Inspection on 19/02/07 for Luke Senior

This inspection was carried out on 19th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Luke Senior 11/03/09

Luke Senior 22/09/05

Luke Senior 11/07/05

Luke Senior 16/11/04

Luke Senior 29/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Luke Senior Park Lane Guisborough TS14 6ER Lead Inspector Jane Bassett Key Unannounced Inspection 19th February 2007 09:30 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 Luke Senior DS0000031344.V330484.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. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Luke Senior Address Park Lane Guisborough TS14 6ER 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) 01287 632378 F/P 01287 632378 Redcar and Cleveland Borough Council Mrs Geraldine Anne Handley Care Home 41 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (31) of places Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 2005 Brief Description of the Service: Luke Senior is registered to provide care to thirty-one older people and ten older people with dementia. The home is owned by Redcar and Cleveland Borough Council. Luke Senior is situated in Park Lane, Guisborough and is close to local shops and amenities. It is a two storey, purpose built facility offering single room accommodation to residents. Bedrooms in the home environment contain a hand washbasin, however not all meet with space requirements of national minimum standards. The dementia unit is situated on the ground floor of the home; this unit has separate lounge, dining room toilet and bathing facilities. Facilities for the older persons unit are situated on the ground and first floor of the home. There are a number of lounge/dining areas and a large communal dining area situated on the ground floor of the home. There is a passenger lift giving access to the upper floor. The home continues to provide day care for a small number of additional older people. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report includes information obtained from a pre inspection questionnaire, the thematic inspection carried out on 18th December 2006, ten resident and four relative / visitor comment cards received by CSCI. An unannounced visit was carried out which lasted a total of five and a half hours. The inspector carried out a tour of the environment, an audit of documentation including staff records and residents files, and spoke to five residents, three staff members, and the manager. Information received by the inspector at the time of the thematic inspection indicated the home has no minimum fee and has a maximum fee of £620 per week. There are additional charges for hairdressing and chiropody. An additional visit was made to Redcar and Cleveland Borough Council offices on 13th March 2007 by a second inspector to look at staff recruitment and selection records for all of the adult services, this additional visit lasted for two hours. What the service does well: What has improved since the last inspection? It was seen that water temperatures are now being recorded for each bath / shower carried out and there is a regular check on the temperature of hot water outlets on hand basins as required at the previous inspection. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 6 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. Luke Senior DS0000031344.V330484.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 Luke Senior DS0000031344.V330484.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): Outcomes for Standards 2 & 3 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given the opportunity to spend time at the home prior to admission. Admissions to the home only take place if the service is confident staff have the skills, ability and knowledge to meet the assessed needs of the prospective resident. EVIDENCE: During the Thematic inspection carried out on 18th December 2006 three residents files were examined, each contained evidence that the home had obtained an assessment of care needs and information relating to that individual prior to their admission to the home. Details contained in these were seen to be adequate to develop a plan of care. The three residents and one family member who spoke to the inspector at the time of that inspection confirmed they or their family were given the opportunity to visit the home prior to deciding if they wished to live there. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 9 The inspector was told that information was given at this time and care needs discussed. Evidence was seen at this inspection visit that indicated the home is currently issuing new terms and conditions to all service users, these include details of current fees and contributions as required at the Thematic inspection. The home does not offer intermediate care. Luke Senior DS0000031344.V330484.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): Outcomes for Standards 7, 8, 9, & 10. were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have an individual plan of care that give a overview of their general health and acts as an indicator to changing needs. Residents have choice in all areas of daily living and are supported and facilitated to be as independent as possible. The home is working to develop a medication policy and procedure that should promote resident’s safety and individuality. EVIDENCE: During the inspection three residents files were examined. These were found to contain a pen picture of the individual resident, plans of care, risk assessments and reviews. The care plans covered both personal care needs and medical care needs. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 11 The plans evident in the files identified the care need, what the resident could do and what assistance was needed. The manager told the inspector that these were to be developed further to include details of preferences in how care should be given. Plans of care in one residents file did not fully reflect their current needs in relation to continence. Risk assessments did not always include the date or signature of the person completing the assessment. Evidence seen in one residents files indicated that they self-administered some of their own medication. There was no evidence to indicate a risk assessment had been carried out. Some information regarding plans of care and risk assessment was seen to be duplicated leading to confusion as to which was current and appropriate. Plans of care in one file had not been reviewed since March 2006. The manager told the inspector that a full audit of files was being carried out new documentation introduced. Evidence was seen in the files that indicated residents are consulted about their care and have access to their own GP and other health professionals. The home operates a key worker system. Discussion with staff indicated they had a good knowledge of residents and the support they needed. The inspector here’ another good’. Others make choices spoke to a number of residents, one said ‘ I am really happy commented on the ‘ really nice staff’ and stated ‘everything is spoke of the support they were given by staff and their ability to about their own lifestyles. One resident’s family commented on the support given to their relative to enable him/her to remain as independent as possible. All residents observed on the day of the inspection appeared comfortable and settled. It was seen there is a good rapport between residents and staff. The home has recently changed the system for administering medication. The inspector was told that staff who administer medication have all undertaken safe handling of medication training and are receiving training in the use of the new system. Further advanced training is planned. As a result of changes to the system and a recent medication error policies and procedures are currently being reviewed and amended. The manager also told the inspector that all staff who administer medication will be subject to regular competency checks in the future. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 12 A sample audit found no major concerns with ordering, storage, recording and disposal of medication. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 13 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): Outcomes for Standards 12, 13, 14, & 15. were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff resources are provided to allow time for activities and stimulation. The home operates a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared. The home has a system of displaying information and bringing attention to community events and activities. Residents enjoy the flexibility of meal arrangements and enjoyed being able to eat in their own room if they wish. EVIDENCE: Residents who spent time with the inspector all spoke highly of the activities and social life of the home. Comments received included ‘ there is always something to do’. Activities spoken of included bingo, social evenings, pie and pea suppers, outings, shopping trips and other entertainments. Resident’s files seen contained details of individual’s preferences and choice in relation to activities. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 14 From discussion with both staff and residents it was evident that the social life of the home was given great importance and the home was viewed as ‘ part of the local community’ with links to churches, library and other groups. A programme of planned entertainment for the coming year was available in the entrance of the home. The home has a rotating four-week menu that offers a good variety and choice of meals. Residents spoke of the ‘ tasty food’ and ‘ being well fed’. The daily menu was displayed, and the main dining room was seen to be pleasant and homely. Residents are given a choice as to where they wish to eat and a number have meals in their own rooms. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 15 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): Outcomes for Standards 16 & 18 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It is available in a number of languages and formats, and is accessible to all who use the service. Residents and others associated with the service state they are satisfied with the service provision, feel safe and well supported by an organisation that has their protection and safety as a priority. EVIDENCE: During the Thematic inspection carried out on 18th December 2006 records of complaints were found to contain details of the complaint, investigation, outcome and response to complainant. Residents who spoke to the inspector confirmed they were aware of how to raise any concerns or complaints. All expressed confidence that any complaints they had would be taken seriously. No one spoken to had any cause for complaint. The policy and procedure in relation to complaints was seen to be available. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 16 Staff who spoke to the inspector confirmed they had received training in relation to prevention of abuse and were aware of the ‘ no secrets’ guidance. They were able to demonstrate through response to question the action they would take if they had any concerns. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 17 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): Outcomes for Standards 19 & 26 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and staff encourage residents to see the home as their own home. It provides a generally well maintained, safe, comfortable environment. There are a selection of communal areas, which means residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other residents. EVIDENCE: The inspector walked round the home, it was found to be have a warm, welcoming and friendly atmosphere. There are a variety of communal areas which were seen to be suitably furnished and decorated. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 18 Bedrooms seen were personalised with the resident’s own pictures, ornaments and possessions. The first floor corridor continues to require some attention and would benefit from redecoration and a new carpet. The manager told the inspector it was hoped that this would be actioned in the near future. Externally there are accessible and pleasant areas to sit. External woodwork continues to need attention due to peeling paint. It was seen that water temperatures are now being recorded for each bath / shower carried out and there is a regular check on the temperature of hot water outlets on hand basins as required at the previous inspection. At the time of the inspection the home was found to be clean and odour free. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 19 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): Outcomes for Standards 27, 28, 29, & 30. were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that all staff within the home receives relevant training that is focussed on improving outcomes for residents. The service has a recruitment process that is being developed further to enhance the information sought and recorded promoting the protection of residents. EVIDENCE: Duty rotas examined during the inspection showed that both units in the home are staffed individually. Discussion with both staff and residents indicated that staffing levels were currently sufficient and can meet the current needs of residents. Staff files and training records examined on the day of the inspection indicated the staff receive a rolling programme of all mandatory and other relevant training. Over 50 of the care staff have achieved NVQ at level 2 or above. Staff who spoke to the inspector confirmed this, stating that training is a priority and encouraged. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 20 An additional visit by another inspector was made to Redcar and Cleveland Borough Council offices on 13th March 2006 to look at recruitment and selection of staff. During this visit four staff files were examined, these were found to contain evidence of references, CRB, application form and identity documentation. However there was not always evidence of exploration of gaps in employment. Senior management told the inspector that a form has been developed and is now in use. The manager of the home confirmed that gaps in employment were investigated during the interview process but as yet this has not been documented. None of the files had evidence of a photograph. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 21 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): Outcomes for Standards 31, 33, 35, 36 & 38 were looked at. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running the home. The manager and staff are resident focused. Records are of a good standard and were found to be up to date. Policies and procedures are in place that promote residents well being and safety. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager of the home has recently returned from a period of secondment. She is appropriately qualified and experienced. A quality questionnaire was issued to residents in September 2006. An analysis has been carried out, however this is in the form of a bar graph. The manager plans to transfer the findings to a more user friendly format and incorporate the outcomes into the homes plan of action for improvement. Regular meetings for both residents and staff take place. The minutes for the last resident meeting in January 2007 were seen to be displayed on the notice board. All residents and staff who spoke to the inspector expressed confidence in the management of the home. Residents also spoke of the support they receive from all the staff and the encouragement to make choices and remain as independent as possible. One resident told the inspector staff will assist her to go shopping. Staff records seen indicated regular formal supervision sessions have not always taken place, however staff told the inspector that there is an open door policy and they can raise issues at any time. The manager stated the regular implementation of supervision is to be addressed and a new programme has been developed. A sample audit of residents personal allowances held by the home identified no issues. Records were maintained for all transactions and a regular check made Information received indicated the home and equipment are maintained as required. A Health and safety audit carried out by the borough council in August 2006 identified no major issues. Records seen on day of the inspection indicated fire safety equipment, fire alarms, emergency lighting, the passenger lift and the hoists are maintained as required. Records of weekly fire alarm tests and regular drills were seen. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 23 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 2 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5, 17 Requirement The home must maintain a record of current individual fees and costs payable by service users / other parties and includes evidence of agreement. Resident’s plans of care must contain clear information as to current needs and how these are to be met. Plans of care must be kept under review to reflect changing needs. The corridors on the first floor must be decorated. (Previous timescale 30/04/06 not met) The corridor carpet on the first floor must be replaced (Previous timescale 30/04/06 not met) The Council must explore any gaps in employment for staff prior to the commencement of employment. (Previous timescale 22/09/05 not met) Timescale for action 01/05/07 2. OP7 15 01/06/07 3 OP19 16, 23 01/08/07 4 OP19 16, 23 01/08/07 5. OP29 13, 17 01/06/07 Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 25 6. OP29 17 Staff records must contain a recent photograph. (Previous timescale 30/12/05 not met) 01/06/07 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. 4. Refer to Standard OP19 OP9 OP29 OP36 Good Practice Recommendations The external wood work should be painted Regular competency checks in relation to administrating medication should be implemented as soon as possible. The Councils reference request should be developed further to seek confirmation of dates of employment Staff should receive regular supervision and this to be recorded. Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Luke Senior DS0000031344.V330484.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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