Inspection on 24/05/05 for St Lukes Care Home

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 23/09/05

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 Palacefields Avenue Palacefields Runcorn, Cheshire WA7 2SU Lead Inspector Anthony Cliffe Unannounced 24 May 2005 09:00 th 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 Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Lukes Care Home Address Palacefields Avenue Palacefields Runcorn Cheshire WA7 2SU 01928 791552 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) Community Integrated Care Care Home 60 Category(ies) of DE(E) Dementia over 65 (60) registration, with number PD Physical disability (2) of places LD Learning disability (2) DE Dementia (10) St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 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 2 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. 3 Date of last inspection 11th October 2004 Brief Description of the Service: St. Luke’s is a purpose built establishment for the provision of nursing care for up to sixty service users 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 service users.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 service users. 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 F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place over a period of eight hours by two inspectors. The inspection was planned following the resignation of the manager and following complaints made about the services provided. The inspectors agreed the format of the inspection with the acting manager. The inspection was carried out using a process of cross referencing the documentation of identified service users following discussion with them, and following the delivery of care and support to them. A tour of the building, including all communal areas, the kitchen and a number of bedrooms, was completed. Four service users and two relatives contributed their experience of living in and visiting the home. Ten of the staff on duty were spoken with. Six requirements remain outstanding from the previous inspection. The Commission for Social Care Inspection has serious concerns how the care home is being managed and will be taking urgent action to address the issues identified. What the service does well: St. Luke’s Care Home provides a safe and well-maintained environment for service users. The home is a two-storey building and is well equipped to meet the needs of service users. Following major refurbishment the home is welcoming and provides a comfortable seating area at the entrance. Service users’ health needs are generally met to a good standard. This is supported by detailed pre admission assessments completed by the acting manager or qualified staff on the units. Service users’ relatives are kept well informed and are involved in their care. Visitors are made welcome. A good variety of food is provided, including the choice of a cooked breakfast every day. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 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 Care Home F51 F01 S5148 St Lukes V228305 240505 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 Care Home F51 F01 S5148 St Lukes V228305 240505 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) 1,3,and 4 The home’s Statement of Purpose and Service Users’ Guide do not inform the reader that a challenging behaviour unit is provided at this home. Therefore the information provided does not fully assist those who need to make a choice to live at the home. Records kept at the home provided evidence that, before moving into the home, all service users had received a full needs assessment that could demonstrate that all service users’ care needs would be met. EVIDENCE: At the beginning of the inspection the deputy manager identified staffing on Aspen unit as a minimum of four staff as this was a challenging behaviour unit. The CSCI had not been informed of a change to the services offered at the home. Care documents relating to a number of service users were examined. These showed that the people most recently admitted to the home had pre-admission assessment documentation completed. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 9 The deputy manager gave an example of a service user admitted to Aspen unit specifically due to having a history of aggressive behaviour. Four care staff interviewed identified Aspen as the challenging behaviour unit and the previous manager had informed them of this. The qualified nurse in charge said the unit was ‘perceived as the challenging behaviour unit and it had been reported as moving toward it’. The deputy manager identified staff as having undertaken ‘CPI’ training but could not explain what the term meant or what the training encompassed, other than it was not control and restraint techniques. A member of the care staff described her training as having taken place ‘ early on last year, it showed you how to stand by them and guide them but no hands on’. Six of the thirteen service users on Aspen unit presented with challenging behaviour. One staff member had been injured by a service user during an incident and was off work for seven weeks. The CSCI had not been informed of the incident. See requirements 1 and 2. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 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, 9 and 10 Management and staffing on Aspen unit is not sufficient to deal with the numbers of service users who present with challenging behaviour and are not suitably trained in dealing with the levels of aggression presented and the health and welfare of service users are at risk. Service user plans do not ensure that health and social care needs are identified and met. The procedures for managing medication had deteriorated and service users’ health is at risk from them not receiving prescribed medication or the indiscriminate use of ‘as required’ medication. EVIDENCE: On Aspen unit care staff interviewed were not clear if there was guidance in care plans on how to deal with challenging behaviour and when asked about a specific service user said ‘we know how we do it, we know how to calm her down, we sit with her, taking her out helps’. The service user had been involved in several incidents when staff and other service users had been attacked resulting in injuries to them. There was no clear guidance on if and when restraint should be used. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 11 When the nurse in charge on Aspen unit was interviewed he confirmed a plan of care in place to manage the challenging behaviour of a service user, which was not adequate and referred to the registered provider’s policy on managing challenging behaviour which he was not familiar with. Following incidents when service users and a staff member had been assaulted by a service use, behavioural monitoring forms were introduced to monitor the challenging behaviours of the service user. Further incidents were recorded and the care plan was not reviewed and there was no analysis of the incidents recorded. As required medicines were used to manage the agitated and aggressive behaviour of service users. Daily records referred to service users having settled and manageable days when they interacted with other service users and staff and did not present challenging behaviour. Daily records and medicine records noted that as required medication was used when service users did not present challenging behaviour. There was no rationale for the use of as required medication. One service user had been given this for up to four times a day. Records examined showed that the service user had been reviewed by a psychiatrist and medication increased to manage challenging behaviour. Yet over a short period of time the dosage was increased to double the original and still being given up to four times a day. The service user’s daily records recorded the service user was drowsy for long periods of time. The service user had also lost a considerable amount of weight in a short period of time yet this had not been identified as a problem. A member of the care staff was observed attempting to assist a service user to eat lunch while the service user was walking around and who did not wish to sit and eat. The staff member attempted to place food in the service user’s mouth with a spoon, which increased the service user’s level of agitation. The staff interviewed said they were familiar with the policies on dealing with service users who presented with agitated and violent behaviour but were not aware of supporting documents to be completed by them on managing incidents. On Aspen unit the nurse in charge admitted he had not read the care plans pertaining to service users and preferred to get to know individuals needs by caring for them. Care plans were not being updated as needs changed and reviews were not being completed monthly. Examples were that the continence needs, nutritional needs and risk of developing pressure ulcers were not reviewed regularly. Records recorded weight loss, increased incontinence and the development of pressure ulcers. The nurse in charge on Aspen unit identified there were no service users with pressure ulcers on the unit yet the records of a service user recorded a pressure ulcer and no care plan was in place. On Laurel unit the nurse in charge identified two service users with pressure ulcers. For one of these the care plan referred to only one pressure ulcer when daily records recorded two were present. The other care plan identified the pressure ulcer and how frequent the dressing should be changed but there was no wound monitoring plan in place. Care plans examined on Willow and Rowan units were detailed in how to meet service users’ needs and supported by risk assessment and risk management plans. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 12 Medication administration had not improved. Signatures had not been recorded for the administration of medicines for service users on all four units. The code O had been used as the reason for non-administration of medicines but this was not a code identified on the medicine administration sheet. Medicines had been recorded as being out of stock. Medication administration took the qualified staff approximately an hour on Aspen unit. This was due to several interruptions to answer enquires by telephone and from staff. The qualified member of staff identified he had not signed for the administration of some medicines earlier in the morning. Hand written medicine administration sheets did not record the quantities of medicines received into the home. See requirements 3 to 6. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. Service users are supported to exercise choice in their lifestyle, but choice in how their social needs are addressed needs to be demonstrated. Families and friends are welcomed into the home at any reasonable time. Service users have a good choice of meals in pleasing surroundings. EVIDENCE: Service users were seen to be free to move around the units within the home. There was access to the internal courtyard and sensory garden. A variety of sitting areas were available. Staff were observed spending social time with service users. There were no planned activities in the morning as some staff were attending the funeral of a service user. In the afternoon the activities organisers were providing beauty therapy in the first floor units. There was a programme of activities displayed in the units but in discussion with qualified and care staff they commented that the activities organisers visited the units in turn to provide activities, but this was not on a daily basis. Staff interviewed identified the two activities organisers as doing a good job with weekly trips out and opportunities to go to the pub. Some service users’ care plans recorded their preferences regarding social care, but there was no evidence if the programme of activities reflected service user choice. Two service users have individual care packages. One of the service users has additional social care provided for activities outside of the home. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 14 On the day of the inspection a planned trip out was cancelled for the service user as the home’s transport was used to take another service user for a hospital appointment. In discussion with the staff caring for the individual the staff member said that transport was cancelled on other occasions, and the transport provided by the home was the only suitably adapted transport available. There were a number of visitors to the home throughout the day. They were made welcome and were clearly comfortable in approaching staff. A visitor said that his wife had been a resident at the home for three years. He said he or his daughters visit every day and he visits until lunchtime and can visit at any time he wished. He said he did not stay during lunch as staff noticed his wife became increasingly agitated at this time. He said his wife did not like him to see her eating and he agreed with staff not to stay for lunch. The home provides three full meals a day. A cooked breakfast was observed to be served to several service users. The menu provides service users with an alternative choice at mealtimes. The kitchen was clean and well organised and food storage was safe. The chef was enthusiastic and said she would provide service users with whatever they chose if the alternative on the menu did not suit their choice. See recommendation 1. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Complaints are not acted upon appropriately. Service users are not adequately protected from abuse. Managers at the home need to monitor and report the incidents of physical incidents and confrontation between service users and report these under the adult protection procedures when necessary to improve the protection of service users. Staff awareness and training of how to manage challenging and aggressive behaviour needs to improve to ensure service users are protected from abuse. EVIDENCE: Prior to the inspection the CSCI received a written complaint, which was referred to the provider to investigate. The provider notified the CSCI of a further complaint it was investigating using its complaints procedure. Examination of the complaints records noted a third complaint made by a visiting professional to the local authority contracting officer regarding health and safety of service users during the refurbishment of the home. These complaints were not adequately recorded. Records lacked a cohesive audit trail. There was no format to document general information of the person who made the complaint or who investigated it. The records lacked details on the complaint, investigation methodology, investigation findings, and summary of findings on conclusion of the investigation to identify the outcome with an action plan if needed. Training records identified that training on adult abuse had not taken place and a course arranged for January 2005 had been cancelled. The nurse in charge and a carer on Aspen unit were not clear on what approach should be used with a resident who presented agitated and aggressive behaviour. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 16 Both stated they did not read the service user’s care plan. They were aware the service user was physically aggressive and the care assistant said she would not use physical restraint but would walk away when presented with aggressive behaviour. The care plan in place to manage this dated back to December 2004 and in review identified the use of minimal restraint but was not clear what ‘minimal restraint was. The risk assessment to manage the behaviour dated November 2004 advised staff to ‘retreat for a short period of time and return later’. There were a number of incidents recorded of assaults on service users by other service users and assaults on staff. It was not clear if these matters had been considered abusive and referred to the local authority. See requirements 7 and 8. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 17 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, 20 and 26 Service users live in a safe and well-maintained home, which is clean and hygienic. There is a commitment to improving the standard of accommodation for the benefit of service users. EVIDENCE: St. Luke’s is a two-storey building and all rooms and areas, including the gardens, are spacious and are accessible to wheelchair users. All communal areas, the kitchen and some of the bedrooms were seen during this inspection. The home has had a refurbishment programme completed. This has included decoration of the units and replacement of carpets and furniture. Curtains and bedding are yet to be replaced. Externally the enclosed courtyard has been resurfaced and raised manhole covers removed. A sensory garden has been created. The home was free from odours and visitors said the home was always clean. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 18 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) 27,28, 29 and 30. Recruitment procedures have improved and build in some protection for service users. However, the health and welfare of service users is at risk because staff are not sufficiently trained to do their jobs. The health and welfare of service users on Aspen unit is at greatest risk because staffing levels and training are inadequate to care for the num of service users who present with challenging behaviour. EVIDENCE: The deputy manager gave an example of a service user admitted to Aspen unit specifically due to having a history of aggressive behaviour. Four care staff interviewed identified Aspen as the challenging behaviour unit and the previous manager had informed them of this. The qualified nurse in charge said the unit was ‘perceived as the challenging behaviour unit and it had been reported as moving toward it’. The deputy manager identified staff as having undertaken ‘CPI’ training but could not explain what the term meant or what the training was other than it was not control and restraint techniques. A care staff described her training as having taken place ‘ early on last year, it showed you how to stand by them and guide them but no hands on’. Six of the thirteen service users on Aspen unit presented with challenging behaviour. One staff member had been injured by a service user during an incident and was off work for seven weeks. The CSCI had not been informed of the incident. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 19 Recruitment procedures for staff had improved with the registered provider ensuring that Protection of Vulnerable Adult and Criminal Records Bureau checks were completed prior to staff commencing employment. Applications for employment contained a chronology of the applicant’s previous employment details. Only four of the forty-two support workers employed have an NVQ level 2 in care. The deputy manager identified staff as having undertaken CPI training but could not explain what the training was other than it was not control and restraint techniques. A care staff described her training as having taken place ‘ early on last year, it showed you how to stand by them and guide them but no hands on’. Training records noted that training on adult abuse had not taken place and a course arranged for January 2005 had been cancelled. The nurse in charge and a carer on Aspen unit were not clear on what approach should be used with a resident who presented agitated and aggressive behaviour. Training records recorded that staff last had training in moving and handling in 2003, with thirty-seven of the current staff having no record of this training. Only six of the forty-two support workers had received training in basic food hygiene with the dates recorded as 1998. Only four support workers had a first aid certificate. Fire training had improved but sixteen of the forty-two support workers and one qualified staff member had not received fire training or attended a fire drill. Nine out of forty two support workers had received training in dealing with challenging behaviour and six of the trained staff. See requirements 2, 3 and 9 and recommendation 2. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 20 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) 31,32,36 and 38 There is no leadership guidance or direction in the home to ensure residents receive consistent quality care. The ethos of the home is unclear. This results in some practices that do not promote and safeguard the health and safety of people living in the home. EVIDENCE: The previous manager has resigned since the last inspection visit and an acting manager is in place. The registered person has not appointed or proposed a manager for registration and no application for registration as manager has been submitted to CSCI. Support workers interviewed said they received supervision in excess of six times a year as recommended and communication within the home was good. There were examples of the qualified nurses on two units not reading the care plans of service users and not being aware of service users’ health needs. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 21 Staff are unclear about the role of Aspen unit and this is perceived as a challenging behaviour unit. Despite training in dealing with aggressive behaviour, staff are unclear about the use of restraint. There are no guidelines on the use of ‘as required’ medicines which seem to be used indiscriminately without a clear rationale. There were no records available of the electrical safety certificate for the home. 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. See requirements 10 and 11. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 3 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x 3 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 1 1 x x x 3 x 1 St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 23 YES 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. Standard OP1 Regulation 4 Requirement The statement of purpose must be reviewed to ensure that it includes details of a service for people with challenging behaviour. The registered person must review the staffing numbers to ensure the health and welfare needs of service users are met. The registered person must provide staff with appropriate training in dealing with the management of aggressive and challenging behaviour. The registered person must ensure that records that identify service user needs and staff responsibilities in meeting their health and welfare are kept under review, including appropriate risk assessments, risk management strategies and where necessary treatment and advice from health care professionals on tissue viability.(Timescale 10.11.04 not met) The registered person must inform the Commission for Social Care Inspection of any event in the care home which adversely Timescale for action 1.08.05 2. OP3 and OP27 OP3, OP27 and OP30 18 1.8.05 3. 18(1)(i) 1.9.05 4. OP7 and OP8 14 and 15 1.8.05 5. OP3 and OP7 37 1.7.05 St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 24 6. OP9 7. OP16 8. OP18 9. OP27 and OP30 10. OP31 11. OP38 affects the well being or safety of any service user. 13(2) The registered person must ensure that staff record on medication administration record sheets all administrations of medicines, and any reason for non-administration. The quantities of medicines received in the home must be recorded and adequate stocks of medicines maintained. (Timescale 1.12.04 not met) 17(2) The registered person must Schedule ensure there is a complaints (4)(11) procedure, which is appropriate and to the needs of service users, Regualtion ensures that all complaints are 22 fully investigated, and informs the person making the complaint of the outcome and action, if any to be taken or outcome. (Timescale 1.12.04 not met) 18(1)(i) The registered person must ensure staff are aware of and attend the providers and local authority training on adult abuse and understandiing adult protection procedures. (Timescale 1.12.04 not met) 13(5) The registered person must 18(1)(i) ensure that staff are trained in 23(4)(d) moving and handling, basic food hygiene, first aid and fire safety. (Timescale 1.12.04 not met) 8(1)(a) The registered person must ensure that an application for a suitably qualified and experienced manager is submitted to the Commission for Social Care Inspection. 23 and 24 The registered person must ensure that fire containment measures and electrical safety systems within the home are maintained. (Timescale 1.12.04 not met F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc 1.7.05 1.8.05 1.8.05 1.8.05 1.8.05 1.8.05 St Lukes Care Home Version 1.30 Page 25 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 OP12 OP28 Good Practice Recommendations An activities programme based on the interests and preferences of service users should be available to service users throughout the day. There should be further investment in training to maintain a skilled workforce. St Lukes Care Home F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire, 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 F51 F01 S5148 St Lukes V228305 240505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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