Inspection on 23/09/05 for St Lukes Care Home

This inspection was carried out on 23rd September 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 Lukes Care Home 16/12/09

St Lukes Care Home 11/12/07

St Lukes Care Home 04/07/06

St Lukes Care Home 24/05/05

St Lukes Care Home 11/10/04

St Lukes Care Home 26/04/04

St Lukes Care Home 09/03/04

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

CARE HOMES FOR OLDER PEOPLE St Lukes Care Home Palace Fields Avenue Palacefields Runcorn Cheshire WA7 2SU Lead Inspector Anthony Cliffe Announced Inspection 23rd September 2005 09:00 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 Lukes Care Home DS0000005148.V249794.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. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Lukes Care Home Address Palace Fields Avenue Palacefields Runcorn Cheshire WA7 2SU 01928 791552 01928 712072 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) Community Integrated Care Miss Deborah Ann Lewis Care Home 60 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (60), Learning disability (2), Physical disability of places (2) St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 60 service users to include: * up to 60 service users in the category of DE(E) (dementia, over the age of 65 years) * up to 10 service users in the category of DE (dementia, under the age of 65 years) * 2 named service users in the category of PD (physical disability, under the age of 65 years) * 2 named service users in the category of LD (learnng disability under the age of 65 years) diagnosed with dementia The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection. 23rd August 2005 2. 3. Date of last inspection Brief Description of the Service: St. Luke’s is a purpose built establishment for the provision of nursing care for up to sixty residents diagnosed with dementia inclusive of 2 places registered for physical disability.This service is provided within four separate units located over two floors, each unit has its own lounge, dining room, utility kitchen and staff team. Each unit provides accommodation for a maximum of 15 residents.The design features include passenger lifts, safety alarmed exit doors, single level flooring with external access, grab rails, and adaptations in all communal areas, bathrooms and toilets.Externally there is a central patio area and sensory garden accessible to all residents. St Luke’s is located in a large residential area on the outskirts of Runcorn. The home is on a main bus route and rail links are within two miles of the home at Runcorn East station. The service is provided by Community Integrated Care, a not for profit organisation. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over seven hours. It included inspection of records, observation of staff practice and discussion with residents and staff. Feedback was given to the manager at the end of the inspection. Information was also provided in a pre inspection questionnaire. Seven relative/ visitors comment cards were returned prior to the visit. All seven comment cards recorded awareness of the complaints procedure. Two comment cards recorded that the complaints procedure had been used but did not specify the nature of the complaints. Two comment cards referred to staffing levels. One recorded ‘ I am very pleased with the numbers of staff when there is four on duty, but the weekends the number isn’t good enough’. Another comment card recorded ‘ Staff levels can be low more so at weekends’. Four of the comment cards recorded that there were always sufficient staff on duty. One comment card recorded that the relative/visitor was not aware of access to inspection reports. One comment card recorded ‘’Although access to the home is very flexible, there is a lack of being made welcome, of being informed, rather than having to ask and being consulted rather than perusing answers. Communication would make a huge improvement to the overall care. All the above due to lack of permanent caring staff who know the residents’. Five of the comment cards returned said that relatives/visitors were welcomed as St Luke’s. Relatives’/visitors were informed about important matters affecting their relative or friend and they were consulted about their care. Two comment cards made overall positive comments. ‘ Some staff are naturally not so helpful as others but considering the difficulties they have to deal with overall I think they do very well. I do not worry about my husband’s care and don’t think I could find anywhere better’. ‘My husband always seems clean and well cared for when I visit. St Lukes is always kept very clean’. One care manager comment cards was returned. This recorded satisfaction with the understanding of residents’ needs, the standard of records keeping and communication with staff. The comment card said’ no recent action required regarding complaints but some problems occurred over twelve months ago and there are no current problems. I am satisfied with the care currently provided’. One general practitioner comment card was returned and recorded that staff communicated clearly and incorporated specialist advice into the residents’ care plans. No complaints had been received about St Lukes. There needed to be senior staff with which to confer about residents’ health and staff did not always demonstrate an understanding of residents’ health needs. This information was fed back to the manager and operations director present. The details of the authors of the comment cards were not given to the manager and operations director. On 23rd August 2005 an additional visit took place to monitor the requirements identified during the inspection of 23rd May 2005. One requirement identified St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 6 on 23rd May regarding an application for registered manager was extended to October 2005. The other requirements were met. What the service does well: What has improved since the last inspection? What they could do better: Ensure that all relevant information regarding the needs of residents are incorporated into care plans, risk assessment and risk management plans and reviews of residents’ care. Further investment on NVQ training and the completion of Regulation 37 notices are needed. The recommendations about fire containment made by Cheshire Fire Services in October 2004 should be completed. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 8 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 Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 9 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): 1 and 3 The statement of purpose does not need to be amended to include the details of a challenging behaviour unit. Residents are fully assessed before moving into St Luke’s to ensure their needs can be met. EVIDENCE: In discussion with the manager, qualified and care staff on Aspen unit it was clear that the staff perception that Aspen unit is a challenging behaviour unit has changed. Staff on duty on Aspen unit did not believe that residents presented significant levels of challenging behaviour. Staff from other units were asked about Aspen unit being a challenging behaviour unit. There was no consistent view from staff that Aspen unit is a challenging behaviour unit A staff member said ‘ I am based on laurel unit and worked on Aspen unit. I enjoyed working their some residents were challenging but not as challenging as anyone else’. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 10 Since 23rd August 2005 no residents had been admitted to St Luke’s following a decision by Community Integrated Care to suspend admissions and provide training for staff. Care documents relating to residents were examined. There was pre-admission assessment documentation completed for the two most recent residents who had moved into St.Luke’s. Assessments were available from the services from where they had been accommodated prior to moving to St Luke’s and from the local authority responsible for their placement. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 11 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 and 10. Residents’ care plans ensure that their health and social care needs are identified and met but the outcomes of interventions used to manage aggressive behaviour need to be recorded in the reviews of care plans. The procedures for managing medication have improved and residents’ health is not at risk from them not receiving prescribed medication or the indiscriminate use of ‘as required’ medication. Residents are treated with respect. EVIDENCE: Evidence from care plans, and from conversations with the unit managers, qualified staff and care staff indicated that the health needs of residents were met. Since the previous inspection visit the psychiatrist at the request staff at St Luke’s had reviewed residents who presented with unpredictable aggressive and agitated behaviour. These residents have also had a review of their care plans. Risk assessments and risk management plans. The unit managers and qualified staff have been given supernumerary time to revise residents’ care plans. At the time of the visit two qualified staff members were reviewing residents’ care plans. An example of this was a resident who had been involved in incidents of physical aggression toward other residents. His risk assessment was reviewed and identified that a trigger to this behaviour was unfamiliar staff or residents. The risk assessment identified the resident became tense and this resulted in verbal and physical aggression. The action plan was to St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 12 introduce new staff and residents to him and explain who they were and why they were in his home. If the resident was noted to be tense staff were to use distraction techniques to divert his attention from the trigger. There was information on subjects that would divert his attention such as his favourite singer, sportsperson and family members. If the resident became resistive to staff they were instructed to allow him time to calm down. It was recorded that if other residents agitated the resident at mealtimes he could have his meals in his bedroom or sitting room if he wished. There was a care plan in place to support this strategy. The review of this recorded the reduction on incidents from 16 incidents in July to 3 incidents in September. A Psychiatrist reviewed the resident in July and his medication reviewed. Staff described that the resident became agitated if he did not receive as required medication on some morning when he was observed to be tense then his behaviour became aggressive. This behaviour was repeated at night if he refused medication. This information was not transferred into his risk assessment or the reviews of his care. Two other residents had their care plans reviewed following aggressive incidents. One care plans identified that a resident became unpredictable around male staff and female carers were to provide personal care when possible or a female present at the time. The other care plan identified that a resident became resistive to staff help when he was agitated and attempted to grab out at them or twist their arms. Training on the use of breakaway techniques had been provided to staff and advised to wear a covering on their arms that would easily come off if the resident took hold of their arms. A psychiatrist had reviewed both residents and their medication reviewed. Residents’ health needs were monitored. A resident was identified as loosing weight despite staff monitoring this and supervising him at meal times. His care plans identified he needed time and prompting to eat his meals. A dietetic referral was identified as needed. Another resident had been reviewed by a physiotherapist and a decision that she could not be rehabilitated to walk made. It was identified that the resident was able to cooperate with staff and weight bear with their assistance. A risk assessment, risk management plan and care plan to assist the resident to maintain a degree of mobility was in place. Medicine administration, storage and management were examined on all four units. Medicine administration and management had maintained an improvement with only minor errors noted. The manager had continued with the procedure that staff responsible for the administration of medicines complete an audit after each medicine round. This identified errors and the actions taken to rectify the errors noted. A resident talked about the care she received and said ‘I have a problem with my memory, it’s embarrassing when you can’t remember when you spoke to someone or remember their name. Staff don’t mind this they say don’t worry and repeat their name to me they are good like that and remind me of things’. See recommendation 1. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 13 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): 12 and 14. Residents are able to choose and participate in social activities. Residents are able to make choices about and exercise control over their lives. EVIDENCE: The social care element of residents’ care plans had been reviewed. In a resident’s care plans it was recorded that the resident was ‘ a sociable person who enjoys the company of others and social occasions’. Records of activities noted that the resident participated in a visit by the Kingsley drama group, which she enjoyed and joined in a sing a long. Records noted the resident enjoyed a sensory stimulation session. In conversation the resident said ‘I like living here it’s not my own home. I get on well with the others, but sometimes they argue, I don’t get involved. I know the manager’s name Sandra. The staff are good and they help me when needed. I had toast for breakfast this morning but could have had sausage, bacon and hash browns. We went to Blackpool the other week, it was great. If it wasn’t for Jackie the activities lady I would not get out. We go out regularly’. Another resident said I have been doing things recently; I went to a party upstairs this morning. I went out shopping for clothes yesterday with staff. I am well looked after, I have a great laugh here’. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 14 The care of two residents has been reviewed with their family and other professionals involved in their care. It has been recognised that the residents need a distinct staff team separate from that of the care home but still part of the staff team. Internal and external advertisements have been placed to recruit staff. Existing staff dedicated to care for the residents will transfer to the staff team. The staff team will remain under the supervision of the unit manager. Two staff responsible for the care of the residents talked about the development. One staff member said she was to transfer to the team and another said she had applied for a position in the team. The staff interviewed said ‘it’s a positive move, recognition that a flexible care package is needed with staff having more autonomy and responsibility for planning and providing social care’. A staff member said ‘one of the desirable skills is that you can drive and I have been asked if I am prepared to do so. This is what’s needed’. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 15 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): 16 and 18. Complaints are acted upon appropriately. Staff awareness and training of how to manage challenging and aggressive behaviour has improved to ensure residents are protected from abuse. EVIDENCE: Complaint records demonstrated that a complaint made in May 2005 had been acknowledged and a response sent to the complainant. There were details of the complaint and investigation of this on file. Staff on the four units confirmed that they had undertaken training on managing challenging behaviour. A staff member said training had been provided specifically about the care of one resident and the training had ‘showed me how to deflect his hands when he grabs at me and breakaway and how to divert his attention’. Two staff that worked on Willow unit said they had read a resident’s risk assessment and risk management plan on how to approach the resident. Both said that incidents of aggression at lunchtime had reduced. One of the staff said ‘I agree with Pearl, with him it’s mainly about how you approach him. Some staff doesn’t approach him correctly even after we have discussed it with them. They either don’t listen or read the care plan. For example a staff member only works a few hours a week so to the resident she is a stranger and he reacts to stranger, so we don’t leave her alone with him’. A deputy manager from another home had provided training on the local authority adult protection procedures and additional training was planned for 29th September 2005. Risk assessments and risk management plans gave clear directions on how to approach and manage residents who presented with agitated and aggressive behaviour. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 16 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): 22 There is a commitment to improving the standard of specialist equipment for the benefit of residents. EVIDENCE: The manager had purchased a number of individual slings for residents’ use. Additional transfer belts, slide sheets, face masks and aids for eating had also been purchased. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 30. The skill mix and numbers of staff is adequate to meet residents’ needs. Training has improved to provide a more skilled workforce but further training is needed to develop the staff team and provide skilled staff. EVIDENCE: The staffing on Aspen unit had been revised and a twig light shift introduced between the hours of 5pm to 11pm. Staff on the unit said this had made a difference as an additional staff member of staff could provide one to one support for residents who presented with agitated and aggressive behaviour. The manager confirmed this was the only unit that was having additional staff support. The care of two residents has been reviewed with their family and other professionals involved in their care. It has been recognised that the residents need a distinct staff team separate from that of the care home but still part of the staff team. Staff were on duty in a supernumerary capacity to attend a review of a resident, accompany a resident for a hospital appointment and review residents’ care plans. Staff were interviewed about the staffing arrangements. A staff member said ‘ There have been overall improvements on Willow unit. I have been working additional shifts of my own choice. The environment has improved now the refurbishment has finished. We only encounter problems when agency staff are on duty that do not know the routines. That makes it hard, as we can be busy. We need more regular staff. I enjoy my job and have worked here eleven years. If we had more regular staff we continue o provide a good standard of care. It’s no good when agency staff doesn’t know the residents. This doesn’t help us much’. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 18 The pre inspection questionnaire detailed that out of the 46 care assistants employed at St Luke’ s only eight have an NVQ level 2 qualification. The manager produced a training matrix, which recorded that staff had undertaken training in manual handling, fire awareness, food hygiene, health and safety and managing challenging behaviour. A recently appointed qualified staff member said ‘I see that training has improved. There is lots more available. You need a trained staff group. Some staff need to be told they need training or they wouldn’t recognise it. The staff give a good standard of care. I don’t think they let other things affect that. I see a lot more staff on days. We have three staff on duty today. I worked on Aspen the other day and we had extra staff. It was great you had time to assess the residents. Masiza was on duty for two hours while he updated care plans. I have asked to be made a permanent member of staff and not just work on the bank’. Another staff member said’ we have had more training. The office has a notice board with training details on. There is a training session on adult abuse later this month’. At the additional visit on 23rd August 2005 Concern was expressed about the English language content and handwriting standards of the Regulation 37 notifications. A recommendation was made about this. Regulation 37 notifications continue to be received with poor handwriting and English language content. See recommendations 2 and 3. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. There is a competent management structure and monitoring of St Luke’s by senior managers that has provided leadership, guidance and direction to ensure residents receive quality care. EVIDENCE: A manager has been appointed who is registered with the Commission for Social Care Inspection but has not completed the registration as the manager at St.Luke’s care home. An application to register her as manager is being processed. There has been monitoring of St Luke’s by senior managers from Community Integrated Care. This has been by unannounced visits at varying times of the day. This has resulted in changes to working practice at St Luke’s. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 20 A number of staff was interviewed at their own request. Some staff said they were dissatisfied with changes. On the whole staff said the changes were positive and the staff team at St Luke’s was being managed. Staff members said the shift pattern had changed to a twelve-hour shift and this had affected those staff that used public transport having to catch later buses and consequently get home later. The assistant director of care clarified that individual staff had been invited to discuss their own personal circumstances about public transport and arrangements had been made for individuals so their personal circumstances were not affected. A staff member said ‘ I work eighteen hours a week extra, yes my own choice but if they paid a better rate it would attract more staff. The moral would improve and sickness reduces. Yes there is more improvement and managers are more visible, but they cold listen to us more about theses issues’. Two other care staff talked about changes and said they did not think that overall things had improved. A staff member said ‘things are stricter; we cannot have a smoke break anymore. I have to wait for my break or my dinner it’s a stressful job so you would think that you could’. A staff member said ‘ the qualified staff have become much stricter since the new managers have been in post and are visiting. They are much stricter. Moral among the carers differs some are happy some are not ’. A qualified staff member said ‘ I see a lot of change things are more organised and managed. The care staff are managed you can see they are working. Some of them are not happy with the changes but that’s things that affect them personally. Its things like they cannot have a cigarette when they like’. A care assistant said ‘ I really enjoy working here; I have worked here since June. I think it’s more organised. I have worked on Aspen and on Laurel. I look forward to coming into work and enjoy what I do. I am aware there have been some changes recently and they are positive. For example I don’t smoke and staff that do can no longer keep going off for a five minute break. That’s fair and more organised’. The manager undertakes quality assurance. The manager completes a weekly health and safety audit of the building. The handyman tests the water outlet temperatures over a period of a month as part of the health and safety audit. . The registered providers’ representative recorded regulation 26 visits as taking place monthly. Audits on policies and procedures used in the home are completed monthly. The manager completes a monthly management report on clinical information, care plans, pressure ulcers and treatment, health and safety, accidents to residents and staff. Information is then provided to the home on the statistics for accidents and incidents of pressure ulcers. The system in place uses a minimum data set to compile information and informs staff if further assessment and care planning is needed for individual residents. The home completes an audit of medicines after each medicine round. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 21 Satisfaction surveys were last completed from September to November 2004 and the results published in the spring of 2005 in the registered providers ‘you and me’ publication. Residents’ meetings are held every three months. The last meeting was 2nd August 2005. Relatives attended the meeting and highlighted their concerns about the number of recent managers who had nee employed and left the position staff wearing correct uniform and use of agency staff. The new manager Sandra Watkins and Karen Marion assistant director of care attended the meeting. The meeting was informed that a hairdressing salon is to be created at St Luke’s. A general staff meeting was held on 19th September. The minutes of the meeting were available and covered staff compliance with training days. If staff do not attend statutory training then disciplinary measures may be used. A number of training videos had been purchased and the details of these given to staff. Aspen unit was again discussed and it was reiterated it is not a challenging behaviour unit. Staff were informed that smoking breaks are not allowed and staff who some must do so on their official breaks. The unit managers were reminded that it is the responsibility of the nurse in charge to complete an induction form for all agency staff that work at St Luke’s for the first time and ensure they are familiar with residents and policies and procedures. The home does not deal with any residents’ finances except for personal spending money. Otherwise residents control their own money or have relatives who assist them. Residents have personal money in safekeeping. Receipts are given to relatives for money paid in. Residents’ money is kept in separate envelopes; all transactions are recorded and double signed; receipts for all expenditure made on behalf of residents are filed. The fire officer visited the home in October 2004 and advised that fire doors be fitted with cold smoke seals to provide additional safety to residents in case of a fire. These had not been fitted. Following consultation with the fire officer this requirement has been amended to a recommendation as it was identified as a recommendation only by Cheshire Fire Service. See recommendation 4. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 3 X X X x STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP28 OP30 OP38 Good Practice Recommendations All information regarding the needs of residents should be incorporated into risk assessment, care planning and the reviews of residents’ needs Further investment in NVQ training should be made to provide a skilled workforce. Staff should receive training on the completion of regulation 37 notices. The registered person should ensure that fire containment measures recommended by Cheshire Fire Brigade in October 2004 are provided. St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Lukes Care Home DS0000005148.V249794.R01.S.doc Version 5.0 Page 25 - 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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