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Inspection on 04/07/05 for St Luke`s & The Oaks Residential Home

Also see our care home review for St Luke`s & The Oaks Residential Home for more information

This inspection was carried out on 4th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Written records were well-kept and provided staff with sufficient information to provide good quality care to residents. Service users confirm that their care is provided in a dignified way which takes into account their wishes and feelings. The home provides an excellent range of activities for its users and residents say these activities are enjoyable.

What has improved since the last inspection?

A new wing has opened which can cater for people with a poor short-term memory and low-level dementia. This wing is popular with its residents. St. Luke`s has been redecorated to provide a bright and cheerful place to live. The flooring of the Oaks has been renewed and is more homely.

What the care home could do better:

There is a need to replace a number of curtains on the top floor of the Oaks and to reduce the smell in the corridor of the ground floor.

CARE HOMES FOR OLDER PEOPLE ST LUKES & THE OAKS Marshlands Square Caversham Reading RG4 8RP Lead Inspector Julie Willis Unannounced 4 July 2005 @ 10:15 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 & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Lukes & The Oaks Address Marshlands Square Caversham Reading Berkshire RG4 8RP 0118 946 1424 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) Colley Care Ltd trading as B & M Care Ms Kim Franks Care Home 80 Category(ies) of Older Person OP registration, with number Dementia DE of places ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users category DE not to be admitted under the age of 50 years. Date of last inspection 04/11/04 Brief Description of the Service: ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 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 a period of 5 hours on a weekday morning and afternoon. A tour of the home was undertaken in which the service users accommodation and communal space were visited. A number of care records and health & safety documents were examined. The inspector spoke at length with 9 service users and 10 others in small groups in various parts of the home. The inspector observed care practices and spoke to a small number of staff including the Activities Organiser, the manager of the Oaks and the Registered Manager who was provided with brief feedback at the end of the inspection. What the service does well: Written records were well-kept and provided staff with sufficient information to provide good quality care to residents. Service users confirm that their care is provided in a dignified way which takes into account their wishes and feelings. The home provides an excellent range of activities for its users and residents say these activities are enjoyable. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 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 & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 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) 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 six of the service user care plans evidenced that a manager of the home had carried out a full pre-admission assessment. The assessment was carried out in the users home or in hospital and was comprehensive and holistic in content. Information was gathered from the user, their family and advocates about their personal and healthcare needs as well as their social history and cultural needs. A copy of the Social Work assessment had been provided to the home in the case of social service funded residents. The information gathered pre-admission provided essential information, which formed the basis of the care plan. Service users confirmed that they had the necessary information they needed to decide if they wanted to live in the home. Most could recall their initial visit by a manager and said that this meeting had helped to put their minds at ease ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 9 about entering the home and had provided an opportunity for them to ask any questions that they had. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 Service users personal and healthcare needs are fully met in a manner which maintains their dignity, privacy and independence. EVIDENCE: The written records were generally well-kept and provided staff with sufficient information to enable them to offer the appropriate level of care. There is a need however, to ensure that all parts of the service user plans are completed as soon as possible following admission. Observation of care practice concluded that users, particularly those with mental frailty, were encouraged to remain as independent as possible by providing appropriate levels of support to maintain their privacy, dignity and independence. Service users confirmed that they were provided with access to health and social care professionals when required and were seen in the privacy of their own bedrooms. Service users said that “my doctor will visit when necessary” and “staff provide the care I need in my room when I’m not feeling well”. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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 standard(s) 12 Service users are provided with a range of stimulating and enjoyable activities. EVIDENCE: The inspector had the opportunity to speak with the activity organiser for St. Luke’s and the Lilac Unit and to observe the activities that were in progress at the time of inspection. Service users in St. Luke’s were busy with craft activities such as needlework, card making, knitting etc. The items produced will be sold at the summer fair to raise further funds for entertainments and trips out. One user told the inspector that they were involved in producing posters and other written materials on the activity room computer. They said that they “particularly enjoyed this activity”. In the Lilac Unit service users were playing Bingo. The inspector spoke with 5 service users that said that they were offered opportunities to take trips out of the home and had enjoyed trips to ‘Well Place Zoo’, the ‘Herb farm in Sonning’, shopping trips and walks by the river. The activity schedule consisted of a wide range of activities including ‘music & movement’ by a qualified therapist. Fortnightly visits by the ‘music man’ who plays keyboards and sings. Every 6 weeks a professional company from ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 12 London provide entertainments. The ‘Caversham Singers’ visit twice a year and have been particularly popular with residents. Staff in ‘The Oaks’ were providing residents with one-to-one activities that could offer mental and physical stimulation. The majority of users were listening to music and chatting. Photographs of service users enjoying the recent barbeque were on the notice board and had clearly been enjoyed by the residents and their friends and family. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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 standard(s) 16 The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. EVIDENCE: The homes complaint system is robust. Examination of records indicated that only 1 complaint has been made to the home since the 1st January 2005. The record indicated that management had undertaken a full investigation into the complaint and a satisfactory outcome had been provided to the complainant. Service users were highly complimentary about the ‘open style’ of management. They said that they felt confident in expressing their opinions and knew that they would be taken seriously. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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 standard(s) 19, 26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: A tour of the home evidenced that a number of improvements had been made to the environment since the last inspection. A new unit called ‘Lilac unit’ had been opened in April 2005, which caters for the needs of people with low-level dementia. Service users were highly complimentary about the unit and said that they had “nice rooms” and that the decor was “bright and cheerful”. The communal lounge/diner was pleasantly furnished and decorated and was well used by the residents. Between meals the dining tables are cleared and reused as the activity area. The walls are adorned with photographs of users in the home enjoying activities and various trips out. A new non-slip impervious floor covering has been added to the top floor of the Oaks, which has improved the environment for users, as it is easily cleanable. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 15 There is a need to replace a number of curtains in the bedrooms identified during the inspection where they are faded. The inspector was informed of plans to improve the lower floor of the Oaks by moving the communal lounge/diner and building on a conservatory which will provide a brighter and more airy environment for users on this floor. There is a need to consider providing an alternative floor covering in the passageway, as this part of the home was odorous at the time of inspection. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 16 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) None of the staffing standards were inspected on this occasion. EVIDENCE: ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 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 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) 38 Service users live in a home where their health, welfare and safety are considered paramount. EVIDENCE: Examination of health and safety records evidenced that they were up-to-date and in good order. Routine maintenance and servicing of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment. Hazards to service users safety are fully risk assessed and management strategies are in place to reduce the risk of occurrence. Service users confirmed that they feel safe and well cared for and have the opportunity to take appropriate risks. ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 19 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. 2. Standard 26 19 Regulation 16 (2) k 16 (2) c Requirement Ensure that the odours on the ground floor of the Oaks are eliminated Ensure that the curtains that are faded in the Oaks are replaced Timescale for action By 4.10.05 By 4.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading 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 ST LUKES & THE OAKS H51-H01 11065 St Lukes Oaks V233992 040705 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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