’s Hospital, and is situated in a residential area of Oxford, close to the citys NHS hospitals, shops and recreational facilities. Accommodation consists of 48 single en-suite bedrooms with direct line telephone and television, and individuals can stay for short or long periods. The matron and her team of nursing and care staff are responsible for the care provided to the residents. The current daily fee charges range from £121 to £134. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ during which the inspector assessed a number of the standards considered most important (‘key’) by the Commission out of the 38 standards set by the government for care homes for older people. The inspector arrived at the service at 10.20 am and was in the service for 7.0 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s managers in the form of the Annual Quality Assurance Assessment (AQAA) - a selfassessment and summary of services questionnaire that all registered homes and agencies must submit to the Commission each year; and any information that the Commission had received about St Luke’s since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The inspector spoke to a number of residents and staff during the visit. The inspector also asked the views of the residents, relatives and health and social care professionals about the home, through questionnaires (comment cards) that the Commission had sent out and some of their comments are included in the report. A total of 6 residents and 5 relatives and one health care professionl completed comment cards. The home’s registered manager, Mrs Zannifer Mason (Matron) was available during the inspection visit, as was the general manager, Ms Catherine Grogan. The inspector fed back to the managers at the end of the day’s visit. The ethos of St Luke’s is that of a hospital (similar to a community hospital, rather than an acute care hospital). Care is provided within a traditional medical type model, by a team of registered nurses and nursing auxiliary staff, headed by Matron; and the individuals cared for are referred to as ‘patients’. In this report the people receiving care are called ‘residents’ and nursing auxiliaries as ‘care staff’. The inspector focussed more attention on the care of people for whom St Luke’s is their home, rather than for those who spend a short time of recuperation after an operation or medical treatment in an NHS hospital, or who have a time of ‘respite’ care in St Luke’s Hospital. The inspector would like to thank all the residents, relatives and staff for their welcome and assistance both on the day and in taking time to complete questionnaires. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The planned programme of redecoration and improvements is continuing, with the redecoration of the corridors, installation of air conditioning units to four sitting/dining rooms, upgrading of the kitchens, sluice rooms and laundry. The corridors and some residents’ rooms have been improved by the addition of a large number of new pictures. All residents have adjustable height/position beds for their comfort, and the health and safety of staff. The Matron has started informal monthly ‘tea with Matron’ sessions that give long-stay residents and their relatives more opportunity to discuss any concerns or comments. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply as the home does not provide intermediate care. Quality in this outcome area is good. People who use this service have good information about it so that they can make an informed decision about whether it is likely to be right for them. Personalised assessment means that prospective residents’ needs are identified and planned for before they move to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Luke’s admits people needing long-term care and those needing a short stay for respite care or recuperation. The home’s matron usually visits prospective residents to carry out an assessment and gathers information to make sure that the home can meet the needs of the individual. The first four weeks of a long stay admission regarded as a trial period for the benefit of the prospective resident and the homes minimum fee rate is charged during this period. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 10 During the trial period, further assessment is made of the individuals care needs and if the person decides St Luke’s will provide the care and facilities they need, this in-depth assessment is used to advise the person of the ongoing cost of their care. All prospective residents and their representatives are encouraged to visit St Luke’s as part of their decision-making process and appointments are offered from Monday to Friday. They are sent a service user’s guide and are shown around by Matron. Examination of a sample of residents’ care records showed that information is included in the assessments from health and social care professionals and family members. Residents and relatives’ surveys showed that the majority felt they had enough information about the service to help them make decisions and that St Luke’s meet the needs of the residents. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The staff have a good understanding of residents’ health and personal care needs and there is evidence that the homes’ staff work well with health and social care colleagues to provide the best care for residents. The standard of written records of care should be improved to reflect the standard of the practical care provided. Care plans should be person-centred and residents and their representatives actively involved in drawing up and reviewing their care plans to show that the staff listen and respond to individuals’ choices and decisions about their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of three residents’ care plans was looked at. The records are kept in individual folders and are well-organised with guidelines for staff setting out the time scales for completing the various sections – for example initial assessment within 7 days, moving and handling risk assessments within 2 days of admission and a full assessment and review within 10 days. For one person, who has lived here for more than 2 years, the care plans have not been rewritten during this period, though it is evident from changes in the St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 12 person’s condition that the aims and objectives of their care have significantly changed. All the care plans are signed and dated to indicate they are reviewed monthly. From discussion with Matron and the staff, and the positive comments from the Commission’s survey responses, and from the home’s AQAA information, it was clear to the inspector that the care needs of the residents were well known and provided for in practice. Staff have a detailed verbal handover about residents’ care needs and any changes at the beginning their shift. There was little evidence of evaluation of the care provided – that is, are the staff interventions meeting the person’s assessed care needs and if not, what changes should be made. Staff sign a daily accountability sheet to indicate that they have given the care outlined in the care plan during their shift; a short generalised statement is included in a daily record. There was some evidence that the home has started to include resident’s ‘life story’ information – an account of the person’s interests, former occupation and achievements and their family and social support – in their care records. This is very helpful to staff in enabling them to get to know residents and to plan care in a way that fits with the individual’s preferences and current abilities. A long-standing staff member said how valuable this was in appreciating the whole person and their perspective of their life in St Luke’s. There is no indication that residents and/or their representatives have been actively involved in drawing up their care plans, or have discussed and agreed any changes. This was highlighted in the last inspection report and the recommendation is made again for the manager to ensure that residents (and their relatives’ or representatives’, if the resident is not able to contribute meaningfully themselves) are consulted about the care plans, and that this is recorded, in accordance with Regulation 15 of the Care Homes Regulations 2001. The inspector discussed the care plans and suggested areas for improvement with the Matron and a senior nurse during the inspection. Though the majority of residents and relatives who used the Commission’s comment cards felt that overall the care and support provided was of a high standard, there was a concern raised by one relative and 2 residents about the communication skills of staff ‘especially with deaf people’. One person wrote that ‘All staff need to remember to speak slowly and clearly. This would save a great deal of time and irritation. (Some seem to think that volume is all that matters)’ Matron said she has a specific interest in this topic and confirmed that several senior staff had attended training in communication skills with hearing impaired people. Consideration should be given to training all staff and St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 13 involving those residents with hearing impairment to share their experiences and suggestions with staff and incorporating information in people’s care plans. The home has a formal contract for their GP service and the GP visits twice a week to oversee the medical care if residents. Through this contract the home is also able to access the out of hours GP service. The managers said that they consider the GP service provided is excellent and the GP is readily available for advice and consultations at times other than his/her routine visits. In response to the Commission’s survey question about whether residents receive the medical support they need, 50 (3) stated ‘always’ and 50 (3) that this was ‘usually’ the case. The management, records, storage and disposal arrangements for medicines are good. Registered nurses administer the medications to residents. In addition to their professional training and experience in safe handling of medication the nurses have completed a National Vocational Qualification (NVQ) at Level 3 in the safe administration of medicines as part of their continuing professional development. The home provides single en-suite rooms for residents. Residents are addressed by their preferred title or name and staff were seen to be respectful and polite when helping and talking with residents. Several comments in surveys reflect peoples’ appreciation that staff respect residents’ individuality: ‘[Care is given with] flexibility according to individual needs’ ‘Taking the needs of each individual and responding to those needs’ ‘Matron is ‘hands-on’ and knows each patient as a person as well as [their] medical needs’ ‘The staff seem to have a genuine feeling of engagement with my [relative] as well as with members of the family’. There is greater ethnic and cultural diversity amongst the staff team than the current residents. However, from the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. People using the service do not always have the opportunity to participate in social activities that match their expectations and preferences and this could be developed further. Meals are nutritionally balanced, offering both choice and variety, and cater for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individuals who choose to stay at St Luke’s are usually aware that the ethos and environment is more that of a hospital than a care home, so the lifestyle usually meets expectations. Residents’ interests are recorded in an ‘Activities and Interests’ form in their care records. The home has two recreational therapists who arrange and publicise group activities. The work of the recreational therapists is much appreciated: one person wrote that ‘Individual attention from Activities staff excellent (regular supply of large print reading matter)’. The schedule of events for the month was readily available and includes such activities as word games, quizzes, visits from a PAT dog, as well as the regular monthly ‘Tea with Matron’, and weekly and monthly chapel services. Several St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 15 residents enjoy the challenge of completing crosswords in their daily newspaper. One relative wrote that they consider that a ‘serious weakness [of the home is the] low staffing level at weekends creating a feeling of emptiness (“nothing happens here at weekends)’. The same relative considers that the home could involve relatives, friends and volunteers more in the life of the home, to provide practical and fund-raising support: currently their involvement is ‘very limited contact at the Autumn sale and Christmas Carol Service’. Of the 6 residents who responded to the Commissions survey question ‘Are there activities arranged by the home that you can take part in?’ one person ticked ‘always’; one ‘usually’; 2 ‘sometimes’ and one ‘never’ (because the resident ‘does not wish to take part in activities’). At the last inspection, it was recommended that the care staff and recreational staff work together more, so that all staff have the confidence and ability to organise ‘ad hoc’ individual and group activities at times when recreational staff and visitors may not be available to help involve residents in meaningful activities of their choice, and in conversation. This is still an area that could be improved. Two people commented that poor hearing and sight limited their involvement. One person queried why there is no loop hearing system in the chapel as audibility is poor for those people with a hearing deficit. In fact, there is a loop system installed, so it is not clear whether residents are aware of and/or are reminded by staff, to adjust their hearing aids to benefit from this; or if the system is working correctly. Other communal rooms do not have a loop hearing system; the home might consider this as it would improve the facilities for people who want to join in some of the group activities but are discouraged by because they cannot hear properly against a background of conversation. The home provides large screen TV’s in all residents’ rooms, with earphones available for those with hearing loss. A tropical fish tank has been installed in a first floor sitting room in response to a relative’s suggestion. The garden (part of the Quiet Garden Trust Scheme) is a very attractive feature; as one person wrote - ‘beautiful garden and devotion of the gardening team are enormous assets’. However, because the garden is set away from the home, most residents need to use a wheelchair and staff help to access it and stay with them. This sometimes limits residents’ full use and enjoyment of the gardens, if they do not have a staff or family member to accompany them. Access to other local community facilities – shops, library or churches, for example – are similarly limited for those residents who do not have regular family or friends to take them out. Whilst the inspector acknowledges that St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 16 many residents are too frail or do not wish to be involved in arranged activities, there is scope for inviting suggestions from residents and their residents (especially those for whom St Luke’s is their long-term home) about activities and access to community events and facilities outside the home. The home has a terraced area that is accessible from the first floor for residents; this has attractive planters and tubs and garden furniture set out for people to use in the good weather. Flowerbeds and garden areas nearer to the building provide attractive outlooks for many of the residents. The kitchen facilities on both ground and first floor units have been upgraded since the last inspection. The menus (a sample was seen by the inspector) provide variety and nutritionally balanced meal choices. The chef consults regularly with residents about their preferences and has recently adapted the menus to include more traditional dishes in response to residents’ requests. There was a mixed response to the commission’s survey question about meals at the home; two out of 6 people ‘always’ like the meals; 3 ‘usually’; and one person ‘sometimes’. (It should be noted that people who were short-stay residents completed 2 of the 6 surveys; this may have affected the time they had had to form a view on the meals and variety offered). One resident’s survey response included a comment that they ‘would like much more varied choice of fruit and vegetables’. By contrast, a relative/representative of a resident was particularly impressed by the home’s provision of ‘a variety of tempting food for someone not able to choose from a list and [staff] noting what they seem to like’. From comments made by residents on the day and the inspector’s own observation and experience, meals were attractively served and looked appetising and were tasty. Staff were sensitive to resident’s requests to vary the size of the meal served to them and additional portions were offered. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has a satisfactory complaints system and residents are confident about how to make a complaint if necessary and that complaints would be investigated and acted upon. The homes policies, procedures and staff training ensure that residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The general manager confirmed in the AQAA that, in line with the requirement made at the last inspection, all residents now have a copy of the complaints procedure. Four of the 6 residents who responded to the Commissions survey indicated that they knew how to make a complaint, whilst 2 said they did not (one person said they would consult their relative ‘if necessary’). Relatives’ responses were similar – 3 out of 5 knew how to make a complaint; one did not and one person could not remember but added they ‘had not felt the need to make a complaint’. The home has not received any complaints in the past 12 months and no individual has contacted the Commission with a concern about the home since the last inspection visit. The Matron visits all residents individually daily and regularly communicates with relatives: the homes AQAA document states that as a result ‘any potential issues are dealt with immediately and in person’. She reported that the informal ‘Tea with Matron’ sessions that have been introduced since the St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 18 last inspection provide another opportunity for residents and their relatives to raise any concerns or make suggestions. All new care staff have information about safeguarding through the General Social Care Council (GSCC) Codes of Conduct document they receive when they start work in the home. New care staff complete an induction programme that meets the Skills for Care national standards and that covers how to identify and report suspected abuse. The sample of staff records looked at showed that all staff are required to attend regular training and updates about safeguarding adults from abuse. The home has copies of the local Multi-agency Code of Conduct for the Protection of Vulnerable Adults available to staff to read as part of the homes policies and procedures. Staff sign that they have read and understood the home’s these. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The environment is well maintained, hygienic and well managed so that residents live in a clean and safe environment. There is ongoing improvement to the building and facilities provided for residents through a programme of planned refurbishment. Bedrooms are comfortable and personalised and are equipped with aids and adaptations that meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were visited during the inspection. The home was commendably clean, bright and airy. Four of the 6 residents who replied to the Commissions questionnaire stated that the home was ‘always’ fresh and clean, and two that this was ‘usually’ the case. Redecoration of the corridors and the addition of a large number of pictures on the corridor walls make these areas look less clinical. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 20 On the day of the inspection, the ground floor corridor was being repainted. Residents said that the work was being done efficiently and had not disturbed them unduly. In the past 12 months, the kitchens, sluice rooms, clinical rooms and laundry have been upgraded. All the beds are electrically adjustable for residents’ comfort, and for the health and safety of the staff. Seven smaller rooms have been converted into four more spacious rooms and a further seven rooms have been completely refurbished to a high standard. Air conditioning units have been installed in four of the communal rooms. The laundry floor has been replaced with a suitable sealed flooring material. The laundry is tidy, well-organised and appropriate infection control measures are in place. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. There is a good match of well-qualified staff offering consistency of care to residents within the home and residents feel well cared for and supported by staff who are trained and competent in their roles. The standard of vetting and recruitment practices are sufficiently thorough to protect residents from unsuitable staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff rota that shows how the care and nursing staff are allocated between the floors and between nights and days. The inspector looked at copies of the duty rotas in the staff office. These confirmed the information provided in the home’s AQAA – namely, that there are always a minimum of two qualified nurses on duty at all times, two at night and at least four during the day. The proportion of qualified nurses exceeds that of most care homes, and meets the wide range of needs of residents – from short stay respite and post-operative care to long term and end of life care. The homes does not use agency staff, but (as stated in the AQAA) ‘employ a small number of bank care staff who work regular shifts to maintain their competencies and familiarity with the patients and practices of the Hospital’. The recreational therapists and physiotherapist are also additional to the nursing and care staff team. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 22 Residents’ responses to the commission’s survey questions about whether staff listen to them and act on what they say - 5 out of 6 said ‘yes’; and on staff availability when the residents need them – 2 out of 6 said ‘always’ and 4 that this was ‘usually’ so. One person added ‘Waiting [for staff] is inevitable but can be frustrating’. Relatives’ written comment cards were very complimentary about the standards of care – ‘very good, with a friendly and welcoming atmosphere and flexibility according to individual needs’; ‘good standard of nursing care’; ‘St Luke’s provides some of the best care our [relatives/friends] have received in the Oxford area, if not the best care’. The inspector looked at the recruitment and training files of three staff members. These showed that a systematic and thorough vetting process had been completed, including satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (PoVA) checks and references had been received before people were offered employment in the home. Managers confirmed that new staff worked under supervision until full CRB clearance had been received (in cases where a PoVAFirst initial check had been undertaken prior to confirmation of the full CRB check). The home takes undergraduate student nurses from Oxford Brookes University on placement as part of their training. St Luke’s Hospital is accredited by the University and the NMC as a provider of training within the adult nursing module of the undergraduate nursing course. Eight of St Luke’s Registered Nurses have achieved the teaching and assessing qualification necessary to mentor nursing students and overseas nurses who are undertaking ‘adaptation’ courses to enable them to apply to register with the NMC to work in the UK. Matron is supernumerary to the nursing staff numbers, but is closely involved in overseeing the day-to-day care of residents, assessing prospective new residents and in the clinical supervision of nursing staff. She has a keen interest in staff training at St Luke’s and the home’s induction programme for new staff meets the Skills for Care (nationally approved) standard. After induction, care staff members are helped to take the National Vocational Qualification (NVQ) Level 2 in care, and the home meets the national minimum standard of 50 NVQ trained staff (13 of the total of 26 care staff have NVQ Level 2 or above). Nine staff are working towards this qualification. Mandatory training in safe moving and handling, fire safety and food hygiene is provided for staff and staff are expected to attend training. Training in other care topics has continued especially in palliative and end of life care, and in the care of individuals with dementia. The inspector talked to a staff member about the training they had received and saw evidence of their current training from certificates in their file. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 23 All staff have received training in infection control measures. The recent Department of Health guide ‘Essential Steps’ has been implemented by the matron to assess the infection control management. On the day of the inspection, a member of qualified staff was assessed by matron in their practical skills in caring for a resident with a tube-feeding device (PEG). All nurses are assessed in relation to insertion of urinary catheters, PEG feed catheters and wound care. This demonstrates a commendable and rigorous approach to assessment of staff to ensure that high standards of infection control are maintained. This is of particular importance in St Luke’s where many people are admitted for post-operative care and recuperation after acute illness. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The manager provides clear leadership throughout the home. Residents benefit from receiving care provided by staff who demonstrate an awareness of their roles and responsibilities. Further improvement is needed in relation to quality assurance processes to ensure that the views of all the people who use the service are obtained and are taken into account in the running of the service. The homes policies and practices protect the health and wellbeing of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Luke’s has a General manager, Ms Grogan, the ‘Responsible Individual’ who acts on behalf of the Council of St Luke’s Hospital and is responsible for the overall management of the home; and the registered manager, Ms Mason, (Matron) who is responsible for the nursing care provided. The registered St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 25 manager is a registered nurse, with a BSC in Health Studies and a Masters degree in Business Administration. She has extensive training in care issues, particularly in palliative care and has a keen interest in staff training. The home is managed by an executive team of three - the Matron, General Manager and Finance Manager - who report to the board of non-executive trustees, known as the Council of St Luke’s Hospital. Relatives’ survey responses indicated their appreciation about the way the home is run, for example: ‘I think the care home does everything well – from the receptionist and ‘backroom’ people right through to the nursing and care staff. . .everyone seems to know what their role and duties are and the place seems to be well run, efficient and effective’. The inspector also spoke to three residents during the visit who confirmed their satisfaction with the care and attention they receive here. Quality questionnaires are sent monthly to a sample of individuals who have stayed for a recent short stay, and comments are invited regarding communication, nursing services, other staff and catering. Information is collated quarterly and results are reported in the form of a ‘Review of Quality and Service Development’ to St Luke’s Council. The inspector was given a copy of the September 2007 report that includes ‘patient satisfaction questionnaire’ results for a 9-month period from November 2006 to July 2007. 91 of the 47 people who completed a questionnaire were ‘very satisfied/satisfied’ and 9 ‘not entirely satisfied’. All said they would recommend St Luke’s to their friends and family. As reported in the last inspection report informal arrangements are in place for residents and relatives to raise issues with the matron through her daily visit to them. Since the last inspection, Matron has introduced a monthly ‘tea and chat’ session to which all long-stay residents and their representatives are invited. Any suggestions or ‘grumbles’ raised informally are dealt with promptly and the Matron now keeps a record of any such issues and how they have been addressed. Additionally, Matron attends hand over reports and does her own ‘spot checks’ (sometimes at night) to ensure that standards are maintained and specific problems are satisfactorily resolved. The AQAA states that the evidence for their good quality service is shown through ‘staff retention rates, satisfactory feedback from patients and relatives, verbally, to Matron on her ‘daily visits, and in writing via thank you letters and questionnaires’ However, despite the home’s AQAA statement that there is a ‘comprehensive quality assurance programme and plan in place’, it is not clear how this involves long-term residents, their relatives, and staff. There are still no formal arrangements such as residents’ or representatives’ meetings or formal St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 26 surveys in place to receive information on quality issues affecting the individuals who live long term at the home. It was evident from the responses to the Commission’s questionnaire sent out to a sample of residents and their families and representatives that there are some issues that have not been raised by residents and their families. It is therefore again strongly recommended that long term residents and their representatives be regularly asked about their views of services and facilities at St Luke’s, and they be informed of the results of the surveys. Residents or their representatives manage their own financial affairs, and the home only manages a small amount of petty cash for some residents. St Luke’s has a health and safety policy statement and has procedures in place to meet its responsibilities. There is a named individual responsible for health and safety matters at St Luke’s, and service contracts are in place. Fire records are kept and a fire safety risk assessment is in place. All policies and procedures are reviewed annually and revised as necessary in line with current legislation and best practice guidance. St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations * Care plans should be based on the assessment of care needs for all aspects of people’s well being, including their social and spiritual care. * Care plans should be updated and re-written where there have been significant changes in a resident’s care needs. * Care plans should include evaluation of the planned care to indicate whether the staff interventions are effective. * The registered manager should develop a method to record relatives’ or representatives’ agreement with the care plans. * The inspector recommends that the activities and care teams be better integrated, so that the home can be proactive in meeting the needs of the residents. * Particular consideration should be given to people with visual, hearing or dual sensory impairments and to those DS0000027171.V346802.R01.S.doc Version 5.2 Page 29 2. OP12 St Luke`s Hospital with dementia, when planning individual and group leisure and recreational activities. 3. OP13 Consideration should be given to involving local community groups and/or volunteers and increasing, where possible, relatives’ and friend’s involvement with the life of the home in accordance with residents’ preferences. All staff should have training in communication skills with residents who have hearing, visual or dual sensory impairments The inspector recommends that long term residents and their representatives are regularly asked about their views of services and facilities at St Luke’s through, for example, anonymous user satisfaction questionnaires as well as through individual and group discussion. The results of any service user surveys should be published and made available to current and prospective residents, their representatives and other interested parties, including the Commission. 4. 5. OP30 OP33 St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Luke`s Hospital DS0000027171.V346802.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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