Inspection on 22/09/05 for Luke Senior

This inspection was carried out on 22nd September 2005.

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

Luke Senior 11/03/09

Luke Senior 19/02/07

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 Katherine Acheson Unannounced Inspection 22nd September 2005 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.V256097.R01.S.doc Version 5.0 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.V256097.R01.S.doc Version 5.0 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 01287 632378 Redcar and Cleveland Borough Council Mrs Sarah Jane Brunton 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.V256097.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Policies and procedures must be reviewed in order to meet the National Minimum Standards and Care Homes Regulations 2001. A copy of the policies and procedures must be forwarded to the Commission for Social Care Inspection by 30 April 2004. The Registered Person must address the recommendations of the Fire Authorities letter dated 16 March 2004, within a 12 month timescale. 11th July 2005 2. Date of last inspection 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 provides day care for three additional older people. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 9.30am and lasted for four hours. During the inspection seven residents, one relative, three staff members and the Manager were spoken to. Numerous records including care plans, menus, complaints, quality assurance and medication systems were examined. A tour of the premises was carried out. Requirements identified at the last inspection were re-visited. An additional visit was made to Redcar & Cleveland Borough Council offices on 20th September 2005 to look at staff recruitment, selection and training records for all of the adult services, this additional visit lasted for four hours. What the service does well: What has improved since the last inspection? Since last inspection The Manager has developed a system in which to record and evaluate medical problems of residents, this will further enhance the systems that are already in place within the home. Residents at the last inspection highlighted the need for a call system within the conservatory area to enable them to summon the help of staff, this had been addressed. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 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. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 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.V256097.R01.S.doc Version 5.0 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): EVIDENCE: The above standards were not inspected. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 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): 9 The home’s medication policy/procedure promotes safe practice for dealing with medication. EVIDENCE: The home’s system for storing, administering and recording medication was seen to be effective. Storage is safe and complies with the relevant regulations and records of medication received at the home, given to residents and returned to the pharmacy were seen to be accurate. Records of controlled medication were well maintained. Those residents who are able are encouraged to self medicate, a risk assessment is carried out on the resident to determine ability and safety, and lockable storage for medication is provided. A requirement identified at the last inspection in respect of care plans was revisited. Care plans examined at the last inspection in July 2005 were found to be informative in terms of activities of daily living, however further development was required in care planning for those residents that had a medical condition. Since last inspection the Manager has developed a format and care planning system to address this. Two plans of care examined during Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 10 this inspection were observed to have care plans in place for medical conditions. A call system had also been fitted to the conservatory area, which enabled residents to summon the help of staff. Residents spoken to during the inspection complimented the Manager and staff and the care that they received. One resident said, “I am over the moon with this place”, another said, “I’ve never been happier”. One relative spoken to said, “I’m coming home when I come here, it’s like going to my mothers own house”. One resident spoken to during the inspection said that she did not have a key worker at this moment in time as her key worker was off sick. She went on to say that this had not affected the care that she had received, however felt that it was important that a new key worker be allocated to her. This was pointed out to the Manager at the time of the inspection who took immediate action to rectify the situation. During the inspection the Inspector took the opportunity to speak to this resident again who said that she was over the moon that this had been sorted. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 11 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): 15 The home provides a wholesome, varied and appetizing menu that ensures dietary needs of residents are met. EVIDENCE: The home offers a four-week menu with an alternative choice offered at each mealtime. Menus examined were wholesome and showed variety. Records were available to confirm that appropriate temperature checks are carried out on fridge, freezers and food. Records of food provided were available for inspection. Four residents spoken to during the inspection said that they liked the food that was provided. One resident said, “You get a choice of menu at dinner and tea”, another said, “The menus are lovely, they are always coming round and offering you cups of tea”, another said, “If I am hungry I can have a snack, we talked about food and snacks at the residents meeting last week. Mealtime was observed to be relaxed and enjoyable, beautifully presented menus were displayed in all lounge and dining areas. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 12 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 The home provides effective arrangements to ensure that residents are enabled and supported to make any complaint they consider necessary. EVIDENCE: The home has a complaints policy/procedure in place. Records examined confirmed that the home have an effective system in place to ensure that complaints are handled efficiently. Complaints received are recorded individually ensuring confidentiality and data protection. Residents spoken to said that they felt able to approach the Manager and staff and make any complaint necessary. One resident said, “The staff are always there for you they are second to none”. One relative spoken to said, “If I am worried about my mam, I just go to the office and by the time that I leave everything is sorted”. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 13 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 standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. Refurbishment of corridor areas would further enhance this. EVIDENCE: A tour of the premises found the home to be warm, welcoming and friendly. Suitable communal space is provided for residents and these areas are decorated in a homely and comfortable manner, as are the home’s toilet and bathroom areas, which provide any aids needed by residents. Resident’s bedrooms are homely and personalised with personal possessions being evident. Residents bedrooms visited were well decorated and furnished. Since last inspection the home’s main dining area on the ground floor of the home had benefited form re-decoration and new curtains. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 14 It has been highlighted at previous inspections that the corridor on the first floor of the home would benefit from re-decoration; as yet this has not been addressed. The decoration in the corridor areas has become increasingly worn and the carpet is in need of replacing, having been marked. The home’s offers pleasant grounds and an enclosed garden for residents to enjoy. The exterior of the home would benefit from painting. The Manager said that all baths, showers and sinks in the home environment are temperature regulated. She went on to say that bath and shower temperatures are taken on a weekly basis and that sink water temperatures are taken on a monthly basis. It was suggested to the Manager that all water temperatures should be carried out on a weekly basis. Records were available to confirm that staff at the home take and record water temperatures, however this was observed to be out of date. The Manager said that she would take immediate action to rectify the situation. At the time of this inspection the home was found to be clean and odour free. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 15 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 Staff receive appropriate training and as such care needs of residents are met, however staffing levels must be reviewed to ensure sufficient staff are on duty. The Council’s procedures in respect of recruitment of staff are not robust and as such do not provide safeguards to offer protection to people living at the home EVIDENCE: Duty rotas examined during this inspection highlighted that both units in the home environment are staffed individually. The Manager said that staffing levels fluctuate depending on dependency and resident numbers. Staff spoken to during the inspection said that on occasions, especially when the home is full, they do not feel that there is sufficient staff on duty. Residents spoken to during the inspection said that they felt safe and that their care needs were met. The complaints record highlighted two residents who had complained about insufficient staffing on one occasion, the Manager said that both residents were unhappy that bingo had needed to be cancelled on one particular evening due to a short fall in staffing. An additional visit was made to Redcar & Cleveland Borough Council offices on 20th September 2005 to look at staff recruitment, selection and training records. The Council keep a record of each staff member working at the home, qualifications and relevant experience gained. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 16 At the start of the visit the Inspector intended to view eighteen staff records, however following a thorough examination of six it was felt that information required had been obtained. Of six staff files sampled none were found to have a photograph of the staff member. Three were found to have a full employment history on the application form three did not, and the Council had not explored these gaps. Four files were observed to have proof of identification, two did not. Following discussion with staff and examination of records it became evident that the Council are not carrying out appropriate Criminal Record Bureau Checks on all staff prior to the commencement of employment. The Council have been accepting Criminal Record Bureau Checks that have been undertaken by previous employment. An immediate requirement was left in respect of this and as such the Council must cease to carry out this practice immediately. This will be followed up as a separate issue. It was observed that the Councils employment reference does not ask the referee to confirm dates of employment. The Council offer a rolling programme of all mandatory and other training relevant to the job that staff are employed to do. Induction training is provided on commencement of employment. Discussion with the Training Manager of the Council during the additional visited highlighted that each staff member has a personal training and development plan, and that the department monitor staff employed and ensure that all training is undertaken. 76 of staff employed at Luke Senior are trained to NVQ level 2 and above in care. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 17 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, 33 Luke Senior is a well run home the Manager offers a clear sense of direction and leadership. Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents EVIDENCE: The Manager, Sarah Brunton, has worked in social care for many years and has been the Registered Manager of Luke Senior since September 2004. Sarah has achieved a management qualification and is currently working towards achieving an NVQ level 4 in Care. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 18 It is evident from the inspection that Luke Senior is well run. The Manager communicates a clear sense of direction and leadership, which staff and residents understand. Residents and a relative that was spoken to during the inspection spoke extremely highly of the Manager and staff team. One resident spoken to during the inspection said, “The Manager is lovely, and the staff are absolutely marvellous”, a relative said, “I can walk out of the home’s front door and not have a worry”. Appropriate quality assurance monitoring is in place to ensure that the home is run in the best interests of the residents. Residents and relatives meetings are carried out on a regular basis. Standard 38 was not inspected in full, however a requirement highlighted at the last inspection in respect of the Council needing to provide suitable fire training had been addressed. Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 2 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X x Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 20 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 3 Standard OP20 OP20 OP21 Regulation 16, 23 16, 23 13 Requirement The corridors on the first floor must be decorated The corridor carpet on the first floor must be replaced The Manager must ensure that staff in the home environment take and record all bath, shower and sink water temperatures on a regular basis. Any abnormalities must be addressed. The Registered Person must carry out a review of staffing to ensure that there are appropriate numbers of staff on duty • The Council must carry out and be in receipt of appropriate POVA/Criminal Record Bureau Checks for all staff prior to the commencement of employment The Council must carry out appropriate Criminal Timescale for action 30/04/06 30/04/06 22/09/05 4 OP27 13, 18 22/09/05 5 OP29 13 22/09/05 • Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 21 6 OP29 13, 17 7 OP29 17 Record Bureau Checks for all staff that have been employed since July 2004 where the Council have accepted a copy of a Criminal Record Bureau Check that has been carried out by a previous employer. Supervision of such staff must be put in place until a satisfactory check has been received The Council must explore any gaps in employment for staff prior to the commencement of employment • Staff records must contain a recent photograph • Staff files must contain proof of identification 22/09/05 30/12/05 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 5 Refer to Standard OP19 OP20 OP21 OP31 OP29 Good Practice Recommendations The external wood work should be painted The carpet in the lounge designated for those residents who wish to smoke should be replaced Water temperatures in sinks that are accessible to residents should be taken and recorded on a weekly basis The Manager should continue to work towards achieving her NVQ level 4 in care by 2005 The Councils reference request should be developed further to seek confirmation of dates of employment Luke Senior DS0000031344.V256097.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 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.V256097.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!