CARE HOMES FOR OLDER PEOPLE
Lourdes Nursing Home Ursuline Convent 225 Canterbury Road Westgate-on-sea Kent CT8 8LX Lead Inspector
Clair Brown Announced Inspection 10:05 12 13 December 2005
th th 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 Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 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. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lourdes Nursing Home Address Ursuline Convent 225 Canterbury Road Westgate-on-sea Kent CT8 8LX 01843 833242 01843 831290 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) The Trustees for the Roman Union Josephine Cutting Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. All 15 beds are registered for the admission of nursing patients or residential clients DE(E) is restricted to persons whose DOB are 20/06/1910; 22/04/1913; 11/12/1908; 18/02/1924. 7th March 2005 Date of last inspection Brief Description of the Service: Lourdes Community is a building within the grounds of Ursuline Convent. There is accommodation on two floors and all rooms are registered as single. The building has been extended to provide additional communal space and so that all bedrooms meet the minimum size, The Home provides nursing and personal care. The aim of the Home is to provide a high standard of spiritual and emotional care in an environment in which the Sisters can continue to live their community life. More recently the number of female service user from the general public community has increased. There is a shaft lift and all rooms have a TV point and nurse call system. The Home has access to the extensive grounds of Ursuline Convent and is within easy reach of the local shops, amenities and public transport. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s announced inspection. The inspection was conducted by one inspector and the duration of the inspection was 9 hours over two days. The Homes representative was the registered manager. Additional time was spent in planning the inspection and report writing. The inspectors spent time talking to 3 service users and 4 staff to gain their views. Some staff were actively involved in the inspection. Due to the increase in number of service users with dementia observations were also made and the case tracking of files. Four service users and one relatives completed inspection comment cards. A full tour of the premises was conducted, documents and records were examined, service users files were case tracked and medications were checked. What the service does well: What has improved since the last inspection? What they could do better:
The deputy manager has moved away and this vacancy has been filled, however her leaving has had an impact and a period of adjustment is underway. This has coincided with other personal events, which has understandably needed the registered managers attention. Taking this into
Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 6 consideration the areas of improvement are not causing major concerns and the history of the home, with the registered manager having always demonstrated their commitment to meeting the national minimum standards. The statement of purpose needs bringing up to date to include details of the rooms sizes and environmental facilities. There were a small number of gaps in the medication records. The home has unintentionally developed an excess of medication, this needs to be sorted and medication synchronized with the MAR charts. All new staff need to have a minimum of a POVA First check prior to starting work, including the induction period prior to starting work date. Although it is noted that the CRB checks are completed prior to them starting work. The home already conducts an annual quality assurance programme, however a report needs to be produced following the collation of the information gathered. The current electrical certificate needs to be located. Historically the home has produced comprehensive care plans, a new format has been introduced, but these need completing. All care provided should be recorded in the daily reports. The home handles only a few service users finances, these records were in-order and no concerns are raised, but these would benefit from a 2 signature procedure. 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. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 7 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 Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 The statement of purpose does not provide adequate information to enable prospective service users to make an informed decision. Prospective service users are fully assessed prior to admission to ensure their needs can be met. EVIDENCE: Although the registered manager has produced a comprehensive statement of purpose, information regarding specific details about the size of bedrooms and communal space and the number of bathrooms has not been included. Detailed pre-admission assessments records were read, these showed evidence of an holistic approach and the gathering in-depth information. Comments made by relatives and service users on the inspection comment cards expressed that individual needs are being met and provided for. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Individual service users needs and health needs are met but are not fully supported by detailed care plans. EVIDENCE: The registered manager has changed the care plan format, although these have been introduced, they have not been completed, so there are some gaps in the records. One service users file was without a nutritional assessment. Details of a sore area on an arm requiring dressings was recorded in the daily reports but was not entered on the care plan. Some of the daily reports lack sufficient details of the care provided. Other records such as doctors visits provided evidence that healthcare professionals are being accessed appropriately. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The programme of activities satisfies the wishes of the service users. A nutritionally balanced diet is provided. Visitors are made welcome. EVIDENCE: The home offers a variety of activities both within the home and activities outside the home. These reflect the spiritual needs of many of the service users and the usual range of activities that includes, gentle exercise, quizzes, video afternoons and activities in the gardens of the home. The meals provide a good quality of freshly prepared, homemade meals. Choice is promoted with the variety of meals on offer. Daily routines are individual, however there is a degree of routine for those who like that aspect of living in a residential environment. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Relatives and service users are confident that their views and concerns will be taken seriously. EVIDENCE: No new complaints had been received at the time of the inspection. No change has been made to the policy and procedures for the handling of complaints and adult protection. Service users and relatives comment cards show they are confident in raising concerns with the registered manager and that an agreeable outcome is achievable. This was confirmed when talking with service users. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The building is well maintained and in good order. The home is well equipped to help meet the service users needs and provides a pleasant environment. The home is clean and infection control procedures adhered to. EVIDENCE: There is regular investment in upgrading the environment. All bedrooms have en-suite facilities and are individually furnished. Service users are encouraged to bring in personal items. The home has fully equipped assisted bathrooms and multiple communal spaces. The home benefits from its own chapel and beautiful gardens. The home was very clean and infection control procures are fully implemented. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Care staff are provided in sufficient numbers to meet the needs of the service users. Recruitment procedures are thorough and ensure the safety and welfare of the service users. Staff are attending appropriate training courses. EVIDENCE: The Home currently employs 14 registered nurses, 15 care staff, with an average of 1 registered nurse and 3-4 carers on duty at a time during the day, plus the registered manager. There is two awake night staff, one of which is a registered nurse. The Home also employs a team of ancillary staff comprising of cooks and assistants, maintenance person and a housekeeper and cleaners. Five care staff have completed the NVQ level 2 or above in care with a further 2 staff due to complete the course. The training matrix shows that staff are attending a variety of training courses, including the mandatory subjects. A thorough recruitment procedure is in place, however, the majority of new staff complete an introductory induction prior to starting contracted work. At this time many of the staff have not had their checks completed. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,37,38 The registered manager has the skills and knowledge to continue to bring the home forward. Overall the health & safety practices are satisfactory. EVIDENCE: The registered manager is well qualified for the position and has completed the registered managers award. The home has been well managed with the homes ethos being maintained. There has been a change of deputy manager for which there is a period of adjustment for staff. Service users financial records were seen to be update, however these would benefit from using a two signature procedure. The environmental health & safety certificates were up to date although it was found that the most recent electrical certificate could not be located. Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 15 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 2 X 3 X 3 3 Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 16 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. 1 2 Standard OP1 OP9 Regulation 4,5 schedule 1 12, 13, 14, 16 Requirement Timescale for action 30/06/06 31/01/06 3 OP29 4 OP33 5 OP38 All of the required information must be included in the statement of purpose. Medication records must be accurate, with staff signing for medication administered and using the correct codes for nonadministration. 7, 8, All new staff must have a 18,19, sch minimum of a POVA First check 2 prior to starting work, including the induction period prior to starting work. 10,12,15 For a report to be produced 24 following the collation of the information gathered during the annual quality assurance programme. A copy of the report must be sent to the CSCI once completed. 13 For a copy of the electrical certificate to be sent to the CSCI. 31/01/06 30/06/06 31/01/06 Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 17 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 OP7OP8 Good Practice Recommendations To complete the introduction of the new care plan format. To ensure all of the required information is recorded, identifying all of the service users needs. All care provided should be recorded in the daily reports. To clear the excess medication stock and to bring current medication used in line with the MAR charts. To use a 2 signature procedure for the recording of service users finances. 2 3 OP9 OP35 Lourdes Nursing Home DS0000026104.V276088.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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