CARE HOMES FOR OLDER PEOPLE
St Luke`s Care Home Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL Lead Inspector
Sean Cassidy Unannounced Inspection 15th February 2006 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 St Luke`s Care Home DS0000062254.V282308.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. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service St Luke`s Care Home Address Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL 0113 2563547 0113 2560275 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) Eldercare (Halifax) Ltd Mrs Sharon Patricia Dixon Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (4), Physical disability of places over 65 years of age (34), Terminally ill (4), Terminally ill over 65 years of age (4) St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: St Lukes is a modern, purpose built nursing home situated in a residential area of the village of Calverley, the home is within walking distance of a major road to both Bradford and Leeds, and local bus routes. Accommodation is provided in a combination of twenty-two single and six double rooms, all of the single rooms having en-suite facilities. Service users have a choice of two sitting areas one of which is for the use of smokers. The main sitting room is also used for dining, or service users can take their meals in their own rooms. There is a car park to the front of the building, and there is level access to very attractive gardens at the rear of the home. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector and lasted a full day. The purpose of the inspection was to make sure the home was operating and being managed to a satisfactory standard. The inspector spoke to several service users and members of staff. A number of documents were examined which included care plans, policies, procedures and other records. What the service does well: What has improved since the last inspection?
Major improvements have been made environmentally within the home. The corridor which goes throughout the whole home has been tastefully re decorated to a good standard. The conservatory has also undergone a refurbishment and has also been made warmer so that residents are more comfortable. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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. St Luke`s Care Home DS0000062254.V282308.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 St Luke`s Care Home DS0000062254.V282308.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): 3,4 All residents have their needs assessed prior to a place being offered. The residents and relatives spoken to were confident the staff group were able to meet their needs. But, specialist training needs to be provided to staff to enable them meet the specialist care needs of those residents with Dementia. EVIDENCE: Care files examined showed evidence that the home ensures all prospective service users are assessed prior to moving in. Prospective residents and their families are provided with an opportunity to visit the home before making a choice about taking a room. Residents and relatives spoken to over the course of the inspection stated that they felt the care staff were competent in their roles and appeared to have a good understanding of the care needs they were providing for. The home
St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 9 provides specialist care for residents with Physical Disabilities and Terminal Illness. A number of residents living in the home also have dementia. I was unable to identify from the care plans, the environment and the training records that residents’ specialist dementia care needs are being provided for and met. This is an area care staff need specific training to ensure they are providing a “Person Centred Care Approach” to this specialist group. Staff spoken to said they had not received specialist training in this area. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 The home is not ensuring all the identified care needs of all residents are being met. Care plans and risk assessments are not consistently provided and there is little evidence to show the home has consulted with residents or their relatives when developing care plans. Although the home does enable residents to self medicate they are not following their own policy to ensure residents are properly protected. EVIDENCE: The home has developed a new assessment and care planning system. This is in the process of being implemented to all new and existing residents. A random sample of care plans were examined to ensure residents were receiving the correct care. The care files contained evidence to show not all assessed care needs had a plan of care or risk assessment in place. One resident admitted two days previous had no care plans or risk assessments written even though it was clear he had many care needs and was at risk in a number of areas such as pressure sore development and falls. This omission places this resident at risk of harm. Residents identified as having high needs in areas such as continence, eating and drinking, pressure area care and
St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 11 hygiene had no care plans in place. Not all care plans and risk assessments were reviewed regularly and changes were not always added when needed. The care plans examined did not show evidence that the pressure area needs of those residents at high risk are being met. They did not highlight how often residents should be turned whilst in bed and there was no evidence to show that this happened. Two residents identified as having difficulties with drinking fluids had no evidence in their care plans to show care staff were assisting with this need. The inspector recommended that a dietician and a tissue viability nurse be involved with the care of one resident. One resident with pressure sores had not had a Waterlow risk assessment carried out for two months. The manager agreed this risk assessment carried out was not correct and did not reflect the high care need of that resident. The care plans written for the resident’s pressure wounds did not include the correct information to ensure the correct care could be given. The care plans and risk assessments examined showed inconsistency with the involvement of residents or their relatives developing or agreeing to them. Evidence was found to show that the home is not following its own policy with regards enabling residents to self medicate. One resident who is self medicating has not been appropriately risk assessed to ensure they are able to do so. This omission placed that resident at risk of possible harm. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 The home is aware of and provides for the leisure and recreational need of the residents living at the home. However, it could do more to ensure the needs of those with dementia are being provided for and met. EVIDENCE: The relatives and relatives spoken to said they felt the home offered a wide range of activities and events that were flexible and varied. A valentine’s event had been provided the day before the inspection and this was thoroughly enjoyed by those spoken to. The care assessments contained information regarding the interests and hobbies of the service users and an activities coordinator tries to provide activities which they will be interested in. Records are kept to show evidence of resident involvement. The activities co coordinator has attended a course to assist her in her role but feels that this did not provide her with the necessary skills to ensure she can fulfil the role properly. The home displayed a list of planned activities for the week. The care coordinator acknowledged that the planned activities are not always provided, as the care demand of residents with high level needs does not make this possible. She agreed that those residents with dementia could benefit more from activities that are solely structured around this specialist need. More evidence is needed to show the residents with dementia are provided with recreational and leisure activities suitable to their needs.
St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 13 The residents and relatives spoken to expressed they were happy with the community contact they have when living in the home. The visiting times are very open and flexible and relatives said they are made to feel welcome at all times. The home enables service users to bring in their own possessions whenever possible. It was evident that the vast majority of the residents take the opportunity to take in their personal possessions when they move in. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this visit. EVIDENCE: St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this visit. EVIDENCE: St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 16 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): 30 The home assists staff to be competent whilst working within their roles. EVIDENCE: The staff spoken to said they were happy with the standard of training provided by the home. Over 50 of the care staff are now trained to NVQ Level 2 and 3 standard. New staff spoken to said that they did receive a robust and helpful induction at the beginning of their employment. Regular training is provided to care staff throughout the year and this was evidenced from the yearly training programme. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 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): 33,38 The home has systems in place that ensures the quality of the care in most areas is maintained. However, the absence of regular care plan and risk assessment audits means residents are placed at risk of possible harm. EVIDENCE: The manager monitors the quality of care provided within the home and uses a number of different tools to assist this process. These include: resident/ relative/ staff questionnaires, complaints monitoring and accident monitoring. Resident meetings are held and a regular newsletter is published to keep residents and relatives up to date with any changes within the care home. The information gathered from the manager’s audits is correlated and displayed. Residents are not benefiting from the existing managerial audit of the care file documentation as a number of omissions were found during this inspection. These omissions place residents at potential risk of harm.
St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 18 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 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 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 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 3 St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 19 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 12,18 Requirement The registered person must ensure the care home is able to meet the specialist needs of the residents. The residents care plans must set out in detail the action which carers need to take to ensure all care needs are met. (The previous timescale of 31/10/05 was not met) The registered person must ensure the care plans are reviewed at least monthly and that they reflect any changes in care provision. The residents care plan must be drawn up with the involvement of the resident or their representatives. (The previous timescale of 31/10/05 was not met) The registered person must promote and make proper provision for the health and welfare of residents. This refers to the absence of planned care in areas such as continence, pressure area care, pressure sore treatment, nutrition and
DS0000062254.V282308.R01.S.doc Timescale for action 30/04/06 2. OP7 15 31/03/06 3. OP7 15 28/02/06 4. OP7 15 31/03/06 5. OP8 17,12,13 28/02/06 St Luke`s Care Home Version 5.1 Page 20 6. OP8 13 7. OP8 13 8. OP9 12 mental health. The registered person must ensure other health care professionals are involved with the care of a resident when needed. This refers to the resident needing a referral to a dietician and tissue viability nurse. The registered person must ensure that any risks to the health and safety of the resident are identified and where possible eliminated. This refers to the absence of risk assessments being carried out on a new resident. The registered must ensure residents are enabled to take responsibility for their own medication within a risk management framework. (The previous timescale of 31/10/05 was not met) 31/03/06 31/03/06 31/03/06 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 OP12 Good Practice Recommendations The registered person should ensure that those residents with specialist dementia care needs are provided with suitable leisure and social activities. St Luke`s Care Home DS0000062254.V282308.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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