Inspection on 26/07/05 for St Luke`s Hospital

This inspection was carried out on 26th 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 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 15/11/05

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 LUKES CARE HOME WITH NURSING 4 Latimer Road Headington Oxford OX3 7PF Lead Inspector Kate Harrison Unannounced 26 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 CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service ST LUKES HOSPITAL Address 4 Latimer Road, Headington, Oxford OX3 7PF 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) 01865 228800 01865 228899 St Lukes, Oxford Mrs Zannifer Mason Care Home with nursing 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 LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 Date of last inspection 21 September 2004 Brief Description of the Service: St Lukes Hospital is a registered care home with nursing and not a hospital in the traditional meaning of the word. The home is managed by a non-profit making Christian charitable trust and is situated in a residential area of Oxford, close to the citys NHS hospitals, shops and recreational facilities. Accommodation is arranged over three floors, with some facilities on the ground floor being used by consultants and their clients. All the rooms are single and 47 have en-suite facilities, with direct line telephones and colour televisions. The homes responsible individual is based at the home, and care is managed by the matron and her team of nursing and care staff. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over mid morning and early afternoon and was conducted by two inspectors. The inspectors saw all areas of the home, met with residents, staff and a visitor and had discussions with the managers. Records and documentation were also seen. Not all the key standards were assessed at this inspection, and those not assessed will be assessed at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: The policy and procedure regarding the protection of vulnerable adults needs to be amended to show that St Luke’s staff are expected to be familiar with the Oxfordshire Codes of Practice for the Protection of All Vulnerable Adults from Abuse, Exploitation and Mistreatment and are expected to work according to the codes. The complaints procedure for residents could be improved by presenting it on a separate document. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 6 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 CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 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 CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 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) 2 and 3. Contract arrangements are well managed, and care needs assessments are thorough. EVIDENCE: The inspector checked the contract arrangements for one short stay resident and found that all the appropriate documentation was in place. The registered manager (Matron) usually visits the prospective resident at home or elsewhere to assess the individual care needs, but sometimes, when the individual lives too far away, all the relevant information is collected by phone or by fax and a decision is made about a trial stay. The care needs assessments for long and short stay residents are detailed and complete. Care plans are developed for each new resident based on the assessments, and staff sign and date all the appropriate records. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 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 and 8. All residents have appropriate care plans, and good arrangements are in place to make sure that the needs are met. EVIDENCE: The inspector saw detailed care plans, setting out the health and personal care needs of individuals. The individuals are encouraged to contribute to the process, and needs are reviewed regularly. The daily accountability audit of care is a good tool to monitor the delivery of care. The emotional and psychological responses of residents are monitored through the daily record and appropriate referrals to other health care professionals are made when necessary. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 10 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) X None of these standards were assessed at this inspection and all will be assessed at the next inspection. EVIDENCE: ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 11 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 and 18. Complaints are well managed, although information for residents regarding making a complaint needs to be expanded. The home’s adult protection policy and procedure safeguards residents. EVIDENCE: The home has a complaints policy and detailed procedure regarding complaints. The procedure states that its aim is to ensure that all staff working at St Luke’s are made aware of the processes to be followed in the event of a complaint, and the inspector witnessed a member of staff respond very well to a relative’s concern on the day of inspection. The information for residents regarding how they or their relatives can make a complaint is limited and contained within the terms and conditions document. The procedure information for residents needs to be expanded into a stand-alone document, so that residents are aware of who to complain to in the event of matron’s absence and it should include the response timescales, according to Regulation 22. The home has a policy and procedure to protect residents and staff in the event of an incident of abuse in the home, showing that incidents of suspected abuse will be fully investigated. Mention is made of the Oxfordshire Codes of Practice for the Protection of All Vulnerable Adults from Abuse, Exploitation and Mistreatment, but it is not clear from the procedure that St Luke’s staff are expected to be familiar with the codes and work according to the codes, and this advice needs to be included in the procedure. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 12 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 and 26. Good systems are in place to maintain the grounds and building, and systems are in place to manage the control of infection. EVIDENCE: St Luke’s is easily assessable for wheelchair users and has a secluded garden, used by residents, which is part of the Quiet Garden Trust Scheme. Records are kept of routine maintenance of appliances, which is organised on an annual basis or more often if necessary, and there is a system for staff to request repairs on an ongoing basis. The laundry is situated in the basement of the building, and staff use the sluicing facility and appropriate washing cycles to ensure that the laundry is disinfected. A new washing machine has recently been installed with additional features to combat infection. Hand washing facilities are available in all appropriate areas. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 13 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 and 29 Recruitment procedures protect the residents. EVIDENCE: The staffing rota is organised for each floor showing day and night cover. The inspectors saw staff recruitment files showing that the appropriate recruitment procedures are followed, and that systems are in place to monitor the CRB status of staff. One file had some information missing and this was quickly located, and all other files had the required information available. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 14 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) 35 and 36. Residents’ possessions, including petty cash, are safeguarded. Care staff are supervised appropriately. EVIDENCE: No financial transactions are undertaken on behalf of the residents, and individual resident’s petty cash is stored in a secure place. Records are kept of possessions from admission, and receipts are issued when items are held securely. The inspector saw the arrangements for staff supervision and was satisfied that a formal system is in place to ensure that all care staff are appropriately supervised. ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 15 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 x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 3 3 x x ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 16 No 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 Regulation None Requirement Timescale for action 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 18 Good Practice Recommendations The Prevention of Abuse Policy and Procedure should include the expectation that staff should be familiar with the Oxfordshire Codes of Practice for the Protection of All Vulnerable Adults and are expected to work according to the codes. The information for residents regarding the complaints procedure should be expanded so that residents are aware of who to complain to in the event of matron’s absence, and should include the response timescales detailed in Regulation 22. 2. 16 ST LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Burgner House, 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 LUKES CARE HOME WITH NURSING H57-H08 S27171 St Lukes V241154 260705 Stage 4.doc Version 1.30 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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