Inspection on 12/04/06 for St Lukes Nursing Home

This inspection was carried out on 12th April 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 10/01/06

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 12th April 2006 08:30 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.V286645.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.V286645.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 (5), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30), Terminally ill (1) St Lukes DS0000054407.V286645.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) - 30 (both) Physical Disability over 65 years of age (PE(E) - 30 (both) Dementia - over 65 years of age (DE(E) - 5 (Both) Terminal Illness - under 65 years of age (TI) - 1 (Female) The category of DE(E) - over 65 years of age applies where staff are receiving on-going training in dementia care, and the numbers and skill mix of staff are reflective of the levels of needs within the home. The category TI under 65 years of age applies to the service user named in the proposal to register dated 21 September 2005 The maximum number of service users to be accommodated is 30 2. 3. 4. Date of last inspection 10th January 2006 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 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. The current scale of fees are £370:00 - £563:68 St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was carried out over approximately 7 hours at the home. Information already held by the Commission for Social Care Inspection (CSCI) has been taken into account when compiling the report. The site visit consisted of following the care experiences of a sample of residents by speaking with them and looking at their records and those of the staff who work with them. The inspector spoke with 5 residents, the manager, three members of staff and a relative. A tour of the building took place, and a range of general records were looked at. What the service does well: What has improved since the last inspection? What they could do better: Private residents would benefit from the provision of contracts and there could be improvements to the information held in individual files. The home needs to provide lockable storage space for self-administered medication. Although there is access to some activities, residents would benefit from the opportunity to engage in more activity within the home. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 6 There are shortfalls in the training programme such as tissue viability and dementia training, which may result in resident’s needs not being fully met. All health and safety information should be readily available within the home: and improvements could be made to the delegation of responsibilities for senior staff, and communication between the team, in order to maintain the provision of an effective and efficient service to 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.V286645.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.V286645.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): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information to residents and relatives to help them make informed choices, and they are assured that the home can meet their needs through a comprehensive assessment process. Private residents would benefit from the provision of contracts. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User Guide, which is available to residents and relatives in the home. All residents spoken to apart from one said that they were given enough pre-admission information and that they had had their needs assessed before moving into the home. A relative said that they had received good information about the home in order to help make a choice. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 9 Contracts were seen for Local Authority funded placements but there were none available for privately funded residents (refer to Standard 16 for recommendations). The home does not offer intermediate care at this time. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from comprehensive care plans and access to a range of healthcare professionals. However there could be improvements to the information held in individual files. There may be risk to residents due to a lack of lockable storage space for self-administered medication. EVIDENCE: Three resident’s files were looked at during the visit and all contained care plans for needs such as dementia, tissue viability, catheter care, oral hygiene and nutrition. There was evidence of monthly reviews on each file and risk assessments were also available for needs such as moving and handling, falls and tissue viability. There was also evidence that residents have access to McMillan nurses, District nurses and GP’s where they require such. Some information in individual files such as admission details were not consistently completed and a recommendation to record end of life arrangements remains in place. Two out of three files did not contain photographs of residents. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 11 Residents said that staff are ‘very kind’ and ‘they do all they can for you’. They said that staff maintain their privacy, and staff were observed to discuss care needs in private and ensure that they knocked on doors before entering rooms. Call bells were answered promptly, residents who were in bed were comfortably positioned and resources for infection control procedures were retained in individual bedrooms. There is a medicines policy in place, which refers to self-administration however during a tour of the home it was found that there is still no lockable facilities fro residents to keep their own medication. A medicine round was observed and administration practices were satisfactory. Records, including those for controlled medication were completed satisfactorily St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 12 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, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents enjoy a balanced diet based on their likes, dislikes and choices. Although they have access to some activities, they would benefit from the opportunity to engage in more activity within the home. EVIDENCE: Residents said that they have recently had a coffee morning at the home and they have taken part in a quiz, which they enjoyed. They said that the local pub are holding bingo games once a month, which they can attend and they have access to a library and daily newspapers. Staff said that there is now an activity ‘committee’ that is planning a trip to a local cinema in the near future. Residents and a relative said that they would welcome more in-house activity to provide stimulation for those that want it. There is no formal programme of activity available and a previous requirement remains in place. Residents said that they enjoy the food provided by the home and they can have alternatives if they want, comments such as ‘the cook does a lovely job’ were made. They said that staff bring the menus to them and they can choose their evening meal. Staff were observed to discuss choices of evening meals with the residents. Residents said that they could eat their meals where they St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 13 wish to and a relative said that they are invited to take meals at the home. There was a relaxed atmosphere in the dining room and tables were laid nicely with flowers. Meals were well presented and wine was available with the meal for those who wished it. Menus were seen to be balanced and there was a good range of foods available in the kitchen. Fresh vegetables were available and the cook was preparing home baked desserts during the visit. Residents said that they can receive visitors when they wish to and a relative said that staff always welcome them into the home and are kept informed of any changes. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 14 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are safeguarded by policies and procedures, and they benefit from a knowledgeable and appropriately trained staff team. EVIDENCE: There is a copy of the local authority guidance relating to safeguarding adults, and a complaints policy is available in the home. Residents and relatives said that they have no complaints about the home at the moment but they would talk to staff if they did have. The Commission for Social Care Inspection (CSCI) has received one complaint about the home since the last inspection, which related to fees and individual care provision. The complaint was investigated by the home under their complaints policy and was unsubstantiated. A recommendation has been made to provide clear contracts for privately funded residents as a result of the complaint. Records show that staff receive training in adult protection issues, and during discussions staff demonstrated their understanding of the issues and reporting procedures. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 15 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, 24, 25 and 26 Quality in this outcome area is good. The judgement has been made using evidence including a visit to the service. Residents benefit from a comfortable and hygienic environment that meets their individual needs. EVIDENCE: During a tour of the home resident’s bedrooms were seen to be well personalised, clean, tidy and containing specialist equipment in accordance with assessed needs such as pressure relieving mattresses, hoists and recliner chairs. Call bells were accessible in bedrooms and in communal areas and the environment in general was clean and tidy. Residents said that they like their rooms. Cleaning materials were stored appropriately and door guards were in place where doors were held open. The laundry area was tidy and new detergent St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 16 dosing systems are in place for washing machines in order to improve the quality of the laundry. Two new baths have been installed in ground floor bathrooms and new flooring fitting in one bathroom. Specialist equipment such as bath seats, wheelchairs, hoists, walking frames and raised toilet seats were in place where required. The acting manager said that the leaking skylight highlighted at the last visit has been made safe and will be replaced when the weather improves. The lift to the first floor was not working when the inspector arrived at the home but was repaired by lunchtime. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 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, 29 and 30 Quality in this outcome area is good. The judgement has been made using evidence including a visit to the service. Residents are safeguarded by robust recruitment procedures; however there are shortfalls in the training programmed that may result in residents needs not being fully met. EVIDENCE: There was one qualified nurse and four care staff on duty during the inspection, and the acting manager was also on duty. The rota showed that this was reflective of the numbers and needs of the residents. Staff were seen to take time to talk to residents and had time to meet all their needs. During discussion, staff said that there are comprehensive handover periods between shifts and they demonstrated a good understanding of resident’s needs and infection control procedures. Records demonstrated robust recruitment procedures and the information required by Schedule 2 of the National Minimum Standards was available on individual files. There was evidence of induction training and staff said that they have also had training in moving and handling, fire safety and adult protection (see Standard 18); and that they have access to NVQ training. Records confirmed this but there was no evidence of up to date training in dementia or tissue viability. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. The judgement has been made using evidence including a visit to the service. The monitoring of health and safety concerns protects residents but all health and safety information should be readily available within the home. There is a supported and supervised staff team but there could be improvements made to the delegation of responsibilities for senior staff, and communication between the team, in order to maintain the provision of an effective and efficient service to residents. EVIDENCE: The acting manager is a Registered Nurse with experience in caring for people with dementia. She has been in post for approximately two years but to date there has been no application made to CSCI to become the Registered St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 19 Manager. Staff said that the acting manager is approachable and helpful. Records show that individual supervision sessions are taking place. The home conditions of registration were discussed in relation to the provision of terminal care. The acting manager said that she would make an application to vary the current condition of a named bed. Since the last inspection a new fire alarm panel has been fitted and weekly alarm checks are recorded. Records also demonstrate that other fire safety checks are made regularly. Fire and other environmental risk assessment were not readily available for inspection as they had been moved to an alternative file, which the acting manager and responsible individual were not aware of. Data sheets for the Control of Substances Hazardous to the Health, (COSHH) were available but there were still no care plans in place regarding resident’s finances. The deputy manager said that a survey for residents and relatives is in draft and this will be sent out in the near future. The acting manager and the responsible individual said that the deputy manager was responsible for quality assurance, care planning and NVQ assessing. Staff said that there are still no staff meetings being held at present. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 20 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 3 St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 21 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. This requirement was made on 10/01/06/ The time scale for action was not met; a further date has been set. 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. This requirement was made on 10/01/06. It is acknowledged that some progress has been made but further work is required. The responsible person must ensure that the building is kept DS0000054407.V286645.R01.S.doc Timescale for action 12/08/06 2 OP12 16(m)(n) 12/08/06 3 St Lukes OP19 23(2)(b) 12/08/06 Page 22 Version 5.1 4 OP30 18(c)(i) 5 6 OP31 OP33 8 24 in a good state of repair and that risk assessments are in place to protect residents’ safety needs. This requirement was made on 10/01/06 and time scales for action have not been met. A new time scale has been set. The responsible person must ensure that staff receive training in dementia care and tissue viability. The acting manager must submit an application to become registered with CSCI 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. This requirement was made on 10/01/06 and time scales for action have not been met. A new time scale has been set. 12/09/06 12/07/06 12/08/06 7 OP35 15 12/08/06 St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 23 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. 5. 6. Refer to Standard OP1 OP3 OP7 OP16 OP11 OP32 Good Practice Recommendations It is recommended that prospective residents be given a statement of purpose and service user guide at the time of the pre-admission assessment or preferably earlier. It is recommended that individual admission sheets be completed in full on the day of the admission. It is recommended that individual admission sheets be completed in full on the day of admission. It is recommended that photographs be placed on individual files as soon as possible after admission. 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 provide a forum for staff to enable views to be shared and to ensure a robust system of communication. St Lukes DS0000054407.V286645.R01.S.doc Version 5.1 Page 24 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. 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