Inspection on 20/07/05 for St Luke`s Care Home

This inspection was carried out on 20th July 2005.

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.

Other inspections for this house

St Luke`s Care Home 04/09/07

St Luke`s Care Home 15/09/06

St Luke`s Care Home 15/02/06

St Luke`s Care Home 02/03/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE St Lukes Upper Carr Lane Calverley Leeds LS28 5PL Lead Inspector Sean Cassidy Announced 20 July 2005 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 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 Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Lukes Address Upper Carr Lane Calverley Leeds LS28 5PL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2563547 0113 2560275 Eldercare (Halifax) Ltd Mrs Sharon Dixon Care home with nursing 34 Category(ies) of Old age (34) Physical disability (4) Physical dis registration, with number over 65 (34) Terminally ill (4)Terminally ill of places Elderly (4) St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 2 March 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 Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced 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 inspectors spoke to several service users and members of staff. A number of documents were examined which included care plans and other records. What the service does well: What has improved since the last inspection? The gardens and the interior decoration have undergone improvements Residents are now more protected by the implementation of a strict recruitment procedure. Staff training has improved and the home now has a staff group with more than 50 trained to NVQ level 2 and above. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,5. The homes systems for ensuring the residents are fully informed about choosing to move into the home are good. EVIDENCE: The service user files inspected showed that service users are assessed prior to moving into the home. The homes Statement of Purpose and Service User Guide are up to date and contain the relevant information. But, residents spoken to were unfamiliar with these documents and were unsure whether they had ever seen them. Opportunities are given to prospective residents and their relatives to visit the home and assess the facilities prior to making their decision to move in. This was confirmed by a number of residents who had taken this opportunity. Contracts and Terms of Conditions are provided to all new service users entering the home. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 standard(s) 7,9,10 Although all residents have written care plans in place they did not reflect all their care needs. The home has a policy that is committed to ensuring the residents are able to self medicate if they wish but this does not always happen and when it does the correct procedure is not followed. Residents feel assured that their privacy and dignity is respected. EVIDENCE: All residents have care files that contain information which assists staff to provide for their care needs. Those residents that were able to converse stated that they felt their care needs were being met. But they were unfamiliar with care plans and said they did not get involved with these. This was evidenced in the files. The residents’ plans are in place and it was noted that many are pre written which can leave them very impersonal. They are reviewed by staff on a monthly basis. The information contained within the care plans was not always clear and the words used were confusing. Examples of this are, “Implement interventions that are consistent across the care team.” “Use positive posture and approach.” Some staff were unclear as to what these meant. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 10 The plans inspected showed that many care needs were being met but many were not. One resident file seen showed that the persons care needs had changed and that they were now totally dependent on staff. The care plans written for this resident did not reflect the care needs of a person that was totally dependent. The manager agreed this when it was highlighted. The home now has a medication policy in place, which states that residents must be assessed appropriately if they are to self medicate and that they must sign a document that they agree to look after their own medications. One resident self medicates in the home but the procedure has not been followed. Another resident stated that she would like to self medicate and feels capable of this but it has never been discussed with her. Residents praised staff very highly during the inspection. They were observed to interact very well with the residents. All residents spoken to during the inspection said that their privacy and dignity was respected. This was further evidenced in the correspondence we received prior to the inspection. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 standard(s) 15 Mealtimes are a social event and the quality of the food is of a good standard. EVIDENCE: Residents’ mealtime was observed as a social event. Alcoholic beverages were provided prior to the lunchtime meal. Residents said that this was not usual practice although they did enjoy it. Staff were very interactive with the residents who appeared to appreciate this. Residents said that the staff always interacted well and that they enjoyed their mealtimes. Residents unable to feed themselves were assisted by staff in an unhurried manner. The meal appeared appetising and appealing. Residents said that the food served within the home was of a good quality and they regularly received fresh fruit. The cook keeps a record of the food provided. There were gaps when the cook was not on duty which could cause problems for environmental health if they had to investigate an incident. Food temperatures are recorded as are cleaning rotas. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 standard(s) 16,18. There is a good complaint procedure in place. The home has attempted to minimise the risk of abuse by ensuring a good Adult protection policy and procedure is in place, as well as staff training. EVIDENCE: The home does have a complaints procedure. On the day of the inspection this was not displayed due to redecoration. Residents said they were aware of how and who to complain to if they needed to. This was further evidenced from the feed back forms received prior to the inspection. Records of complaints made to the home were kept and these were dealt with appropriately. A new Adult protection policy and procedure has been developed. Staff are undergoing training in Adult Abuse. Residents were very happy with the way in which staff spoke to and treated them. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 standard(s) 19,23,29. The environment of the home is well maintained and there is a programme in place for improving and maintaining the environment. There are difficulties with storing equipment and access for wheelchair users. The home is kept clean and tidy. EVIDENCE: The garden facilities provided by the home are of a good standard and staff assist residents to use the garden whenever they are able. Residents confirmed this. The home is undergoing a period of redecoration. A new maintenance person has been employed and he ensures all the appropriate equipment and facility checks take place. But Portable Appliance Testing has not been appropriately carried out. Residents spoken to expressed that they are very satisfied with the home environment and layout. They said that it was very homely and they would not wish to live anywhere else. The majority of the rooms were very personalised St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 14 and residents said that they were able to take in their own possessions if they wished Although the home is suitable for its purpose they do have difficulty with storing equipment. One Bathroom was used as a storage facility for wheelchairs and Zimmer frames as there was nowhere else for them to be stored. Equipment, such as hoists, is also kept around the passageways. These issues pose potential risks of injury to residents. There are a number of wheelchair users living in the home and they expressed difficulties with the narrowness of the doorways and the space they had available in their rooms. But this was not a major issue for them as they felt the positives of the home outweighed these issues. The home was clean and tidy. Residents spoken to praised the domestic staff as they felt they worked very hard to maintain the cleanliness of the home. Some carpets and furnishings are in need of upgrading, as they are very worn in places. One resident asked if it was possible to get her room redecorated, as it did not suit her taste. This was passed on to the manager who said that she would look into it. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29. Good staffing levels are maintained by the home and prospective employees are put through a strict recruitment procedure before they can commence work. EVIDENCE: The numbers of staff on duty at the time of the inspection appeared suitable for the needs of the residents. No one appeared hurried or rushed and they interacted very well with the residents. Residents spoken to said that these were the usual numbers on duty. The home has met the target of ensuring 50 of staff are trained to a NVQ level 2 standard and above. The home should be commended for its recruitment procedure as the evidence seen showed that they ensure all the correct information is obtained on all new workers before they can commence work. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35. The home is managed well and provides an open and inclusive atmosphere, which is enjoyed by all those spoken to. Residents’ financial interests are protected by the systems put in place. EVIDENCE: The manager and the staff team work hard in their attempt to ensure the quality of care provided within the home is of a good standard. She has attained the necessary qualifications needed to assist her managerial role within the home. Residents spoken to were fully aware of who the home manager was and they spoke highly of her. Regular team meetings, resident meetings and staff supervision are held which was found to be very beneficial by all groups involved. There is a clear management approach adopted and feedback from all parties showed there is an open and inclusive atmosphere in the home. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 17 A new system is now in place, which ensures residents’ monies are handled appropriately. Appropriate records are and receipts are kept for all money transactions made on behalf of the residents. St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 3 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 3 x x 3 x x x St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 19 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 7 Regulation 15 Requirement The residents care plans must set out in detail the action which carers need to take to ensure all care needs are met. The residents care plan must be drawn up with the involvement of the resident or their representatives. The registered must ensure residents are enabled to take responsibility for their own medication within a risk management framework. All portable electrical facilities should be checked regularly by persons trained to do so. Timescale for action 31 Oct 2005 31 Oct 2005 31 Oct 2005 2. 7 15 3. 9 12 4. 22 12 31 Oct 2005 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 Good Practice Recommendations St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 St Lukes J52 S62254 St Lukes V223635 200705 Stage 4.doc Version 1.30 Page 21 - 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!