Inspection on 28/11/05 for St Luke`s & The Oaks Residential Home

This inspection was carried out on 28th November 2005.

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 & The Oaks Residential... 22/11/06

St Luke`s & The Oaks Residential... 04/07/05

St Luke`s & The Oaks Residential... 04/11/04

St Luke`s & The Oaks Residential... 22/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Luke`s & The Oaks Residential Home Marshlands Square Caversham Reading Berkshire RG4 8RP Lead Inspector Julie Willis Unannounced Inspection 09:40 28 November 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000011065.V263855.R01.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. DS0000011065.V263855.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Luke`s & The Oaks Residential Home Address Marshlands Square Caversham Reading Berkshire RG4 8RP 0118 946 1424 0118 947 1887 st.lukesbm@btopenworld.com 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) Colley Care Limited (Trading as B & M Care) Ms Kim Franks Care Home 80 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (37) of places DS0000011065.V263855.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users category DE not to be admitted under the age of 50 years. 4th July 2005 Date of last inspection Brief Description of the Service: St Luke’s & The Oaks are operated by Colleycare Ltd (trading as B&M Care), which operates 15 care homes, some with nursing, in 6 counties across the South of England. The organisations head office is in Hemel Hempstead and provides the home with external management arrangements in the form of an Operations Director. The organisation provides the home with comprehensive procedures, a policies manual and central support in the administration of finance, training and personnel. St Luke’s and The Oaks are purpose built homes providing residential care for elderly people. The Oaks has 31 beds and is registered for those with diagnosed dementia and provides a more supportive environment. Neither home provides nursing care. DS0000011065.V263855.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday morning and early afternoon over a period of four hours. A tour of the home took place in which the service users communal space was visited. A number of care and staff records and health and safety documents were examined. The inspector spoke at length to 8 of the service users plus others in small groups. The inspector spoke to a number of staff whilst they were carrying out their duties and was assisted throughout by the homes two deputy managers. There were no requirements outstanding from previous inspections and only one new requirement arose out of this of this inspection. What the service does well: The home provides residents with a clean and comfortable place to live. The food is good and there is plenty of choice and variety. Staff are caring and kind and there is enough staff on duty at the home to meet the needs of residents effectively. Staff recruitment practices are well carried out and well documented to protect the safety and welfare of residents. A good range of activities is offered to residents, which include trips out, games, crafts and quizzes as well as outside entertainers who come to the home often. Written records are good and provide staff with enough information to give good quality care. DS0000011065.V263855.R01.S.doc Version 5.0 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. DS0000011065.V263855.R01.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 DS0000011065.V263855.R01.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): 3 All service users are assessed prior to admission to ensure that the staff of the home will be able to fully meet their needs. EVIDENCE: Examination of the records of the 4 most recently admitted residents evidenced that members of the management team had carried out a full assessment of the users needs prior to admission. The tool used for the purposes of assessment was holistic and comprehensive in detail and gathered sufficient information to ensure that the home would be able to effectively meet their need. Information was gathered from a variety of sources, including the user, their family and other health and social care professionals. The information gathered was used to produce an initial care plan and to ensure that any aids or equipment needed by the user were available on admission. DS0000011065.V263855.R01.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): 7, 8, 9 The health and personal care needs of users were well met by a team of caring and attentive staff. Care was being provided in accordance with the individuals care plan and there was evidence of effective multi-disciplinary working. The system for the administration of medication is good with clear and comprehensive arrangements in place to ensure the safety of users. EVIDENCE: Examination of the care plans for 4 users evidenced that the users health and personal care needs were well met. Service users are provided with access to other health and social care professionals for advice and support. General practitioners, community nurses, occupational therapists and community psychiatric nurses are regular visitors to the home and provide advice to the staff on all aspects of care. Service users confirm that they regularly see their GP and are referred to hospital when necessary. Routine screening and preventative treatments are provided to all residents. From examination of the medication administration system and discussion with senior staff it is clear that the home follows best practice guidance when DS0000011065.V263855.R01.S.doc Version 5.0 Page 10 administering drugs. Senior staff have been trained in the administration of medication and are regularly in receipt of refresher training. A monitored dosage system is in operation at the home and medication is delivered to the home on a monthly basis. Storage systems are effective and disposal systems are safe. Two signatures are required when administering any controlled drugs and these drugs are stored separately as legislation requires. DS0000011065.V263855.R01.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): 13, 14, 15 Service users are provided with the opportunity to participate in a wide range of leisure activities and entertainments. Service users are encouraged to maintain contact with the local community, their friends and relatives. The meals in the home are good offering users both choice and variety. Special dietary needs can be catered for effectively. EVIDENCE: From discussion with the Activity Organisers, staff and service users it was clear that service users are offered the opportunity to participate in a wide range of activities. On the morning of inspection users were engaging in craft and needlework. Items are produced for sale to raise funds for outings and new activity equipment. External entertainers are regular visitors to the home including singers and musicians and there are a large number of visits planned by local schools and church choirs to entertain residents during the Christmas period. Service users confirm that their visitors are made most welcome at any time and are offered appropriate hospitality during their visits. A number of social events are held throughout the year which promotes community involvement DS0000011065.V263855.R01.S.doc Version 5.0 Page 12 and which provide residents families with the opportunity to engage with the staff and users on an informal and regular basis. Examination of the menu indicated that the home follows a four-week revolving menu. Two choices of main meal are available each lunchtime and two choices are provided for tea. On the day of inspection lunch was sausages in mushroom & onion gravy accompanied by fresh cabbage and creamed potatoes or alternatively egg salad followed by peaches & custard or ice cream. Lunch is provided in separate sittings in different parts of the home with meals provided by hot trolley to the Oaks. Special diets can be catered for including diabetic, vegetarian or pureed meals. Catering staff have been provided with the opportunity to further enhance their knowledge and skills by participating in a distance learning intermediate level food hygiene award. Following completion of the course it is likely that the kitchens Environmental Health Award will be upgraded from Bronze to Silver or Gold standard. Discussion with service users evidenced that the food was well cooked tasty and plentiful in quantity. A number of service users made comments such as “the food is very tasty”, “always a choice” and “me and my friends look forward to dinner it is the highlight of our day, we always sit together and chat over dinner”. DS0000011065.V263855.R01.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): 18 Service users are protected from abuse and exploitation by well-trained and competent staff that demonstrate knowledge of the homes abuse of vulnerable adults and whistle-blowing policies EVIDENCE: There was evidence in staff files that all staff receive training in the abuse of vulnerable adults as part of their formal induction and NVQ training in which it is a core module. Refresher training courses are also offered regularly to staff by the homes management team. Records of abuse training are freely available in the Managers office on the training needs analysis wall chart displayed there. Service users confirm that they feel safe at the home and are well cared for by competent and caring staff. DS0000011065.V263855.R01.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): 26 Service users benefit from living in a clean and hygienic home. EVIDENCE: Service users were highly complimentary about the quality of cleaning in the home. They said that the domestic staff were always on hand to mop up spills and kept the toilets and bathrooms clean and fresh. Users said that their bedrooms were always kept pleasantly clean and tidy. Since the last inspection the carpeting in the hallway, on the ground floor of the Oaks has been replaced by non-slip impervious flooring. This provides an easily cleanable floor, which is odour and stain free and greatly enhances the environment for users. Some of the bedrooms in the Oaks have been provided with new curtains to replace those, which had faded. DS0000011065.V263855.R01.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): 27, 28, 29, 30 Staff individually and collectively were able to demonstrate that they have the necessary skills and experience to effectively meet the needs of service users in their care. Staff recruitment procedures are robust and transparent and protect service users from harm. Staffing levels are sufficient to meet the needs of users of the service. EVIDENCE: Examination of the recruitment files for the 4 most recent employees indicated that all necessary checks are undertaken on prospective staff to ensure the safety and protection of service users. Records were well kept and met the required standard. Staff appeared to have a good understanding of how their individual role benefits the work of the team and a thorough knowledge of the key values that underpin their work with service users. Staff are offered opportunities to gain qualifications to further enhance their knowledge and skills such as National Vocational Qualifications at level 2 & 3. All staff are provided with refresher training at regular intervals, in core skills such as fire safety awareness, health & safety, first aid, manual handling and infection control to ensure service user safety. DS0000011065.V263855.R01.S.doc Version 5.0 Page 16 There was evidence that new staff are provided with induction and foundation training to Sector Skills Council standard. All staff receive on-going support and are formally supervised at least six times a year. Service users were very complimentary about the qualities of the staff that they said were “friendly”, “attentive and caring” and “go that extra mile to ensure residents are happy with the service they provide”. DS0000011065.V263855.R01.S.doc Version 5.0 Page 17 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): 31, 33, 35, 38 Service users benefit from living in a well managed home, where there is evidence that their health welfare and safety is of primary importance. The registered manager is qualified, competent and experienced to run the home for the benefit of residents. The policies and procedures regarding service user finances safeguard the interests of residents EVIDENCE: The Homes Manager is widely experienced and has attained the Registered Managers Award and NVQ 4 in care to further enhance her knowledge and skills. The manager is well supported by two deputies and a team of senior carers. The current management structure appears to be sufficient to reflect the size and complexity of business currently undertaken. DS0000011065.V263855.R01.S.doc Version 5.0 Page 18 Staff confirm that the Homes Manager demonstrates effective leadership skills and vision and is always keen to support individual members of staffs personal and professional development. Staff confirm that they have the opportunity to express their opinions openly in staff meetings, supervision sessions and staff handovers. They say that they are provided with plenty of opportunity to express concerns, share information and to feel included and involved in the way the service is delivered. Service users are highly complimentary about the management of the home and feel that they are kept well informed of what is going on. Residents hold weekly discussion groups where they discuss a range of issues. It would be helpful if the outcomes from these meetings could be recorded and shared with other residents in order to keep them informed and up-to-date. Service users say that the office is always open and accessible and the managers always make time to speak with them. Examination of a sample of service user cash accounts indicates that a safe procedure is followed for deposit or withdrawal of resident’s monies. Receipts are kept of all cash spent. Most service users have family members that deal with their financial affairs and a number are able to carry out their own transactions in the bank and building society. Service users confirm that financial matters are dealt with efficiently by the home. Examination of health & safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for users. All risks to users are effectively risk assessed and managed. There is a need for the home to consider providing a quality assurance system, which is based on seeking the views of users. This could help the management to measure their success in meeting the aims and objectives of the home. From discussion with users it was evident that they are regularly consulted on issues that effect them and feel that their views are taken into account, but it would be helpful if these consultations could be formalised and recorded. Service users confirm that they are visited and asked for their opinions about the service during the monthly proprietors visits, records of these meetings are provided to the CSCI under Regulation 26. DS0000011065.V263855.R01.S.doc Version 5.0 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x x x x 3 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 2 x 3 3 x 3 DS0000011065.V263855.R01.S.doc Version 5.0 Page 20 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 OP33 Regulation 24 Requirement Ensure that a quality assurance system is developed which seeks the views of users. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000011065.V263855.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000011065.V263855.R01.S.doc Version 5.0 Page 22 - 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. 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