Inspection on 21/06/07 for St Luke`s Lodge

This inspection was carried out on 21st June 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 Lodge 01/07/08

St Luke`s Lodge 11/01/07

St Luke`s Lodge 02/05/06

St Luke`s Lodge 25/10/05

St Luke`s Lodge 30/11/04

St Luke`s Lodge 28/04/04

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

CARE HOMES FOR OLDER PEOPLE St Luke`s Lodge 7 Southborough Road Surbiton Surrey KT6 6JN Lead Inspector Jon Fry Key Unannounced Inspection 21st and 28th June 2007 9:40am 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 Lodge DS0000013399.V343951.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 Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Lodge Address 7 Southborough Road Surbiton Surrey KT6 6JN 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) 020 8399 2085 Mr Christie Kamalanathan Rajanayagam Mrs Annapoorani Rajanayagam Post Vacant Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: St Luke’s Lodge provides care to seventeen older people, some or all of whom may have dementia. The home is a detached property situated in a quiet residential area. There is good access to shops, public transport and other local resources. Bedrooms are provided over three floors, all of which can be accessed by a passenger lift. There is a large garden to the rear of the property. A copy of the home’s Service User Guide can be obtained on request from the owners. Fees for the home currently range between £420.00 to £510.00. There are additional charges for hairdressing, chiropody and dry cleaning. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector who spent seven and a half hours in the home over two separate visits. The inspector talked individually with ten people living at the home. One relative of an individual was also spoken with during the inspection. A number of records were examined and discussions took place with the owners and two staff members. Completed surveys were received from two people living at the service, three relatives or friends of people living at the home and two healthcare professionals. What the service does well: What has improved since the last inspection? What they could do better: Procedures for managing medication need to be further improved. There must also be enough protective equipment provided for staff to use and dispose of afterwards. The home should look at how it can provide a more person centred service and how people living at the home can be more involved in purposeful activities. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 6 Care planning needs to focus on social needs and how these can be met both in and out of the home. 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 Lodge DS0000013399.V343951.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 Lodge DS0000013399.V343951.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): 1, 2 and 3. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Good information is available to prospective users of the service about the home. Assessments are completed before people move in to make sure that their individual needs can be met. EVIDENCE: Everybody who completed a surveys said that they had received enough information to make a decision about moving in. One relative or friend of a person living at the home said “we looked at several homes and this was welcoming and kind”. Comments from individuals included “I like it here”, “it’s alright” and “marvellous”. One person said “it could be better” and another said “I don’t like sitting here watching the world go by”. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 9 A user guide is available which contains information about the service provided. This contains some photographs but we have recommended that other formats are looked at for the guide such as tape or pictures to make sure that it can be used by as many people as possible. We saw that there is an admissions procedure and that assessments are completed prior to anybody moving in. Once an individual comes to live there, a care plan is written based on these assessments. In surveys, one person who lives at the home said that they had received a contract while another person said ‘no’ to this question. One relative or friend said that they had received a contract and “have been notified of any changes”. The contracts being used need to be updated as they still reference the Registered Homes Act 1984 that is outdated legislation. Information about fees must also be included in the user guide for the home. The service should additionally look at making the contract available in large print and in other accessible formats as needed. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 10 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans could be more person centred and better address the health, personal and social care needs of individuals. Arrangements for the handling, storage and administration of medication need to be improved. EVIDENCE: Two people who live at the home responded ‘always’ in surveys when asked if they received the care and support they needed. Other comments from individuals included “I like it here with the people”, “everybody is pleasant” and “nice”. Care plans for two people were looked at. These contained some good information about individual needs such as personal hygiene and activities of daily living. One care plan contained very specific information about a person’s St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 11 routine and their preferences around this. The home needs to look at making sure that good person centred information is recorded throughout the care plan. This should include better life histories and further individualised information about their support needs. It is important that each person has a full social care plan in place. This needs to be used to make sure that people can take part in activities they enjoy and to inform the programme followed each day. From observation, we saw that staff tended to concentrate mainly on physical care such as helping people use the toilet or making sure that they were having drinks. There were some missed opportunities for staff to interact more with people and take time to chat. We saw that satisfactory records were kept of any contact with healthcare professionals for each person. Two healthcare professionals returned surveys about the home. Each stated that the home communicated well and worked in partnership with them. One relative or friend commented, “Dr or nurse visits as requested and usually promptly”. We saw that medication is kept securely and procedures are in place for staff to follow when giving medication. There however were a number of instances where the record of administration had not been signed by staff after a medication had been given. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 12 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers a satisfactory range of activities. There is scope to improve this by making sure there is a detailed social care plan for each person and tailoring the activities more to individual preferences. People living at the home generally enjoy the food provided. EVIDENCE: Two people who live at the home responded ‘usually’ when asked if there were activities they could take part in. Comments from individuals about activities included “we sometimes go to the shops” and “I have visitors”. One person did comment that “I sit in this chair all day, there’s nothing else to do” and another person said “I want freedom”. An activities person comes into the home on three days of the week for one and a half hours each time. Activities provided include skittles, quizzes, ball St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 13 games and exercises. One member of staff played dominoes with individuals on both days we visited. As stated previously, care plans need to look more at social needs and these can then be used to organise the activities programme. Better records of who took part in the activities provided will also help to make sure that the individual needs of everyone living there are being addressed. The home could also look at how individuals can be more involved with the life of the home and purposeful activities such as gardening, cooking and other household tasks. Most people spoken with said that they enjoyed the food offered with comments including “lovely”, “alright” and “I couldn’t grumble”. In completed surveys, one person said they ‘always’ liked the meals served and another said ‘usually’. Comments from relatives or friends included “well prepared” and “the food is very good and we get a good helping”. People living at the home looked to enjoy the food being served and the dining room provides a pleasant space for them to do this. We have recommended that the home display the menus in large print or pictures to make sure that everyone knows what is being served. There may also be opportunities to make mealtimes a more social occasion. Ideas to consider could include people serving themselves at the table and for staff to eat their meals alongside the people living there. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements for complaints and safeguarding from abuse are generally well managed. EVIDENCE: Two people who completed surveys said that they knew how to make a complaint. One relative or friend said that “the owners are always available to listen” and another person reported that they had no complaints. Records are kept of any concerns or complaints received and we saw that these are well maintained. There have been no complaints about the service since the last full inspection took place in January 2007. The complaints policy and procedure is part of the guide for the people living there. We recommend that this procedure be available in a large print or picture format. The owners have a copy of the Local Authority Safeguarding Adults procedure. Staff have been given in-house training on abuse awareness. St Luke`s Lodge DS0000013399.V343951.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, 24 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is maintained, decorated and furnished to an adequate standard. The environment is kept clean and tidy. Infection control procedures need improvement. EVIDENCE: People spoken to were generally happy with the environment. Comments from individuals included “comfortable” and “ok”. We saw that the home is well maintained and decorated to an adequate standard. New carpeting has been fitted in the lounge area as required at the previous inspection. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 16 The current layout of the lounge area makes it feel like a waiting room and we have recommended that this be looked at to see if it can be changed. The home environment was clean on both days of inspection. A Requirement has been made for the home to make sure that adequate supplies of disposable aprons and gloves are available for staff to use. One instance was seen where disposable aprons had been put away to be re-used and also staff appearing to be re-using disposable latex gloves. St Luke`s Lodge DS0000013399.V343951.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. People who use the service experience good quality outcomes in this area. Procedures for the recruitment of staff have improved. A training programme provides staff members with the basic skills for meeting the needs of people living at the home. EVIDENCE: Feedback from individuals about the staff included “smashing”, “staff are very good”, “they are polite” and “alright”. Two people who filled in surveys said that staff were available when they needed them. Comments from relatives or friends included “they are well staffed” and “we have witnessed great kindness and consideration”. We looked at records for three members of staff. Procedures have been improved since the January 2007 inspection and contained all necessary documentation including a Criminal Records Bureau (CRB) check. Records showed that there has been training for staff members in Food Hygiene, First Aid, Infection Control, dementia awareness and Safeguarding Adults. Three staff have completed the NVQ Level Two qualification. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 18 It is strongly recommended that the owners look at accessing further training for care staff around activities, dementia and person centred care in order for the service to develop. St Luke`s Lodge DS0000013399.V343951.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, 36 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is generally well run. Health and Safety issues are addressed by the home to keep people living there safe. EVIDENCE: The owners have been running the home for a number of years and continue to take responsibility for its day-to-day management. Comments from relatives or friends included “it is well staffed and well run” and “the impression gained is that the care home is operating as well as it is able”. St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 20 Due to the small size of the home, consultation with people living at the home tends to be informal and ongoing. A report has been produced in June 2007 by the owners auditing the quality of care. This has been supplied to the CSCI. It is recommended that the home start to look at new self-assessment documentation in use for inspection and begin to develop a formal system for self-auditing. A system for regular individual staff supervision is in place. Health and Safety checks take place to make sure people are kept safe and records are kept of these. St Luke`s Lodge DS0000013399.V343951.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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 St Luke`s Lodge DS0000013399.V343951.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. 1. Standard OP1 OP2 Regulation 5 (1) (bc) Requirement In order to make sure that people living at the home or their representatives know how much they are paying for services, the user guide must include details of fees payable by individuals. Each person living at the home must have a care plan in place fully addressing their individual social needs and how these are to be met. This will help to make sure that the social and recreational needs are being met by the service. 3. OP9 13 (2) In order to fully protect the health and welfare of people living at the home, medication records must be correctly maintained at all times. 01/08/07 Timescale for action 01/09/07 2. OP7 15 (1) 01/10/07 4. OP26 13 (3) In order to fully protect the 01/08/07 health and welfare of people living at the home, adequate supplies of disposable gloves and aprons must be made available DS0000013399.V343951.R01.S.doc Version 5.2 Page 23 St Luke`s Lodge for use by staff at all times. Disposable equipment must not be re-used by staff. 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. Refer to Standard OP1 Good Practice Recommendations The user guide to the home should be made available in a variety of formats such as audiotape or pictures. Reference to the Registered Homes Act 1984 should be removed within contracts. It is recommended that the home makes sure that contracts are in plain English and in alternative formats as required. The home should look at ways to make the care plans more person centred and better reflect the individual’s life and preferences. The plan in place should direct the care to be person orientated and not task based. Care plans need to give specific information about how the person likes the care and support to be delivered. 4. OP12 Better records of individual activities need to be kept to make sure that individual social needs are met by the home. The home should look at how individuals could be more involved in day to day ‘purposeful’ activities such as cooking, gardening and other household tasks. 5. OP15 Menus should be presented in user-friendly formats such as pictures or large print. Mealtimes should be an opportunity for people to interact. Practices such as different ways of serving, varying numbers of mealtimes, and staff eating with people who live there should be considered seriously by the home. OP2 3. OP7 St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 24 6. 7. OP24 OP30 The layout of the lounge needs to be looked at to try to make it less like a waiting room. It is strongly recommended that the home accesses further training for care staff around activities, dementia care and person centred care. It is recommended that the home start to look at the new self-assessment documentation in use for inspection (AQAA KLORA) and begin to develop a formal system for self-audit. 8. OP33 St Luke`s Lodge DS0000013399.V343951.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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