Inspection on 12/12/06 for Lourdes Nursing Home

This inspection was carried out on 12th December 2006.

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

Lourdes Nursing Home 21/02/06

Lourdes Nursing Home 12/12/05

Lourdes Nursing Home 07/03/05

Lourdes Nursing Home 20/12/04

Lourdes Nursing Home 27/07/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Lourdes Nursing Home Ursuline Convent 225 Canterbury Road Westgate-on-sea Kent CT8 8LX Lead Inspector Clair Brown Key Unannounced Inspection 12th December 2006 10:40 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.V307034.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. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 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 836841 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.V307034.R01.S.doc Version 5.2 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. 12th December 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 as well as providing nursing care. 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. The fees are: £597.00 to £680.00. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection consisted of an unannounced key inspection visit to the home on 12th December 2006 by one inspector. The inspection takes account of information received from a variety of sources including written information from the registered provider and registered manager, service users and staff. The previously made requirements and recommendation from other inspections were inspected and all key standards. Comment cards were completed by 4 service users. The inspector spent time talking to service users and the staff to gain their views. A partial tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: The assessment of prospective service users is very detailed and includes personal preferences about individual daily routines. The care plans are well written and provide staff with very precise instructions on how to meet the service users care needs. Service users stated they are well cared for and the staff are kind and listen to them. One service user told the inspector of how the staff maintained their modesty when washing them. Senior staff & care assistants have undertaken training in “care of the dying” to enhance their understanding of the service users needs when coming to the end of their life. Medication is handled and administered safely ensuring service users receive tablets appropriately. There is a variety of activities provided, supported by the recent employment of an activities person. Many of the service users are nuns and their spiritual needs are met through the volunteer visiting nuns and the religious services conducted in the homes own chapel. The registered manager has also undertaken a course in spirituality. The registered manager ensures that a thorough recruitment procedure is used, with all of the security checks being completed before new staff work. New staff also complete a basic health & safety induction before working a shift and then proceed to the full induction programme. There is a full training programme that covers all of the mandatory subjects as well as additional specialist courses. The home is purpose built and there is a rolling programme of maintenance and refurbishment which results is the home being maintained to a good standard of repair and there is ongoing development of the home, such as the recently extended kitchen. The home is managed well by the registered manager who is supported by a deputy and two seniors; this enabled them to maintain her high standards during a recent period of compassionate leave. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 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.V307034.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 123456 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The statement of purpose provides sufficient information to enable prospective service users to make an informed decision. The admissions procedure is thorough and ensures the home can meet service users. Intermediate care is not provided. EVIDENCE: The registered manager stated that she is currently reviewing the statement of purpose and that there has been no changes made to the service user contract and that prospective service users are encouraged to visit. A recently admitted service users file was assessed which included a very detailed preadmission assessment conducted by the registered manager. The assessment even specified how many pillows the service users liked to sleep with and their personal nighttime routine. The registered manager confirmed the home does not provide intermediate care therefore standard 6 is not applicable. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 9 Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 10 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 10 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care planning system provides staff with the information they need to meet the service users needs and evidence that health needs are met. Service users feel they are treated respectfully and their dignity is maintained at all times. Medication procedures and practices ensures service users medication is administered appropriately and safely. EVIDENCE: One service users file was case-tracked, this included a copy of the preadmission assessment. The care plan was detailed and individual, with specific information on how to meet their care needs and personal preferences about daily routines, such as preferred bedtime routine and drinks. There were clear nursing instructions for the application of dressings and the monitoring of the Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 11 wounds healing. The care plan included a description about the service user having chronic arthritis in their shoulders and how it affects them moving their arms and independence and tells staff about the type of clothing they likes due to pain in their shoulders. When talking to the service user they described how staff keep her covered with towels to maintain their modesty when providing personal care, this and other matters relating to dignity where included in the care plan. Skin integrity and nutritional assessment were conducted and linked to the care plan. Some reviews of assessments were two weeks over due. The service users dependency score determined the service user had high needs and appeared an accurate reflection of their overall needs. Daily records did not always refer to all of the care needs identified in the care plan such as the mobility programme, but overall the records were satisfactory. Night reports would benefit from more detail being recorded. Changes in medication were recorded including the reasons for change. A medication audit was conducted, only one error was identified, the administration of one tablet was not signed for and the remaining tablets did not correspond with those issued. The member of staff responsible for issuing the tablet was contacted at home who confirmed they had not signed the chart but had administered the tablet and that the reason for the discrepancy was due to the medication being issued at a different time to the others. The registered manager has agreed to investigate this matter further. Senior staff and the deputy manager have attended the care of the dying course. The registered manager also stated that they have been liaising with the PCT and plan to introduce the Liverpool care pathway for the care of the dying. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 12 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 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to participate in a variety of activities and maintain contact with their family & friends. A nutritionally balanced diet is provided. Service users have an active voice, expressing their personal preferences and this is respected and acted upon. EVIDENCE: The home provides a variety of activities and social events and an activities person has recently been employed. The home benefits from beautiful gardens and also has two large communal rooms and a selection quiet rooms and a chapel. There are regular religious services provided in the chapel. A variety of events have been arranged for the Christmas period. Service users stated in the surveys that there are plenty of activities available. Others also choose to attend clubs and social events in the local community. The service users surveys state, “they feel they are listened to and that they are able to Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 13 express their concerns and that they are taken seriously”. Many of the service users are physically frail and require the support of care staff but have been supported to maintain their individual beliefs and personalities. The menu offers two choice of a hot main meal with other alternatives available. Fresh vegetables are used daily and fresh fruit is always available. The main meal was steak I kidney pie or sweet & sour chicken all of which was freshly made by the cook. Special diets are catered for, a service users survey stated, “they make a special effort with their diet”. Relatives also stated that they are able to join their family for meal at the home. The home has implemented the “Safer food better business” in the kitchen. The cook is also doing a distance learning nutrition course. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 14 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 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their opinions and concerns are taken seriously and responded to appropriately. EVIDENCE: Service users comment cards stated that they aware of how to complain and who to complain to. The Commission has not received any complaints since the last inspection. The Home has an adult protection policy and procedure, which includes a whistle blowing policy. This was adhered to when a member of staff used the whistle blowing procedure to raise concerns about another member of staff. The home followed the procedures and the matter was resolved satisfactorily without having an impact on the service users. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 15 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 20 21 22 23 24 25 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The building is purpose built and well maintained providing a homely environment for service users. EVIDENCE: The building is a purpose built home, with its accommodation provided on the ground and first floor, there is a shaft lift to access the first floor. The home employs maintenance staff and has an on going maintenance programme. There is regular investment in the home with the most recent being to the expansion and installation of a new kitchen. Specialist equipment is provided when needed and adaptations to meet the needs of the service users. All of the bedrooms are single and have en-suite facilities. Service users are actively encouraged to bring in pieces of furniture and personal possessions, making Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 16 the bedrooms both intimate and individual. The home provides assisted bathrooms and toilets and has a selection of communal rooms including a chapel in which services are conducted. Infection control procedures are fully implemented and the appropriate equipment provided. The home was seen to be clean and free from offensive odours and this was supported by the comments in the service user surveys. The home has recently employed a designated laundry person and has a team of ancillary staff. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 17 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 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 employs a team of both registered nurses and care staff. There is also a team of ancillary staff and the home has recently employed a designated laundry person and an activities person. There is a minimum of one registered nurse on duty excluding the registered manager, until 3.pm. then the registered manager is the Nurse in charge until 4.30. There are also between 4 and 5 care staff on duty during the day and one registered nurse and one waking carer at night. All mandatory training has been completed and some staff have attended the continence training. Two members of staff have attended the hospices care of the dying course and the deputy manager is near to completing a 7 month advanced course in the care of the dying. The registered and deputy manager have retrained in conducting appraisals. The two senior carers have attended supervisory skills course, the benefits of this training has been seen by the registered manager, developing the staff and the senior carers to work to their Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 18 grade. This has enabled the registered manager to delegate some of the responsibility for supervising staff. 50 of care staff have completed the NVQ level 2 or above in care. All new staff work induction shifts to start with, where they are fully supervised by staff and complete health and safety induction. All staff complete the full induction programme, which the registered manager stated; complies with the “skills for care” programme. The two most recently employed staff files were assessed, these contained application forms, interview records, references, proof of identity, all relevant documentation. The files provided evidence that staff do not start work until receipt of both the CRB and POVA check. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 19 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 32 33 34 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the skills and knowledge to continue to bring the home forward. The home has a quality assurance system implemented. The health & safety practices are satisfactory. EVIDENCE: The registered manager is well qualified for the position and has the registered managers award she has also undertaken training in spirituality course. The home has been well managed with the homes ethos being maintained. The supervision of staff has been divided up and the two senior staff have been Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 20 trained to conduct supervision. There are quality assurance systems in place, a full report has been produced for this year’s process and a plan of action implemented. Service users financial records were seen to include receipts and cash and records corresponded and the home has recently introduced a two-signature procedure. The environmental health & safety certificates were up to date and the fire risk assessment is due for its annual review. Policies and procedures have been reviewed this year. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 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. 2. 3. Refer to Standard OP38 OP37 OP9 Good Practice Recommendations To review the homes fire risk assessment. For daily records of the care provided to have more detail pertaining to the needs identified in the care plan and the actual care provided. For medications to be stored at the correct temperature and not to place medication in the drug fridge unless the instructions specify this. Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Lourdes Nursing Home DS0000026104.V307034.R01.S.doc Version 5.2 Page 24 - 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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