Inspection on 10/01/06 for St Lukes Nursing Home

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Nursing Home 28/11/07

St Lukes Nursing Home 12/04/06

St Lukes Nursing Home 16/08/05

St Lukes Nursing Home 10/12/04

St Lukes Nursing Home 10/05/04

St Lukes Nursing Home 10/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Lukes St Lukes Nursing Home 35 Main Street Scothern Lincoln Lincs LN2 2UJ Lead Inspector Wendy Taylor Unannounced Inspection 10th January 2006 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 DS0000054407.V274864.R01.S.doc Version 5.1 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 DS0000054407.V274864.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Lukes Address St Lukes Nursing Home 35 Main Street Scothern Lincoln Lincs LN2 2UJ 01673 862264 01673 862264 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) Carecall Limited Care Home 30 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care with nursing to service users whose primary needs fall within the following categories:Old age, not falling within any other category (OP). Physical disability over 65 years of age (PD[E]). Physical disability over 65 years of age (PD[E]). The category of DE(E) - over 65 years of age applies to the service user named in the notice of proposal to register dated 16 June 2004 and the service user named in the notice of proposal dated 24 March 2005 The maximum number of service users to be accommodated is 30. 2. 3. 4. 5. Date of last inspection 16th August 2005 Brief Description of the Service: St Lukes Nursing Home is situated four miles north of Lincoln, in the rural village of Scothern. The village has a pub and a church. The home is registered as a care home with nursing, and accommodates 30 older people. The home is a converted two-storey building with a single storey extension to the rear. There are 26 single rooms and 2 shared rooms. There are enclosed gardens to the rear of the property laid to lawns and flowerbeds. These have been made more accessible to service users by means of ramps and handrails. There is also an enclosed courtyard furnished with garden furniture and a containing a water feature. The home has an Acting Manager who is responsible for the management of care. The responsible individual for the company is responsible for the administrative aspects of the homes management. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in January 2006. Observations were made of the general care provision and the environment. Resident and staff files were looked at as well as general records. Residents, relatives and staff were spoken to and the feedback regarding care provision was positive for the most part. Any issues raised are highlighted in the body of this report. Residents made comments such as ‘I’m glad to be living here’ and ‘this is a lovely place and the staff are all very nice’. Relatives made comments such as ‘mum gets great care’ and ‘the staff are wonderful’. Nine requirements and five recommendations were made at this inspection. Progress toward previous requirements and recommendations are recorded below. What the service does well: What has improved since the last inspection? What they could do better: The home needs to provide secure storage facilities in bedrooms for those residents who self-administer medication. They also need to provide opportunity for residents to engage in activities during the day and show that they have consulted with the residents about activities. The home should include financial care plans and risk assessments where needs are identified, and they should develop a robust quality assurance system. There is a need for the home to provide staff training in regard to adult protection issues, and to ensure that all staff recruitment documentation is available in staff files. Although there have been improvements in the provision St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 6 of supervision for care staff, the home needs to ensure that all qualified nurses also receive supervision. There are continuing recommendations that the home provides a forum for staff to share their views and ensure a robust communication system, and that they complete all information sections in residents files, even where information is not available (e.g. N/A or N/K). Further good practice recommendations have been made to record individual end of life arrangement and/or wishes. And to improve the system of menu planning that includes consultation with residents. 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 DS0000054407.V274864.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not inspected at this visit, however the key standards were inspected at the last visit and no shortfalls were found. EVIDENCE: St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10,11 Residents benefit from comprehensive care plans and risk assessments, however they would benefit further from the additional recording of plans/support required for finances and end of life arrangements. Residents are treated with respect and their privacy and dignity is maintained. EVIDENCE: Four resident’s files were looked at during the visit. Files are well laid out and consistent in their format. Care plans included needs such as diabetes, continence, sleep, tissue viability, communication and oral hygiene. There are no care plans or risk assessments in place for financial issues that are highlighted (see Standard 35). They refer to social needs and personal comfort. There is clear recording of peoples likes and dislikes and body charts are used appropriately. There are risk assessments available for issues such as mobility, tissue viability and nutrition. There is also evidence of monthly reviews for care plans and risk assessments. Some sections of the personal records were left blank which may indicate that information has been missed or forgotten. A recommendation made at the previous visit remains in this report. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 10 Although next of kin details are completed, there is no recording of personal end of life arrangements or wishes, however staff were able to give clear and detailed descriptions of how physical, emotional and psychological support is provided. There is a clear medication policy, which includes self-medication. Storage and administration arrangements were observed, including those for controlled medications and they were found to be satisfactory. Recording was also found to be satisfactory. Several people undertake self-medication for sprays, creams and drops but there is no lockable storage available within their rooms. Residents and relatives said that staff maintain privacy and dignity for them when providing care and they said that staff speak to them with respect. Staff described clearly how they ensure bedroom/bathroom doors are closed when providing care, and how they help people with their appearances e.g. hair care, nail care and choice of clothing. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 There is a good level of interaction between residents and staff, however they would benefit from more consultation and choice about menus and activities. EVIDENCE: There was evidence of specific entertainments such as coffee mornings and parties, however there was no programme or evidence of provision of daily activity. One resident said that they did not wish to engage in any set daily activity but others spoken to and relatives said that they would welcome the opportunity to engage in structured activity such as craft sessions during the day. Residents said that staff do spend time sitting and chatting to them, and they take them out shopping. They also said that they have access to communion, hairdressing and nail care by staff. There was a good level of respectful interaction observed between residents and staff. The menu for the day was available on a blackboard in the dinning room but there were no choices listed. Records are kept of what each person has eaten and they demonstrate that alternatives are provided based on likes and dislikes of individuals, and that the diet is varied. They also demonstrate that special diets are appropriately catered for. The cook said that she talks to residents about their general likes and dislikes and prepares a flexible 8 week menu, but this is not based clearly on resident’s choices. Residents said that St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 12 the food was very good and the cook makes her own pastry and bakes her own cakes, however all those spoken to said that they would welcome the opportunity to make more of their own choices. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Residents are protected by policies and procedures relating to complaints and adult protection, and they benefit from staff that understand the issues. There is however a potential risk from shortfalls in the staff training programmes. EVIDENCE: Relatives were aware of how to make a complaint and there was evidence that the home have begun to address issues already raised with them. There has been one issue raised at the home, which was referred to adult protection services. The issue has been resolved with no further action advised. The home has a copy of the Local Authority guidance on safeguarding adults however it is an out of date version. Staff said that they have not received adult protection training but they were able to give clear and detailed descriptions of how they would manage situations. The home has policies and procedures relating to voting, advocacy and residents rights. Residents said that they are supported to use their right to vote by either postal methods or by being taken to the local polling station. Staff said that they support resident’s to locate solicitors or other advocacy services where they are requested. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,24,26 Residents enjoy a generally safe and pleasant environment but there is a shortfall in the maintenance of the building, which could place resident’s at risk. They benefit from a range of specialist equipment for individual needs. EVIDENCE: A tour of the building showed the home to be clean and tidy; and corridors and communal space was generally free from any obstructions to mobility, except that a bowl and slippery surface signs were seen in a corridor. Staff said that this was there because the skylight was leaking. The weather at the time of the inspection was heavy rain. The staff also said that several attempts have been made to fix the leak, without success. Resident’s bedrooms were found to be well personalised with for example pictures, photographs, comfortable chairs, televisions and personal telephones. Door guards are now in place on bedroom doors as required at the previous inspection. Call bells were accessible within individual bedrooms. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 15 Cleaning staff were on duty during the inspection and COSHH (Control of Substances Hazardous to Health) materials were stored and monitored appropriately. Specialist mattresses, hoists, walking frames, wheelchairs and handrails are available throughout the home in accordance with individually assessed needs. The responsible person said that the home is due to begin a programme of redecoration. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 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 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): 27,29 Residents currently benefit from adequate numbers and skill mix of staff. Although recruitment practices are generally robust, there continues to be shortfalls in the availability of required documentation. EVIDENCE: Staff rotas were looked at and they showed that there are 6 staff on duty in the mornings, 5 on duty in the afternoon/evening and 3 at night. Domestic and kitchen staff are also on duty during the day. Staff said that at present the person allocated to do laundry is off sick therefore all staff are helping out. Relatives raised issues regarding the quality of laundry services during the visit and the inspector asked staff to monitor the situation. Staff on duty during the visit matched with the rota. Two qualified nurses are rostered to work on the morning shifts and 1 qualified on each of the afternoon/evening and night shifts. Staff said that the rotas are flexible and are determined by the number and needs of the resident. Staff and residents said that there is currently enough staff on each shift to meet needs but there have been times when they have felt that more staff were needed. Call bells were answered in good time. Four staff files were looked at. Three of the files did not contain identification including a photograph. This issue was raised at the last inspection and the requirement remains in place. All other information required under Schedule 2 of the National Minimum Standards was available. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36,38 Although risk assessments have been updated, the fire indicator panel needs replacing. There continues to be shortfalls in the quality assurance system, and improvements to the arrangements in place to support resident’s financial needs are required. EVIDENCE: Staff said that they receive good support from the acting manager and their supervisors and they said that there is good teamwork at the home. They said that they felt able to speak openly to the acting manager and qualified nurses and felt that they would be listened to. Care workers said that they receive monthly, recorded supervision sessions and daily input from qualified nurses. There was no evidence of supervision for qualified nurses. Staff said that they do not have staff meetings at present. There was no evidence of quality assurance activity within the home. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 18 The fire risk assessment has been updated in October 2005 as required at the last inspection. Weekly fire alarm testing has not been carried out since November 2005. The responsible individual said that the system had been serviced in November 2005 (evidence seen) and is in working order however they are unable to reset the system if it is engaged. There was evidence that a new fire panel was ordered on 23 December 2005. The home has a policy on finances for resident. Accounting records were seen for resident’s personal money and these tallied with the money held by the home. There is secure provision available within the home for the storage of money and valuables. Issues were raised during the inspection regarding money/valuables that residents wish to keep themselves and that the home is not aware of. No care plans or risk assessments were in place were individual needs have been highlighted. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X X 3 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 2 2 X 2 St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes 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 OP9 Regulation 13(2) Requirement In accordance with Royal Pharmaceutical Society guidance (The Administration and Control of Medicines in Care Homes and Children’s Services, Sect 5.1 paragraph 7) the home must provide an individual locked cupboard or drawer in the resident’s bedroom for the storage of medicines. The responsible person must make provision/ arrangements for residents to be able to engage in social and recreational activities where they wish to, following consultation with them regarding their likes, dislikes and choices. The responsible person must ensure that there is provision for the training of staff in relation to the protection of vulnerable adults. The responsible person must ensure that the building is kept in a good state of repair and that risk assessments are in place to protect residents safety needs. The responsible person must DS0000054407.V274864.R01.S.doc Timescale for action 10/03/06 2 OP12 16(m)(n) 10/03/06 3 OP18 18(1)(c) (i) 10/04/06 4 OP19 23(2)(b) 10/03/06 5 St Lukes OP29 19(4)(b) 10/03/06 Page 21 Version 5.1 (i),Sch2 6 OP33 24 7 OP35 15 8 9 OP36 OP38 18(2) 23(4)(c) ensure that staff files contain evidence of the person’s identity, including a recent photograph. The registered person must establish and maintain a system for reviewing and improving the quality of care in the home. This standard is outstanding from the inspection carried out on 10 May 2004. It is acknowledged that some action has been taken but further work is required. The responsible person must ensure that care plans and risk assessments are available in respect of financial issues, and provide evidence that residents and/or their representatives have been consulted about the plan. The responsible person must ensure that all staff are appropriately supervised. The responsible person must ensure that they provide effective fire warning systems and risk assessments. 10/03/06 10/03/06 10/04/06 18/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP11 OP15 Good Practice Recommendations It is recommended that the home complete all information sections in residents files, for example using statements such as not applicable or not known where necessary. It is recommended that the home record end of life arrangements and wishes following consultation with the resident and/or their representatives. It is recommended that the home implement a system of menu planning that includes consultation with residents DS0000054407.V274864.R01.S.doc Version 5.1 Page 22 St Lukes 4 5 OP18 OP32 about their choices. It is recommended that the home obtain an up to date version of the Local Authority guidance on the protection of vulnerable adults. It is recommended that the home provide a forum for staff to enable views to be shared and to ensure a robust system of communication. St Lukes DS0000054407.V274864.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 DS0000054407.V274864.R01.S.doc Version 5.1 Page 24 - 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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