Inspection on 04/09/07 for St Luke`s Care Home

This inspection was carried out on 4th September 2007.

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 15/09/06

St Luke`s Care Home 15/02/06

St Luke`s Care Home 20/07/05

St Luke`s Care Home 02/03/05

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Hawkhills

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

CARE HOMES FOR OLDER PEOPLE St Luke`s Care Home Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL Lead Inspector Ann Stoner Key Unannounced Inspection 6:00pm 4 September 2007 th 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.V348449.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. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 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 Janet Balmforth 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.V348449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2006. Brief Description of the Service: St Lukes is a modern, purpose built single storey nursing home situated in a residential area 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 have en-suite facilities. People living at the home have a choice of two sitting areas, one of which is a conservatory. One section of the main sitting room is also used for dining. 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. The minimum fee is currently £490 rising to £600 depending on the needs of the person. Additional charges are made for hairdressing, newspapers, selected toiletries or private chiropody treatment. This information was provided to the Commission for Social Care Inspection (CSCI) in September 2007. More up to date information about fees can be obtained from the home. Copies of previous inspection reports are on display in the entrance of the home. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection took place on the 15th September 2006. In February 2007 the Commission for Social Care Inspection (CSCI) received a complaint about evening staffing levels, which resulted in a random visit being carried out during the evening of the 3rd April 2007. During this visit staffing levels were found to be inappropriate and a requirement was made that staffing levels and deployment of staff must be reviewed to make sure that the needs of people were met at all times. This inspection visit was unannounced and was carried out by one inspector who was at the home from 6.30pm – 9.00pm on the 4th September and from 9.30am – 5.30pm on the 5th September 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. Survey forms were sent out to people living at the home, their relatives and health care professionals. Information from returned survey forms is reflected in this report. An AQAA (Annual Quality Assurance Assessment) was completed by the home before the visit to provide additional information. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home and their relatives, as well as with the manager and staff. Feedback at the end of the visit was given to the manager. What the service does well: Staff are kind and patient when working with people. A visitor said that one of the reasons she chose the home on behalf of her mother was because of the attitude of staff. She went on to say that since her mother’s admission she has always found the staff ‘friendly’. One person living at the home described the staff as being ‘lovely’ and said, “You don’t have to tell them if you want anything. They already know.” A minister visiting the home said, “This is a lovely place, the staff seem to genuinely care.” Staff are enthusiastic about training and are able to see how staff training benefits people living at the home. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 6 People are encouraged to visit the home before making any decisions about moving in. One relative said that when she visited she liked the atmosphere, and the fact that the home was bright and airy. Visitors to the home are made welcome, offered refreshments and have the opportunity to join their relative for a meal. What has improved since the last inspection? What they could do better: The home should make sure that information recorded on pre-admission assessments is in enough detail to form the basis of a care plan. This will make sure that the home can meet the person’s needs. Each person living at the home must have a care plan that gives staff clear instructions about how to deliver care. This will make sure that people receive care that meets their individual needs. All staff must receive training in keeping people safe (safeguarding adults). This will make sure that people recognise abuse and that proper procedures are followed when reporting any safeguarding issues. Where money is held for safekeeping on behalf of people living at the home a record must be kept of all transactions. This will minimise any risk of financial abuse. The home must be aware of all health and safety risks that affect people living at the home. This includes making sure that fire doors are not obstructed, that cleaning materials are kept in a locked cupboard when not in use and that toiletries are not left in shower rooms. This will make sure that the health and safety of people living at the home is protected. Written information about the home is not always easy to read and understand for people living there. The home should consider using larger print, pictures and visual prompts such as colour to make sure information is accessable to everyone. Qualified staff should have regular training updates in medication so that their practice is kept up to date. Handwritten entries on medication records should be checked and countersigned by a second person. This will minimise the risk of errors. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 7 Activities should be provided that are based on people’s past and current interests and abilities. This will make sure that they have the opportunity to take part in activities that interest them. People should be offered choice in all aspects of their lives. This will make sure that they are in control of their care. Nutritious foods and snacks should not be locked away during the evening and night time. This will make sure that evening and night staff can offer snacks at any time. There should be signs throughout the home to help people with memory loss find their way around the home. When staff test the fire alarm system they should test a different point each time. This will make sure that all fire points are in good working order. A full list of requirements and recommendations made at this inspection can be found at the end of this report. 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. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 8 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.V348449.R01.S.doc Version 5.2 Page 9 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): Standards 1, 2, 3 & 5. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. People have access to a range of information and have the opportunity to visit before making any decisions about moving in. Some people are disadvantaged because written information about the home is not in a style that is easy for everyone to read and understand. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: There is a wide range of information available in the front entrance of the home so that people, who live there as well as those who are thinking about moving in, are aware of what the home has to offer. Information packs are now given out at the point of admission and include an introductory letter, Statement of Purpose, Service User Guide, residents’ charter, complaint procedure, terms and conditions of business, labelling of clothing, and information about where the most recent inspection report can be found. Most St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 10 of the information in the Statement of Purpose is not in a style that is easy to read and understand. The home should consider using a larger font size, colour, photographs and visual prompts, which may make it easier for people to read. The pre-admission process of one person recently admitted to the home was sampled. Evidence was seen that this person’s relative visited the home on his behalf before any decision regarding admission was made. A contract was in place for this person specifying the weekly fees for his stay at the home. The home had carried out a pre-admission assessment to make sure that his needs could be met at the home but the information recorded was not in sufficient detail. Advice about this was given to the manager. During the inspection visit the relative of another person living at the home said that she had looked round several homes before visiting St Luke’s. She said that she liked the atmosphere and staff attitudes and that it had been a good choice. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9, & 10. People who use the service experience adequate quality outcomes in this area. People’s health care needs are met but the lack of specific instruction and detail in care plans means that some care needs may be overlooked. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The care plans of three people living at the home were sampled. In all three more specific information about the precise action that staff should take is needed. For example one person’s plan said that he had dentures but there was no information about how and when these should be cleaned. This person had a catheter fitted but there was no information about catheter care, precise information about when his catheter bag should be emptied, or how to record when his catheter is changed. He had no plan for shaving, bathing or showering. There was no information in the prevention of falls care plan about how and when bed safety rails should be checked. Another person weighed St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 12 41.7kg and his nutritional risk assessment showed a significant increase in the level of nutritional risk. There was no evidence of dietetic input, and no evidence in his care plan of nourishing snacks been offered or food being supplemented. The care plan for personal hygiene said, ‘catheter care required’, again without any further explanation or instruction. Social and leisure activities are incorporated within communication care plans, but fail to address the precise action staff should take to make sure that people have access and opportunities to leisure facilities based on their past and current interests. Care plans are reviewed and evaluated but important information is not always transferred to care plans. For example, ‘sometimes his facial expressions show how he is feeling’ was recorded in one evaluation of a person’s plan but this was not transferred to the main care plan. Medication is ordered, stored, administered and disposed of properly but training records show that training updates for qualified staff are long overdue. Handwritten entries on Medication Administration Records are not checked and countersigned by a second person. This increases the risk of error. One person holds her own medication. Proper records of this were kept. Surveys returned from GPs show that the home seeks advice and acts upon it to improve people’s health care needs. One relative said that her mother had recently been ill and that she was pleased that staff kept her informed of any changes in her mother’s condition. Staff were able to describe the different ways that they protect people’s privacy and dignity. One relative said that staff are very good at changing people’s clothing if it becomes stained with food after a meal. St Luke`s Care Home DS0000062254.V348449.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): Standards 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area. People are offered a nutritious diet and their visitors are made welcome. Some staff routines result in the choices of some people living at the home being restricted. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Staff spoke about offering people rights and choices, but in discussions with people living at the home and from speaking to staff it is clear that some rights and choices for people are restricted. Staff spoke about task centred routines and said that some people are assisted to bed straight after the evening meal at 5pm. At 7pm on the first day of this visit seventeen people were in bed and 6 were sitting in a chair in their bedroom. Staff said that choice is given to the more independent people, but those needing assistance to eat breakfast are woken up at 7am. People living at the home confirmed this, but one person went on to say, “I like it here, the staff St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 14 are lovely you don’t have to tell them if you need anything, they already know.” Staff said that they consult a bathing rota that specifies the days on which people have a bath, but said that there is a degree of choice as people can refuse or change their bath day. There was an activity programme displayed in the home, but during the evening and morning of this visit there was little recreation and leisure or interaction between staff and people sitting in the lounge, other than at times when care was being delivered. One person said that she was bored because there was not enough to do to keep her occupied. Two visitors said that there was very little stimulation for people as staff were always busy, and didn’t have time to spend with people. One relative spoke highly of the home and described how a private celebratory meal had been arranged to celebrate her parents wedding anniversary. All visitors said that they were always made welcome and had the opportunity to stay for a meal. A visiting minister was offered coffee during his visit to one person, and said, “This is a lovely place, staff seem to genuinely care.” Menus show that people have a varied and nutritious diet and people are encouraged to make a choice from the menu. Food cupboards, fridges and freezers were well stocked but because these are locked when the catering staff are not working, food such as yoghurts, cheese and other nutritious snacks are not available during the evening and night. The manager agreed to address this. A number of recommendations were made following a recent environmental health visit but most of these have been addressed. The lunchtime meal was observed on the second day of this visit. Equipment was provided to encourage people to be as independent as possible and where staff assistance was needed, this was given in a discreet way. St Luke`s Care Home DS0000062254.V348449.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): Standards 16 & 18. People who use the service experience adequate quality outcomes in this area. Complaints are dealt with properly but information about making a complaint is not always suitable and accessible to people living at the home. This means that some people do not know how to make a complaint. Overall people are protected from abuse. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: Records in the home shows that there have been 9 complaints in the last twelve months. All have been taken seriously, properly investigated and well recorded by the manager or the organisation. A copy of the complaints procedure is made available to people at the point of admission and there is a copy in the front entrance of the home. In returned survey forms completed by people living at the home the following comments were made: • • Nobody has told me who to speak to if I am unhappy Never been told who to contact to make a complaint St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 16 When asked if staff listen and act on what they have to say five people who returned surveys said ‘Yes’ and two said ‘No’. Written information for people about how to make a complaint should be revised to make sure that it is easy to read and understand. Not all staff have had training in adult abuse or keeping people safe (safeguarding adults). Care staff were aware of the different types of abuse and said that they would report any suspicions or allegations of abuse. Domestic staff were less sure and have had no training. The home does not have a copy of the local safeguarding procedures, which means that senior staff may not report any safeguarding issues properly. The manager and a qualified nurse are due to attend safeguarding adults training soon. St Luke`s Care Home DS0000062254.V348449.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): Standards 19 & 26. People who use the service experience adequate quality outcomes in this area. Lack of proper storage facilities poses some health and safety risks to people and means that some areas of the home are cluttered or inaccessible. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: When looking round the building a number of areas of concern were seen. A hoist and lounge chair restricted access to a fire door at the end of one corridor. The entrance to one toilet is used as a storage area for cleaning materials, all of which were accessible to people living at the home and constitute a health and safety hazard. Bumpers for bed safety rails were also stored in this area posing a risk of cross infection. The home lacks adequate storage space. There are two bathrooms, both of which are used to store portable screens, pressure cushions, wheelchairs, zimmer frames and a free St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 18 standing hairdryer. A member of staff said that these items would be removed if someone needed a bath, but couldn’t answer when asked where they would go. Cleaning rags were left over towel rails in toilets. A member of the domestic team said that toilets and sinks are cleaned with the same coloured cloth. This creates the risk of cross infection. The annual quality assurance assessment states that there are 13 people living at the home who have dementia. There are no signs throughout the home to orientate people with memory loss. Toiletries were seen on shelves in both shower rooms. This creates the potential for communal use and cross infection. A recent environmental health report made a number of recommendations relating to the kitchen, many of which have now been addressed. Maintenance staff test fire alarms weekly, but the same activation point is used each time. One person said this was because the ‘break glass’ points could not be accessed. This is something that must be addressed. The home was clean and there were no offensive odours. Bedrooms were personalised, and a conservatory leads to attractive gardens with a water feature. Although staff have had no training on infection control they were able to describe the measures they take to prevent the spread of infection in the home. These include using hand washing gel, aprons, gloves and water dispersible bags for laundering soiled linen. St Luke`s Care Home DS0000062254.V348449.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): Standards 27, 28, 29 & 30. People who use the service experience poor quality outcomes in this area. Staffing levels and deployment of staff do not always meet the needs of the people living at the home. This means that some people’s choices are restricted. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: As a result of a complaint about evening staffing levels a random visit was carried out during the evening of the 3rd April 2007. During this visit staffing levels were found to be insufficient and a requirement was made that staffing levels and deployment of staff must be reviewed to make sure that the needs of people were met at all times. The annual quality assurance assessment (AQAA) completed by the manager before this inspection states that evening staffing levels have been revised. During the evening of the first day of this inspection visit there was one nurse and four care staff on duty. These staffing levels were unchanged from the random visit carried out in April 2007. When asked about evening staffing levels one carer said it was all right but when something outside of the normal routine happens it can be ‘manic’. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 20 Comments in returned survey forms completed by people living at the home before this key inspection visit include the following: • • • Sometimes short of staff Nobody is available at weekends for cleaning Staff take too long to come and help me. During this inspection relatives said that staffing levels did increase for a short time but this didn’t last long and that people in the main lounge are left unattended. One person living at the home said, “There are too many people living here to do justice to everyone. The staff are very good but I have waited for an hour during the night for someone to answer the buzzer.” Another person said, “There are a lot of heavy (dependent) patients and not enough staff because there is always someone off sick.” Other relatives said that staff were always busy and didn’t have time to spend with people. The manager said that continued long-term sickness was affecting staffing levels. A regulation 26 visit report completed by the home’s operations manager in June 2007 shows that staff said that people living in the home were highly dependent. The organisation agreed to monitor skill mix and staffing levels. The AQAA shows that there are 7 people living at the home who are bedfast, 10 who are incontinent of urine and faeces, 13 who have dementia and 19 who require 2 people to assist with their care during the day and at night. During the morning of the 2nd day of this visit there were seven care staff, two nurses and the registered manager on duty. However, people in the lounge were left unsupervised for most of the time. One person who is at high risk of falling got out of her chair and walked out of the room without staff noticing. Another person needed some urgent assistance but there was nobody about. One person was not assisted to wash and dress until lunch was being served and as a result was too late to have her hair washed and set by the hairdresser. This person said that she has never liked staying in bed, and her relative said that she was always up at 7.45 when she lived at home. A relative of another person living at the home said that sometimes his/her relative is not assisted out of bed until 11.45am because staff are not available. This shows that people’s needs are not being met. The recruitment records of two people were sampled and found to be in order. Staff complete an induction programme based on the Skills for Care common induction standards. Training records show dates of mandatory training such as moving and handling. All staff receive fire training at regular intervals and 13 staff have completed a dementia awareness course. Not all staff have completed training in infection control or safeguarding adults. Training updates for qualified staff St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 21 in medication administration are long overdue. The manager is looking at ways to address this. Staff were enthusiastic about training and one person said that she often pays her own course fees. 75 of care staff have completed a National Vocational Qualification (NVQ) at level 2 or above. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 37 & 38. People who use the service experience adequate quality outcomes in this area. The lack of proper storage space means that people’s health and safety is compromised at times. The lack of financial records creates the potential for abuse. We have made this judgment using a range of evidence, including a visit to the service. EVIDENCE: The registered manager is a first level nurse and although she has recently been promoted to this post she has worked at the home for many years. She is currently working towards the Registered Manager’s Award and is supporting other senior staff to take more responsibility by delegating tasks. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 23 There are systems in place so that the home can obtain the views and opinions of other people. Relatives’ meetings are held twice a year and staff meetings are held every 6 weeks. Surveys are circulated by head office to people living at the home and their relatives annually. Feedback from these are analysed and are then passed to the manager to help her plan future developments. It is recommended that the distribution of the surveys be extended to include other health care professionals. The home holds small amounts of money for safekeeping for some people but proper records of all transactions are not always kept. The manager agreed to rectify this. Information supplied in the AQAA shows that maintenance and servicing of equipment takes place as required. Health & safety audits take place but records of accidents not witnessed bys staff do not always show when the person was last seen and by whom. Accidents are not analysed on a monthly basis to show any patterns or trends. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X 2 3 St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) Requirement People living at the home must have a detailed care plan that gives staff clear instructions on how to deliver care. This will make sure that people receive care that meets their individual needs. All staff must receive training in safeguarding adults. This will make sure that people recognise abuse and that the proper procedures are followed when reporting safeguarding issues. Fire doors must not be obstructed. This will make sure that people are able to leave the building quickly in the event of a fire. Bathrooms and toilets must not be used for storing equipment. This will minimise any health & safety hazards. When not in use cleaning materials must be kept in a DS0000062254.V348449.R01.S.doc Timescale for action 31/12/07 2 OP18 13 (6) 31/12/07 3 OP19 23 (4) (b) 06/09/07 4 OP19 13 (4) (a) 01/10/07 5 OP19 13 06/09/07 St Luke`s Care Home Version 5.2 Page 26 locked cupboard. Toiletries must not be left in shower rooms. This will minimise the risk of misuse or accidents. Staffing levels and deployment of staff must be reviewed to make sure that there are sufficient numbers of staff on duty at all times. This will make sure that people’s needs are met. Previous timescale of 15/5/07 is unmet. Where money is held for safekeeping on behalf of a person living at the home a record must be kept of all transactions. This will minimise the risk of financial abuse. 6 OP27 18 (1) 01/10/07 7 OP35 17 (2) Schedule 4 06/09/07 St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations The Statement of Purpose should be in a format suited to the needs of people living at the home. This will make sure that people have information that is easy to read and understand. Pre-admission assessments completed by the home should have enough information to form the basis of a care plan. This will make sure that the home can meet the person’s needs. Qualified staff should have regular medication training updates. This will make sure that their practice remains current and up to date. Handwritten entries on Medication Administration Records should be checked and countersigned by a second person. This will minimise the risk of errors. Activities should be provided that are based on people’s past and current interests and abilities. This will make sure that people have the opportunity to take part in interesting and stimulating leisure activities. Care tasks should be person-centred and people should be offered choice in all aspects of their lives. This will make sure that people are in control of how their care is delivered. Nutritious foods and snacks should be available to people at all times of the day and night. This will make sure that evening and night staff can offer food and snacks on request. The format of the complaints policy and procedure should be amended so that it meets the needs of people living in the home. This will make sure that people have information on how to make a complaint that they can read and understand. St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 28 2 OP3 3 OP9 4 OP12 5 OP14 6 OP15 7 OP16 8 OP19 A different fire activation point should be tested each week as part of the home’s weekly fire alarm test. This will make sure that all fire points are in good working order. There should be signs throughout the home indicating different areas. This will make sure that people with memory loss are able to find their way about the home. The distribution of the home’s quality assurance system should be extended to include health care professionals. This will make sure that home seeks the views and opinions of all interested parties. The manager should analyse all accident and incident reports on a monthly basis. When a person living at the home has an accident that is not witnessed by staff a record should be made of when the person was last seen and by whom. This will make sure that any patterns or trends are identified. 9 OP19 10 OP33 11 OP38 St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Luke`s Care Home DS0000062254.V348449.R01.S.doc Version 5.2 Page 30 - 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. 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