Inspection on 16/08/05 for St Lukes Nursing Home

This inspection was carried out on 16th August 2005.

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 10/01/06

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 Nursing Home 35 Main Street Scothern Lincs LN2 2UJ Lead Inspector Wendy Taylor Unannounced 16 August 2005 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 Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Lukes Nursing Home Address 35 Main Street Scothern Lincs LN2 2UJ 01673 862264 01673 862264 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) Carecall Limited N/A Care Home with Nursing 30 Category(ies) of OP -Old Age - 30 registration, with number PD(E) - Physical Disability over 65 years - 30 of places DE(E) - Dementia over 65 years - 2 St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 10/12/04 Brief Description of the Service: St Luke’s 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 Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in August 2005. A tour of the building took place and resident and staff files were looked at. Five residents and two visitors were spoken to and comment cards were received from two relatives; and their feedback was generally positive. Observation of the care provided and general interaction between staff and residents took place throughout the inspection. The atmosphere in the home was comfortable and relaxed. There were five requirements and three recommendations made at the last inspection. Progress will be indicated in the following report. What the service does well: What has improved since the last inspection? What they could do better: Whilst residents said that staff talk to them about aspects of their lives at the home, there could be more formalised documentation to demonstrate this. The residents would also benefit from a more formalised activity programme. Although there has been improvements to the care planning process, the home need to improve the processes for reviewing and updating the care plans, and also the risk assessments for the home. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 6 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 Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 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 Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 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) 1,3,5,6 Resident’s benefit from clear, comprehensive and accessible information on which to base their choices and the opportunity to visit prior to making a choice of home. They are assured that the home can meet their needs by way of a comprehensive needs assessment. EVIDENCE: The home has recently updated their statement of purpose and service user guide and they remain comprehensive documents. The service user guide is now available on the home’s recently created web site. Both documents were available in the home on the day of inspection. One relative said that they had chosen the home after making an initial visit. Relatives of a prospective resident were visiting the home to look around at the time of the inspection. Three resident’s files were looked at and all contained needs assessments carried out by the home and, where applicable, placing authorities. Assessments include areas such as tissue viability, nutrition, speech and language and likes and dislikes. Terms, conditions and contracts were available on files. The home does not provide intermediate care. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 Although there are some aspects of care plan recording that needs to be improved, generally they are clear and comprehensive documents that demonstrate that needs are met. Residents enjoy a respectful and dignified approach to their care from staff. EVIDENCE: Three resident’s files were looked at and care plans were available in each file. The care plans were in accordance with assessed needs. Care plans included personal hygiene, tissue viability, mobility, optical and dental care, nutrition and pain control. There was no evidence of monthly reviews since May 2005 on two of the three files. The acting manager said that the named nurse was had not bee available since May 2005. It was agreed that another member of staff would review those care plans. Records demonstrate that residents have access to appropriate health care services such as GP’s, District Nurses and chiropody. There is a comprehensive medicines policy. Medicine administration records were completed satisfactorily and care plans were in accordance with prescriptions, for example oxygen therapy. There are no residents who currently self medicate. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 10 Residents said that staff are always friendly and respectful. Relatives said that staff carry out care in private and ensure dignity is maintained for residents, especially when providing terminal care. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Resident’s benefit from being able to make choices in all aspects of their lives, and from being offered appropriate activities and social contacts. They also benefit from a nutritionally balanced diet. The home could make improvements to the system of recording consultation with residents, and for programming activities. EVIDENCE: Residents and relatives said that visitors to the home are welcomed at any reasonable time. Residents said that staff would always ask them what they want to do and what they want to eat. They said that if they don’t like what is on the menu they can ask for alternatives of their choice. They said that the food is very good, especially the puddings and there is always plenty of it. There was a relaxed atmosphere in the dinning rooms and food was well presented in ample portions. Menus show that the diet offered is balanced and nutritious. One resident receiving respite care said that she would like to come back as it is a ‘very friendly home’. Relatives said that the home provided ‘very good care’ and said that they ‘treat residents very well’. Some residents were receiving manicures from staff during the inspection, which they all said that they enjoyed. The acting manager said that a volunteer activity co-ordinator would be starting work in the home in the near future. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 12 Records indicate that activities such as hairdressers and musical afternoons take place. Feedback from residents and relatives indicates that activities that are provided are done so after consultation with the residents, and they can choose whether or not to join in. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents benefit from comprehensive complaints and adult protection procedures; and from the homes prompt responses to issues raised. EVIDENCE: The home has comprehensive policies and procedures in place for complaints, adult protection and whistle blowing, including local authority guidelines for adult protection. Records show that staff have received training in adult protection procedures, and staff were able to demonstrate their knowledge of the issues. Records demonstrate that the home has followed policies and procedures for the one complaint received since the last inspection. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22-26 Resident’s benefit from a choice of areas within the home in which to spend their time. They enjoy generally safe, well-maintained and pleasant surroundings, although there may be risk from some fire safety precautions. EVIDENCE: On the day of inspection the home was very clean and tidy, and free from offensive odours. Hazard warning signs were being used appropriately, for example for wet floors and oxygen storage. Resident’s bedrooms were comfortable and personalised to whatever degree the resident wished. Hoists, bedrails and specialist mattresses were available in accordance with care plans. All bedrooms have call bells that are easily reached by the resident. Residents said that they liked their rooms. One resident said that she was very comfortable in her room and found the home in general to be very comfortable. She said that she would not want to live anywhere else. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 15 There are secure, well-maintained gardens and a patio area available to residents, which contain a range of garden furniture. There are also alternative lounge and dinning areas available. Furniture, décor and flooring are well maintained and there are risk assessments in place for keeping bedroom doors open. There are currently 10 automatic door guards in place on bedroom doors but others were held open by door wedges. A recent fire inspection report said that the use of door wedges should cease immediately. The responsible individual agreed to remove door wedges and replace them with appropriate door guards. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Residents are protected by generally robust recruitment practices although the home must ensure consistency of information. Residents benefit from a staff team that are trained to meet their individual needs. EVIDENCE: There were five staff on duty on the day of inspection, including 2 qualified nurses. There were also domestic and catering staff and the Responsible Individual available in the home. Residents said that they always get there needs met and call bells were answered promptly. Three staff files were looked at. One file did not contain clear identification for the person but all other information required in Schedule 2 of the National Minimum Standards was available. Records show that staff have received training in areas such as infection control, challenging behaviour, dementia care, moving and handling, fire safety and basic food hygiene. Staff were observed to be carrying out general infection control procedures wherever necessary. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,37,38 Records keeping systems that are in place help to ensure that the resident’s health, safety and welfare is promoted, although the reviewing of risk assessments needs to be more timely. Residents would benefit from a formalised system for obtaining their views about the service. Inconsistent provision of staff supervision has the potential to put staff and residents welfare at risk. EVIDENCE: Residents’ files contained risk assessments for issues such as wound care, mobility, bed rails and breathing. Records show that not all staff receive regular supervision. There are risk assessments and data sheets for COSHH materials. Records demonstrate that fire equipment is checked regularly, including extinguishers, call points and emergency lighting. There is evidence that fire drills are carried out regularly. A fire risk assessment is available but requires updating as St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 18 recommended in a recent fire inspection report. Water temperatures are recorded regularly. The home has comprehensive policies and procedures including health and safety, COSHH, confidentiality and physical intervention. The acting manager said that a questionnaire has been developed for obtaining residents’ views but has not been used as yet. Residents say that consultation does take place and they are able to tell the staff how they feel. St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x 2 3 2 St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 20 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. 2. Standard OP 7 OP 24 Regulation 15(2)(b) 23(4) Requirement The responsible person must ensure that all care plans are kept under review. The responsible person must ensure that door wedges are not used within the home and suitable alternatives are provided where required. It is acknowledged that the reponsible individual took immediate action in response to the requirement. . The responsible person must ensure that staff files contain evidence of the persons 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 all staff are appropriately supervisied. The responsible person must ensure that the fire risk Timescale for action 30 September 2005 30 September 2005 3. OP 29 4. OP 33 19(4)(b) (i), Schedule 2 24 30 September 2005 31 October 2005 5. 6. OP 36 OP 38 18(2) 24 31 October 2005 30 September Page 21 St Lukes Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 7. assessment is regularly reviewed 2005 and kept up to date. Any findings from the assessment should be implemented, with high risk items taking priority. . 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 OP 7 OP 12 OP 32 Good Practice Recommendations It is recommended that the home complete all sections of assessments, for example using statements such as not applicable or not known where necessary. It is recommended that planned activities be presented in a formal programme to further demonstrate consultation with reidents. 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 Nursing Home C53 C04 S54407 St Lukes V246066 16-8-05 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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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