Inspection on 08/01/07 for St Luke`s Hospital

This inspection was carried out on 8th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 15/11/05

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 Unannounced Inspection 8th January 2007 10.15 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.V325479.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 Hospital DS0000027171.V325479.R01.S.doc Version 5.2 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.V325479.R01.S.doc Version 5.2 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 15/11/05 Date of last inspection Brief Description of the Service: St Lukes Hospital is a care home with nursing registered with the Commission for Social Care Inspection and is not a hospital in the traditional meaning of the word. The home is managed by a non-profit making Christian charitable trust, the Council of St Luke’s Hospital, and is situated in a residential area of Oxford, close to the citys NHS hospitals, shops and recreational facilities. Accommodation consists of 48 single en-suite bedrooms with direct line telephone and television, and individuals can stay for short or long periods. The matron and her team of nursing and care staff are responsible for the care provided to the residents. The daily minimum charge at present is £119. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.15am and was in the service for 6.5 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s managers, and any information that the Commission had received about the home since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The home’s registered manager (matron) was available during the inspection visit, as was the general manager. The ethos of St Luke’s is that of a hospital, care is provided on a medical type model and the individuals cared for are referred to as ‘patients’. In this report the individuals are called ‘residents’. The inspectors asked the views of the residents, relatives and health and social care professionals about the home, through questionnaires (comment cards) that the Commission had sent out. The inspector also had conversations with several residents and some relatives on the day, and their views are reflected in this report. The inspector considered evidence on how the home addresses issues of equality and diversity. Residents are treated as individuals through the care planning process and staff training is good, therefore the inspector is satisfied that the home would be able to meet the needs of people from different ethnic, cultural, social and religious backgrounds. Arrangements are in place to help staff members with physical difficulties work effectively at St Luke’s. However, it is not clear that groups of residents are treated equally, as the long stay residents are not formally consulted about the home in the same way that those staying for a short stay are. This needs to be addressed, as the long stay residents’ interests may be different from the interests of the short stay residents, and need to be known and addressed. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. What the service does well: Residents said that the care was ‘good’, and that ‘staff do their very best’. One comment received was that the nursing care was ‘excellent’, and several residents commented on the high quality of the food. Residents’ health and personal care needs are met, and good group and individual activities are available. The environment is hygienic and well maintained, and the staff group are well trained. The health and safety of residents and staff is taken seriously. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 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.V325479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. The home does not provide intermediate care. Quality in this outcome area is good. All individuals have an assessment of their needs carried out before coming to stay at St Luke’s. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Luke’s admits individuals needing long-term care and those needing a short stay for respite care or recuperation. The home’s matron usually visits prospective residents to carry out an assessment and gathers information to make sure that the home can meet the needs of the individual. The inspector saw individual care records and was satisfied that care plans are developed from the pre- admission assessment, and residents told the inspector that the admission process went smoothly. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Residents’ health and personal care needs are known and met, although consultation about their care with residents and/or their representatives needs to be demonstrated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Risk assessments are conducted to make sure that individuals’ health and personal care needs are known, and reviews of the care plans take place regularly. The inspector saw care plans detailing how the needs of two residents are being met. Each was registered with a General Practitioner and had a detailed care plan showing the actions carers needed to take to meet the needs of the residents. A local GP visits twice a week to discuss the health care needs of the residents. The ‘General Risk Management’ form is used to inform relatives of identified risks, but it is not clear from records that residents and/or representatives are appropriately consulted about the care planned. Matron said that consultation takes place and residents or their representatives give verbal agreement to the plan. The inspector recommends that the registered manager develops a St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 10 method to record relatives’ or representatives’ consultation about the care plans, because a record will demonstrate that residents and/or representatives are consulted about care plans in accordance with Regulation 15 of the Care Homes Regulations 2001. The home has policies and procedures about the management of medication, and the inspector saw that medication is appropriately managed. All the individuals who replied to the Commission’s comment cards said they were satisfied with the overall care provided. Residents said that staff members show respect for them and that personal care is provided in private. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. The routines of daily life generally meet the expectations of the residents, but the views of the long-term residents are not formally sought, so it is unclear that residents’ feedback is taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individuals who choose to stay at St Luke’s are usually aware that the ethos and environment is more that of a hospital than a care home, so the lifestyle usually meets expectations. Residents’ interests are recorded and the home has two recreational therapists who arrange and publicise group activities. The schedule of events for the month was readily available. Individual activities are also provided, and individuals can also arrange to have massage and aromatherapy treatments and these are charged as extras. Residents also told the inspector that they value the garden. The activities team provide a service that is very valuable for the residents and are well placed to support residents’ psychological and emotional needs. At present the two recreational therapists work separately from the other care staff members, and the inspector recommends that the activities and care teams be better integrated. More communication between the care and St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 12 recreational teams could improve outcomes for the long-term residents, especially regarding emotional needs. Cooperation between the teams will also help meet St Luke’s philosophy of caring for residents in a holistic manner. Residents can choose if they wish to attend religious services in the home’s chapel, and visitors can visit their relatives at reasonable times. Food preferences are recorded and one relative said that the chef comes regularly to discuss the menu with the resident. Residents said that the food was fresh and ‘good’ and examples were given to the inspector of how the chef paid attention to detail and took a personal interest in their food preferences. The chef is committed to continually improving the food provision at St Luke’s, and has an interest in the continuing training of the kitchen staff. The views of the long-term residents are not formally sought regarding life at St Luke’s, or how it can be improved for them, and no formal arrangements are in place to hear the views of their relatives or representatives. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. Residents do not receive all the information necessary through legislation regarding the home’s complaints procedure, and so are not fully aware of St Luke’s responsibilities and their own rights regarding complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No individual has contacted the Commission with a concern about the home since the last inspection visit. The home has a complaints policy and procedure, and residents told the inspector that they knew whom to address verbal complaints to, as did 2 of the individuals who replied to the Commission’s comment cards. One respondent said that he/she was not aware of the complaints procedure, and one resident said that one might not always want to verbally discuss complaints during the matron’s regular visit. The inspector did not see a copy of the complaints procedure displayed within the home. A summary of the complaints procedure is included under the heading ‘General’ in the Terms and Conditions for Residence sent as part of the service user guide to long and short stay residents before admission. Residents do not receive a full copy of the home’s complaints procedure, and individuals need to request a copy if they need it. The general manager explained that, although this arrangement does not fully meet legislation, it was not seen necessary to provide a full copy of the complaints procedure to all the residents at St Luke’s, as matron is usually available for residents and relatives. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 14 A copy of the home’s complaints procedure must be provided to all residents, so that the legislation is met and so that residents have control over how they can raise complaints if they wish to do so. Staff members know how to address issues regarding the safeguarding of vulnerable adults and care staff members have attended appropriate training. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. The environment is well maintained, hygienic and well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector saw all areas of the home and noted that the environment, though clinical rather than homely, was clean, fresh and bright. A system is in place to manage day-to-day maintenance issues, and refurbishment of private and public areas is ongoing. All the beds are adjustable, the bathrooms are equipped with appropriate aids and each floor has a small kitchen for the preparation of drinks and snacks. The laundry area was seen and infection control measures are in place to prevent the spread of infection. The maintenance personnel are aware that the laundry floor needs attention so that the surface is easily cleaned, and this is in hand. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 16 St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. Although sufficient staff members are usually on duty and staff training is good, the recruitment procedure is not sufficiently robust to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff rota that shows how the care and nursing staff are allocated between the floors and between nights and days. Comments from relatives and residents show that there are no concerns about the numbers of staff available, and on the day of the inspection visit appropriate numbers of skilled staff were on duty. Matron has a keen interest in staff training at St Luke’s and the home’s induction programme for new staff is now meeting the Skills for Care standard. The home takes student nurses for part of their training and two of the home’s nurses have gained their assessors’ qualification. After induction, care staff members are helped to take the National Vocational Qualification (NVQ) Level 2 in care, and the home exceeds the national minimum standard of 50 NVQ trained staff. Mandatory training in safe moving and handling, fire safety and food hygiene is provided for staff and staff are expected to attend training. Training in other care topics has continued especially in palliative care and in the care of individuals with dementia. The inspector saw three staff files to assess the home’s recruitment procedure. Two of the staff members had started induction training on the day of the visit. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 18 Both were working under supervision and information was received that neither of the individuals were on the Protection of Vulnerable Adults list, but full clearance from the Criminal Records Bureau (CRB) had not been received. The other individual (who does not provide personal care to residents but with access to residents) had a Standard clearance from the CRB, and the inspector understood that the individual had access to individuals’ rooms and was not always supervised. The registered person should make sure that residents’ interests are safeguarded by risk assessing the level of unsupervised contact that staff without Enhanced Criminal Record Bureau clearance have with residents. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38. Quality in this outcome area is adequate. Although the home is safely managed it is not clear that long-term residents’ views (or those of their representatives) are sought and valued. The views of the longterm residents are necessary to make sure that the home is run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Luke’s has a general manager who is responsible for the general management of the home, and the registered manager is responsible for the care provided. The registered manager is a registered nurse, and has a qualification in management. She has extensive training in care issues, particularly in palliative care and has a keen interest in staff training. Her line St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 20 manager is the general manager, and the general manager reports to the Council. Quality questionnaires are sent monthly to a sample of individuals who have stayed for a recent short stay, and comments are invited regarding communication, nursing services, other staff and catering. Information is collated and results are reported to St Luke’s Council. Although informal arrangements are in place for residents and relatives to raise issues with the matron, no formal arrangements such as residents’ or representatives’ meetings or formal surveys are in place to receive information on quality issues affecting the individuals who live long term at the home. The inspector recommends that long term residents and their representatives be regularly asked about their views of services and facilities at St Luke’s, and they be informed of the results of the surveys. Residents or their representatives manage their own financial affairs, and the home only manages a small amount of petty cash for some residents. Records were seen and the cash is kept securely. St Luke’s has a health and safety policy statement and has procedures in place to meet its responsibilities. There is a named individual responsible for health and safety matters at St Luke’s, and service contracts are in place. Fire records are kept and a fire safety risk assessment is in place. One individual who replied to the Commission’s comment cards said St Luke’s is ‘a well-run efficient establishment’. St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 22 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. 2 Standard OP16 Regulation 22 Requirement A full copy of the home’s complaints procedure must be supplied to all residents. Timescale for action 28/02/07 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 2 3 Refer to Standard OP7 OP12 OP29 Good Practice Recommendations The registered manager should develop a method to record relatives’ or representatives’ agreement with the care plans. The inspector recommends that the activities and care teams be better integrated, so that the home can be proactive in meeting the needs of the residents. The registered manager should make sure that residents’ interests are safeguarded by risk assessing the level of unsupervised contact that staff without Enhanced Criminal Record Bureau clearance have with residents. The inspector recommends that long term residents and their representatives be regularly asked about their views of services and facilities at St Luke’s, and they be informed of the results of the surveys. 4 OP33 St Luke`s Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Hospital DS0000027171.V325479.R01.S.doc Version 5.2 Page 24 - 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!