Inspection on 15/11/05 for St Luke`s Hospital

This inspection was carried out on 15th November 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 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

St Luke`s Hospital 08/01/07

St Luke`s Hospital 26/07/05

St Luke`s Hospital 29/03/05

St Luke`s Hospital 21/09/04

St Luke`s Hospital 02/03/04

St Luke`s Hospital 08/10/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE St Luke`s Hospital 4 Latimer Road Headington Oxford Oxfordshire OX3 7PF Lead Inspector Kate Harrison Announced Inspection 15th November 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 St Luke`s Hospital DS0000027171.V256182.R02.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. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Luke`s Hospital Address 4 Latimer Road Headington Oxford Oxfordshire OX3 7PF 01865 228800 01865 228899 admin@stlukeshosp.co.uk www.stlukeshosp.co.uk St Luke`s, Oxford 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) Zannifer Mason Care Home 51 Category(ies) of Dementia (51), Old age, not falling within any registration, with number other category (51), Physical disability (7), of places Physical disability over 65 years of age (51), Terminally ill (3), Terminally ill over 65 years of age (3) St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of people to be cared for, at any one time, must not exceed 51 Older people may be admitted from the age of 60 years Up to 7 people with physical disabilities may be cared for, at any one time, aged between 18 and 65 years on admission Up to 3 people may be admitted for terminal care, at any one time, aged 40 years and over 26/07/05 Date of last inspection Brief Description of the Service: St Luke’s Hospital is a care home with nursing, and is managed by a non-profit making Christian charitable trust. The home is situated in a residential area of Oxford, close to the city’s hospitals, shops and recreational facilities. Accommodation is arranged over three floors, with some accommodation on the ground floor used by consultants and their clients. All the private accommodation is in single rooms, with direct line telephones and television, and 47 rooms have en-suite facilities. The matron (registered manager) and her team of care staff and nurses care for the residents, and the general manager (responsible individual) is responsible for the general running of the home. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This CSCI announced inspection took place over one day when the inspector saw several areas of the home, met with residents and staff and discussed the running of the home with the registered manager and the responsible individual. The CSCI pre-inspection questionnaire had been completed and returned to the inspector, with supporting documentation. The inspector also received completed comment cards from residents, relatives and health and social care professionals regarding their experience of life in the home. This was the second inspection of the service this inspection year, and the inspector looked at the key standards not assessed at the unannounced inspection on 26th July 2005 What the service does well: What has improved since the last inspection? Staff training has included palliative care and visual awareness. The complaints procedure has been updated. Updating of the environment has continued. St Luke`s Hospital DS0000027171.V256182.R02.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. St Luke`s Hospital DS0000027171.V256182.R02.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 St Luke`s Hospital DS0000027171.V256182.R02.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): Standard 3 was assessed at the last inspection in July 2005, and Standard 6 does not apply to St Luke’s. EVIDENCE: Not assessed. St Luke`s Hospital DS0000027171.V256182.R02.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 and 10. Medication is well managed and the recording system has now been improved to make sure that all medication received into the home has been recorded. Residents are treated with respect. EVIDENCE: The inspector checked the medication system and was satisfied that the storage, administration and disposal of medication is well managed. The inspector could find no evidence that the reception of medication into St Luke’s is recorded. Medication is ordered monthly and the pharmacy supplies a monthly medicine administration record (MAR) for staff to complete. As the medication is delivered in weekly amounts, staff do not sign the MAR as it would signify the reception of the monthly supply. The inspector understood from discussion with staff that the reception into the home of medication was not recorded, although a delivery note is signed. All medication received into the home must be recorded and, following the inspection, matron informed the inspector that a record of the receipt of medication has now been introduced. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 10 Staff are instructed on residents’ rights at induction. Residents told the inspector that they feel respected, and information from the comment cards confirms that residents’ privacy is respected. St Luke`s Hospital DS0000027171.V256182.R02.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): 12, 13, 14 and 15. Residents enjoy the lifestyle, including the food, at St Luke’s and can keep control of their lives for as long as possible. The quality of the food is to be commended, as is the range of group and individual activities provided. EVIDENCE: All the residents who completed comment cards said that they liked living at St Luke’s, as did the residents the inspector saw on inspection day. Residents are able to be as independent as possible, and can continue to manage their own financial affairs for as long as possible. There are two part-time recreational therapists and a programme of events is discussed with residents and published monthly. One recreational therapist told the inspector that she knows the individual interests and hobbies of the long-term residents through life story work and individual discussion, and works to make sure that individual as well as group activities are available. The matron also sees residents regularly. Visitors can come at any reasonable time. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 12 The chef discusses food preferences with new residents and has contact with the community dietician for advice on diets if necessary. The inspector saw the menus showing several choices including fresh vegetables, fruit and salad. Good quality food and drink is supplied, and residents told the inspector that the food is very good. The chef keeps up to date with training and promotes training for new staff in the kitchen. Information from the comment cards regarding individual preferences was discussed. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 13 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): Standards 16 and 18 were assessed at the last inspection in July 2005. EVIDENCE: Not assessed. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 14 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): Standards 19 and 26 were assessed at the last inspection in July 2005. EVIDENCE: Not assessed. St Luke`s Hospital DS0000027171.V256182.R02.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): 30 Staff are trained and competent to do their jobs, and a structured induction programme is being developed. EVIDENCE: The home has an informal induction programme for new staff, and matron is developing a structured induction programme. New staff are supervised by a mentor and meet with matron after their first week to discuss any issues arising. Mandatory training is provided, and the inspector is awaiting clarification on the topic of first aid training for staff. NVQ training is in place and St Luke’s now has two NVQ assessors. Matron has a keen interest in training and seeks out training opportunities for care staff to meet the needs of the residents. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 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 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, 37 and 38 This is generally a well managed home although the inspector identified some issues for improvement. Good quality assurance systems are in place, but residents should receive feedback from their contribution to the satisfaction questionaire. Monthly quality assurance reports required by regulation are not being submitted to CSCI. First aid provision for residents needs clarification. EVIDENCE: The home has quality assurance systems working at formal and informal levels, including management meetings, discussions with residents and staff and the home’s policies and procedures. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 17 The inspector saw the home’s quality assurance programme and, on the day of inspection, saw figures from a recent service user satisfaction questionnaire. The figures showed that the level of satisfaction was high, especially with the nursing care. This information is not currently formally shared with residents and the inspector recommends that residents be informed regularly of the outcomes of the questionnaires. The inspector has not received copies of reports resulting from monthly unannounced visits by a representative of the Council of St Luke’s as required by the Care Standards Act 2000. This was discussed with the general manager who is also the responsible person for the home, who is of the view that the reports are not needed. This does not meet the requirements of the regulation and a statutory requirement to supply copies of the reports to the Commission is therefore being made. There is a need for clarification in relation to provision of first aid for residents. While nurses are able to provide first aid, they may only do so if they consider themselves competent to do so. The registered manager should develop a system so that it is clear who amongst the staff are qualified in first aid. St Luke’s has a written policy on safe working practices and the inspector saw evidence that appropriate risk assessments are carried out. The inspector discussed safety topics with the appropriate persons and was satisfied that fire safety and equipment maintenance is appropriately monitored. St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 2 St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 19 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 Standard OP37 Regulation 26 Requirement Copies of the monthly visit reports in accordance with Regulation 26 must be sent to the Commission. Timescale for action 31/12/05 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 Refer to Standard OP38 Good Practice Recommendations The registered manager should provide evidence that appropriate numbers of nurses who consider themselves competent in first aid are available to residents on each shift. Residents’ feedback from the quality assurance process should be shared with them so that they are included in the whole process. 2 OP33 St Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Luke`s Hospital DS0000027171.V256182.R02.S.doc Version 5.0 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. 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