Inspection on 28/11/07 for St Lukes Nursing Home

This inspection was carried out on 28th November 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Lukes Nursing Home 12/04/06

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 Nursing Home 35 Main Street Scothern Lincoln Lincolnshire LN2 2UJ Lead Inspector Doug Tunmore Unannounced Inspection 28th November 2007 10:00 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 Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 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 Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Lukes Nursing Home Address 35 Main Street Scothern Lincoln Lincolnshire LN2 2UJ 01673 862264 F/P 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 Paula Willows 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) St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home with nursing - Code N To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Physical Disability, over the age of 65 years - Code PD(E) Dementia, over the age of 65 years - Code DE(E) The maximum number of people who can be accommodated is: 30 2. Date of last inspection 12th April 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 fees at the inspection visit on the 28/11/2007 ranged from £371:00 to £585:00 each week. Extras are for hairdressing which range from £6:65 upwards, chiropody £8:50, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the manager of the home. The service user’s guide is available from the manager and is kept in the office. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector who was accompanied by an expert by experience undertook this visit to the home. This formed part of an unannounced key inspection. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. ‘Have Your Say’ surveys were sent to the home by the commission and residents returned six and seven were returned from carers. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The expert by experience spoke with a number of residents and two visitors; she also briefly joined an interagency meeting that was assessing the ongoing care needs of a resident. The inspector spent time with the provider, registered manager, the administrator and two carers. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The manager stated that a new administrator has been employed who is now undertaking an audit of all administration issues and updating were necessary. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 6 She also commented that training programmes are ongoing for all members of staff working at this establishment. All residents files are being updated with new care plan formats and risk assessments. Decoration of the home is ongoing, with plans for an extension that would be built in the near future. Residents are consulted about the meals, with their likes and dislikes recorded and choices are always available. What they could do better: 1. The provider has not produced an up to date statement of purpose, which complies with The Care Homes Regulations. A copy must be sent to the commission. 2. All residents are not given a copy of the service user guide in a form that is user friendly and summarises the homes main service user guide. A copy must be sent to the commission. 3. The provider does not send a letter to prospective residents advising them whether the needs of the residents can be met or not by the provider. 4. An accurate record of accidents to residents is not kept, in line with the homes practice and procedures. 5. Risk assessments need to be introduced for all residents who selfmedicate and they need to be advised of the risks of self-medication. 6. A record of complaints is not kept, with the outcomes recorded for all complaints received by the provider. 7. Consideration needs to be given in moving a sluice in a bathroom. This is not in keeping with the domestic style of the home and is questionable in relation to hygiene by using an industrial appliance in this setting. 8. All areas of the home need to be checked to ensure that all areas are free from offensive smells. 9. Care plans need to demonstrate when a method of restraint is used on a resident and the reasons why and who has been informed. Care plans need to identify the practice for the use of a wheelchair harness for the information of all staff and policies regarding this practice must also be available in the home. 10. The provider needs to have an accurate method of accounting for resident’s monies. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 7 11. Robust employment practices needs to be in place to protect residents from the possibility of harm. 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. The summary of this inspection report can be made available in other formats on request. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3,4 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not receive information about the home, which helps them to make an informed decision about where to live. The clear assessment process assures them that their needs can be met within the home. Residents are not informed that the home can meet their needs. EVIDENCE: This visit found that the statement of purpose and the service users guide was not available to prospective residents or those people who live in the home. The manager stated that the statement of purpose and the service users guide are to be amended and include intermediate care provision. These documents must contain all the information required by the Care Homes Regulations, Care St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 10 Standards Act 2000. A copy of these documents must also be sent to the commission. We looked at two of the files of residents who were being case tracked which evidenced that care needs assessments had been undertaken and were comprehensive. However, there was no evidence that prospective residents had been written to by the provider confirming that their needs could be met. The providers AQQA states that ‘ the Matron, or her deputy, can demonstrate St Luke’s capabilities to carry out the optimum care necessary to ensure the resident’s care, comfort and needs to all concerned. Prospective service users and their relatives are encouraged to visit the home and talk with the staff and residents beforehand’. The provider undertakes intermediate care, having two beds at the present time. Full care need assessments are undertaken and on the day of the visit the intermediate care nurse and physiotherapist were reviewing the care of their patients. Four residents surveys returned to the commission showed that four felt that they received a contract from the home, one was not sure and one resident felt that he had not received a contract. All six residents stated that they had enough information about the home prior to admission. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents accident records are not always accurate, so as to inform staff when falls have occurred. Residents who self-medicate do not have risk assessments and are not advised of the risks of keeping their own medication. EVIDENCE: The providers AQAA shows that ‘plans of care are prepared by trained nursing staff with the aid of the service user and their family. The comprehensive care plans compiled for individual residents ensures that all health care requirements are identified and catered. A regular visit by a podiatrist and a hairdresser is also available to our service users. All trained nursing staff have received additional training in the handling and administration of drugs. We also have a policy for the self administration of drugs where a risk assessment deems it safe to do so’. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 12 We looked at two residents files who were being case tracked which showed that care plans are being updated, with a new format currently being introduced. Care plans also described residents health and welfare needs and included admission details, personal history and moving and handling assessments, risk assessments and daily reports. However, one accident form seen had not recorded the right date of the accident to a resident. The manager said that she would amend the report and discuss this issue with the member of staff concerned. The manager stated that all residents or their relatives are to be encouraged to sign care plans to acknowledge that they are aware of the care plans and are involved. Two visitors seen by the expert by experience stated that they were fully involved in the writing of the initial care plan, and the admissions assessment. The ‘new’ visitor said he felt that the care plan was fully inclusive, and was of the understanding that he would be kept fully informed of any changes made. A previous visit in April 06 evidenced that monthly reviews were available on each file and that residents have access to McMillan nurses, District nurses and GP’s where they require such. During this visit the intermediate care nurse and the manager of the home were conducting a review of a residents needs. One visitor told the expert by experience, ‘that he was pleased that his wife’s deafness was being investigated by staff’ and he had accompanied his wife to the hospital - he said that it showed staff were committed to ensuring that his wife had the best advantage of ‘normality’ despite her condition. We looked at residents medication sheets and an accurate record was kept. The senior nurse on duty confirmed that only nurses administer medication. One resident who self medicates did not have a risk assessment showing the potential risks from administering her own medication. The manager said this was an oversight and a risk assessment would be undertaken relating to the inhalers that she currently takes. A tour of the building found that only two bedrooms had lockable facilities for residents to keep medication or valuable possessions in. The provider confirmed that steel lockable facilities are to be bought and attached to all bedroom walls within one week. Surveys returned from residents confirmed that five felt that they always received the medical support they needed and one usually did. The training records were seen and showed that all nurses undertook distance learning for the safe handling of medication. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 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. 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 this service. Service users are able to express choices in their daily lives and receive a nutritious, varied diet, meeting individual preferences and health requirements. EVIDENCE: The providers AQAA evidences that ‘our service users are given choices in their daily routines with regard to attending the hairdresser, podiatrist, or other service and whether or not to participate in social activities. They also have the choice of whether to eat in the dining room or in the privacy of their room’. It also states that ‘Visitors are free to visit at any reasonable time and also have the opportunity of joining their relative at mealtimes. Links with the local community include the local church sharing gifts provided at harvest service; guides and scouts visit and talk with the residents; PAT dogs visit; carol singers at Christmas time, but our policy of ensuring residents’ freedom of choice allows them the opportunity to attend or not as they desire’. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 14 This visit found that there was a list of activities for the information of residents and outings had ben planned for Christmas to which relatives were invited. Evidence was also seen that Christmas cards had been made by residents as part of an activity. Residents surveys showed that one felt that acitivties are usually available, three felt that they sometimes were and two were unable to partake in activities. One visitor confirmed to the expert by experience that, although his wife was bedridden, he was pleased that on her ‘good’ days she was taken downstairs to enjoy the company of other residents. Residents informed the expert by experience that they have ball-playing activities using light balls. They said that they also enjoy dominoes, cards, bingo and weekly visits by a hairdresser. She found that residents are taken out mainly in the summer months, but are not ‘that bothered’ in the colder months. They are currently involved in creating ‘pictures’ which, when finished, are to be displayed in the dining room/lounge areas, before being hung in bedrooms. When craftwork is in progress a large table is used in the lounge, and a glass of sherry enjoyed. The providers AQAA showed that ‘Our residents receive three meals a day. Although generally served at set times for ease of planning, meals can also be served to suit individual needs and preferences’. Residents surveys showed that one always liked the meals provided and five usually liked the meals. Written comments from one relative was that ‘sometimes food at tea time is the same everyday, depends on who ispreparing meal. Sometimes very good. It seems a long time to go from 4:30-5:00 one day to 9:30 am the next day without any food’. One survey recorded that a resident is a vegitarian and he said that we cater for him well. The expert by experience noted that, There is no choice of lunch, but the usual choice at tea time i.e. soup, sandwiches, beans on toast etc. The meal of gammon, mashed potato and vegetables, with white sauce, was served on small plates, was hot and well cooked. Residents were not ‘over faced’ by huge amounts of food, but no ‘seconds’ were offered. The hot desert was equally enjoyable, and residents were offered ice cream or yoghurt if they wished. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are at risk due to inadequate procedures. Residents and visitors are not empowered by the provider’s complaints procedures. EVIDENCE: The providers AQAA shows that ‘a complaints procedure is made available to all residents and their relatives at the time of admission and within the Statement of Purpose. Timescales and first points of contact are clearly identified. All staff are trained in identifying and dealing with physical, verbal and financial abuse’. Evidence seen in a confidential file showed that the manager had taken appropriate action regarding an adult abuse allegation. The provider does not keep a record of complaints made by residents or visitors, which would also inform the providers quality assurance audit of areas where the home could improve. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 16 We looked at one residents file and could not find a risk assessment or care plan detailing the care required for restraint undertaken by the use of a wheelchair support strap. There was no evidence that the use of this device had been discussed with the resident or her representative. Records show that staffs have received training in adult protection issues. Resident’s surveys showed that five of the six knew who to speak to if they were unhappy. Five of the six residents also knew how to make a complaint. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 21 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a comfortable and clean environment that meets their individual needs. Odour management solutions would benefit residents who live in this home. 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 and hoists. Two hospital beds are now in use and the provider has plans for all rooms to have these specialist beds in the near future. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 18 Call bells were accessible in bedrooms and in communal areas and the environment in general was clean and tidy. In a previous visit in 2006 residents said that they like their rooms. One bathroom seen had a sluice appliance, which is not in keeping with the general ambiance of this home. The provider stated that he would talk to his builder about moving this piece of equipment or build a partition wall around it. A decorator was painting hallways on the day of this visit. The manager stated that first floor corridors have been painted; there are new dining chairs and lounges are to be painted before Christmas. Resident’s surveys showed that one felt the home was always fresh and clean, with five residents stating that the home is usually fresh and clean. However, a tour of the building by the expert by experience found that corridors both up and down stairs are free of odours, apart from one area where the smell was offensive, both in the hall and outside the building. The manager stated that she would contact the builder, as it appears that an outside drain may be blocked. The providers AQAA shows that ‘a programme of decoration and refurbishment is currently under way to bring a greater sense of comfort and homeliness to St Luke’s. Maintenance contracts are in force to ensure that grounds, equipment and the premises are maintained and kept safe and in good order. Infection control procedures are strict and diligently maintained’. The expert by experience noted positive practices in that, all residents had their beds facing the window and could enjoy the view of the well tended gardens. Those residents that she spoke to commented that, they liked their rooms and found them comfortable. She also found that there are telephones with outside lines in some bedrooms. During this visit it was noted that all areas of the home were warm and comfortable for residents. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not protected by the providers recruitment procedures. Residents benefit from a knowledgeable staff team who are well trained. EVIDENCE: The providers AQAA shows that the ‘ staff rota is available to view at all times to indicate the staff on duty day and night. The staff rota includes 2 trained and 5 care staff on duty during the morning; 1 trained and 3 care staff are on duty during the afternoon; 1 trained and 2 care staff are on waking duty during the night. Recruitment of new staff at St Luke’s is clearly defined with a recognised system in place to ensure equal opportunities are observed, and that references and checks are implemented. Induction training and in-house training cover areas of care, safe working practices including health and safety and moving and handling’. We looked at two personnel files and found that one had a Criminal Record Bureau check form, which had not been sent and the carer has been employed without adequate procedure being undertaken. The manager stated that she St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 20 would phone the carer concerned and ask her not to come into work until they send off and receive back her Criminal Record Bureau check. There was one qualified nurse and four care staff on duty during the inspection, and the manager was also on duty. The rota showed that this was reflective of the numbers and needs of the residents. Residents surveys reflected that four always received the care and support they need and two felt they usually did. All six were unanimous in stating that staff listen and act upon what they say. There was evidence that a new induction training pack is now available and in use. We looked at the training files which evidenced that distance learning is undertaken on dementia care other training consisted of, manual handling, infection control, fire training. Staffs also have access to National Vocational training for elderly people with six workers having completed this course and a further six currently undertaking this training. This visit found that workers in the home have not been given the General Social Care Councils pack relating to the registration of care workers and the philosophy of the Care Council for all social care homes. The manager took information regarding the GSCC website and stated that she would contact them within a few days for registration details. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well managed meeting the needs of residents whose health, safety and welfare are protected. Accurate accounts are not kept of resident’s monies. EVIDENCE: The providers AQAA show that ‘the registerd manager at St Luke’s is a qualified SEN and ADNS (Advanced Diploma in Nursing Studies) and is currently undertaking further study towards the Managers Award. With four years at a senior management level, two of which as deputy at St Luke’s, she took on the role of manger six months ago. Quality assurance procedures are in place to monitor and regularly review the care of service users. Feedback St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 22 from the multi-disciplinary team, service users and their families, together with their views, helps us to monitor our progress as a care provider’. Carers surveys have not been used in this report but issues raised were discussed with the manager, which she will take up at the next staff meeting. Confidentiality was maintained in respect to the above. Two carers seen by the inspector stated that, improvements have been made in the home by the new manager - there is new furinture, the décor is improving, there is more training, regular staff meetings are held and the manager is approachable if we have any problems. The providers AQAA states that ‘whether the service user wishes to control their own money, or prefer to keep it in the office safe, St Luke’s can provide a safe and appropriate method of record keeping and maintenance of resident’s moneys and other possessions’. We looked at resident’s finances and found that there was no written record of accounts kept since June 07. However, monies are kept in individual wallets and receipts are available for any monies spent by residents. The providers AQAA showed that; gas safety inspections have been carried out, electrical wiring checks, fire precautions checks, and portable electrical equipment checks. The manager stated that risk assessments are available relating to the home environment. Staff had been trained in Health & Safety, Fire procedures, etc. St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 23 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 2 3 3 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 x 2 x x x x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 3 St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(2) 5(2) Requirement The provider must ensure that the statement of purpose complies with the Care Homes Regulations, Care Standards Act 2000 and that a copy is supplied to the commission The provider must ensure that all residents have a copy of the provider’s service users guide so that they can refer to it for information when they so wish. The service users guide must comply with the Care Homes Regulations, Care Standards Act 2000 and that a copy is supplied to the commission. A system must be established to ensure that all prospective residents are written to by the provider confirming that their care needs can be met at the home. A system must be established to ensure that all residents who self medicate have a risk assessment so as to show the level of risk for this procedure. A system must be established to ensure that a complaints record is available and entries made of all DS0000054407.V354860.R01.S.doc Timescale for action 15/02/08 2. OP1 5 15/02/08 3. OP4 14(1) (d) 15/02/08 4. OP9 13(1)(2) 15/02/08 5. OP16 22(1) 15/02/08 St Lukes Nursing Home Version 5.2 Page 25 6. OP18 13(6) 6. OP21 23(1)(k) 7. OP29 19(1) 8. OP35 16(2)(i) complaints made. A system must be established to ensure that aids and adaptation that are used as a restraint are used only with the consent of residents or their representatives. Care plans and risk assessments must also be available and give details of actions taken by who and why. A system must be established to ensure that sluicing facilities are provided separate from residents bathing and toilet facilities. A system must be established to ensure that robust recruitment practices are in places with all checks undertaken to help ensure the safety of residents. A system must be established to ensure that an accurate account is kept of resident’s monies, which is signed by more than one member of staff. 28/11/07 15/05/08 15/02/08 15/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Lukes Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Nursing Home DS0000054407.V354860.R01.S.doc Version 5.2 Page 27 - 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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