This inspection was carried out on 21st February 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Lourdes Nursing Home Ursuline Convent 225 Canterbury Road Westgate-on-sea Kent CT8 8LX Lead Inspector
Clair Brown Unannounced Inspection 21st February 2006 12:00 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.V282713.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.V282713.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 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.V282713.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. 27th July 2002 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.V282713.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 unannounced inspection. The inspection was conducted by one inspector and the duration of the inspection was 2 hours with the main focus being on the previously made requirements. The Homes representative was the deputy manager. Additional time was spent in planning the inspection and report writing. Documents and records were examined and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better:
Two of the previous requirements were not inspected due to the registered manager being on annual leave. Care plans for those who have more complex needs should be more instructive about how to provide the care ensuring staff are given clear step by step instructions. Lourdes Nursing Home DS0000026104.V282713.R01.S.doc Version 5.1 Page 6 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.V282713.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.V282713.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): 1,4 The statement of purpose provides sufficient information to enable prospective service users to make an informed decision. Service users needs are met. EVIDENCE: Additional information has been added to the statement of purpose and now it contains the required information. Records showed that service users needs are being met with records of care being provided kept. One service user has arrived back at the home from a stay in hospital, there is some concern that the illness has changed their mental state and the home maybe required to consider their current registration. Lourdes Nursing Home DS0000026104.V282713.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 The care plans for service users with complex needs fail to provide staff with sufficient instruction. EVIDENCE: Two service users with complex needs files were seen. Although the new care plan system has been introduced and were fairly detailed they did not provide sufficient information to enable the staff to use them as a point of reference. Mobility needs had been identified but it did not specify the equipment to use, similar incidents for continence needs were identified. Both service users have developed some behavioural issues, again these had been acknowledged in the care plan and appropriate action was taken to gain specialist consultations, the care plan did not provide staff with possible triggers identified and clear details on how to manage these situations. The deputy manager was able to verbally demonstrate a knowledge of management of behavioural issues. Lourdes Nursing Home DS0000026104.V282713.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): Not inspected EVIDENCE: Lourdes Nursing Home DS0000026104.V282713.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): Not inspected. EVIDENCE: Lourdes Nursing Home DS0000026104.V282713.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): Not inspected. EVIDENCE: Lourdes Nursing Home DS0000026104.V282713.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): 29 Thorough recruitment procedures are used to ensure the welfare of the service users. EVIDENCE: The deputy manager confirmed that new staff do not start work until the CRB has been received at the home. Lourdes Nursing Home DS0000026104.V282713.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): 32 The new management structure of the home is beginning to become established. EVIDENCE: The registered manager was on annual leave, the new deputy manager was incharge and took the inspection. The deputy has discovered the demands of being both clinical and in a management position. She was able to demonstrate how she has managed a number of situations that have occurred since her arrival and was open to advice and information shared during the course of the inspection. Being the only registered nurse on duty and managing the home did present some difficulties with demands for her time and the responsibilities she was required to fulfil for both roles. Lourdes Nursing Home DS0000026104.V282713.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 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X X X X Lourdes Nursing Home DS0000026104.V282713.R01.S.doc Version 5.1 Page 16 Yes 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. 1 Standard OP4 Regulation 12,14,18 Requirement Timescale for action 31/03/06 2 OP7OP8 3. OP33 The service user who returned from hospital on the day of the inspection to be monitored re: dementia. For the registered manager to make an application for a variation to the registration if applicable. 12,13,14 Care plans must acknowledge all 15, 16, 17 identified care needs and provide staff clear instructions on how to meet those needs. To ensure that cross referencing between assessments and the care plans, ensuring they are up to date and that needs identified in the assessment (e.g. Skin integrity) is recorded in the care plan. 10,12,152 For a report to be produced 4 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. 30/06/06 30/06/06 4. OP38 31/03/06 Lourdes Nursing Home DS0000026104.V282713.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 OP35 Good Practice Recommendations To use a 2 signature procedure for the recording of service users finances. Lourdes Nursing Home DS0000026104.V282713.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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