Care Home: St Luke`s Care Home

Similar services:

• Abbey The
• Snydale Care Home
• Hawkhills
• Larchfield Manor
• Beeches The - North Yorkshire County Council
• Staveley Birk Leas Nursing Home
• Carentan House

What the care home does well What has improved since the last inspection? All the requirements from the last inspection have been dealt with. The home has worked hard since the last inspection to improve the quality of the service provided to people. For example the care records have been improved to provide better information about people`s needs and abilities, this helps to make sure that people consistently get the support they need. The home has also made improvements to the environment to make it a safer place for people. When we visited work was being done to improve the bathrooms to make them easier to use and nicer for people. What the care home could do better: The home must make sure there are always enough staff to meet people`s needs in a timely way. Some people were particularly concerned about staffing at weekends and the use of agency staff that do not always know about people`s needs. A number of people said the home should provide more activities. The manager is aware of this and is looking at ways this can be achieved, for example she is looking at how they can encourage more evening activities Staff must be more aware of people`s dignity and in particular must pay attention to how their actions, such as talking over people`s heads, could compromise this. CARE HOMES FOR OLDER PEOPLE St Luke`s Care Home Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL Lead Inspector Mary Bentley Key Unannounced Inspection 14th August 2008 09:20 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 DS0000062254.V370192.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. DS0000062254.V370192.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Luke`s Care Home Address Upper Carr Lane Calverley Leeds Yorkshire LS28 5PL 0113 2563547 0113 2560275 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) Eldercare (Halifax) Ltd Mrs Janet Balmforth Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (4), Physical disability of places over 65 years of age (34), Terminally ill (4), Terminally ill over 65 years of age (4) DS0000062254.V370192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2007 Brief Description of the Service: St Lukes is a modern, purpose built single storey nursing home situated in a residential area of Calverley. The home is within walking distance of a major road to both Bradford and Leeds, and local bus routes. Accommodation is provided in a combination of twenty-two single and six double rooms. All of the single rooms have en-suite facilities. People living at the home have a choice of two sitting areas, one of which is a conservatory. One section of the main sitting room is also used for dining. There is a car park to the front of the building, and there is level access to very attractive gardens at the rear of the home. In August 2008 the weekly fees ranged from £416.58 to £630.00. Additional charges are made for hairdressing, newspapers, selected toiletries, or private chiropody treatment. Copies of previous inspection reports are on display in the entrance of the home. DS0000062254.V370192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection in September 2007. This unannounced inspection was done by one inspector between the hours of 9:20am and 5:00pm. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records and looked at parts of the building. Before the visit we sent surveys to the home to be given to people living in the home, their relatives, staff and health care professionals. In total 18 were returned. Before the visit we sent a self-assessment form to the home, this was returned and gave us the information we had asked for. It showed us that the home has identified ways in which it will continue to improve the service. What the service does well: Relatives of people living in the home said: • • “The home is clean and warm and the food is good” “Very clean and friendly” People living in the home said they are well cared for and said they enjoy the food. The home has a friendly atmosphere and we saw visitors coming and going throughout the day. People are encouraged to visit the home before moving in so that they can decide if it is the right place for them. The home is on one level, which makes it easy for people to get around. The garden is well kept and people told us they enjoyed being out there when the weather permits. DS0000062254.V370192.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000062254.V370192.R01.S.doc Version 5.2 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 DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 does not apply. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about the range of services offered, they are encouraged to visit and their needs are assessed before they move in. EVIDENCE: Since the last inspection the home has made some changes to the Statement of Purpose to make it easier for people to get clear information about the services offered. Most of the people who completed our surveys said they had been given enough information about the home before moving in. The home has a new format for recording pre-admission assessments. We saw one that had been completed, and it provided detailed information about the person’s needs. We also saw evidence that the person’s relatives had been to look around before choosing the home. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People or those close to them are involved in drawing up their care plans and overall people’s personal and health care needs are met. Staff need to be more aware of how their actions could compromise people’s dignity. EVIDENCE: We looked at the care plans of four people living in the home. Since the last inspection the home has worked hard to improve the standard of record keeping. The care plans are based on a detailed assessment of needs and set out how personal and health care needs will be met. The care plans reflect people’s preferences and abilities. For example there is information on when people prefer to get up and go to bed and on what people can do for themselves. We saw evidence that people or those close to them are involved in drawing up the care plans. In most cases the plans had been reviewed every month. We DS0000062254.V370192.R01.S.doc Version 5.2 Page 10 saw that care plans are checked by the manager and/or regional manager and shortfalls in the records are identified. Areas of risk are identified and where necessary care plans are in place to show how the risk will be managed. For example, when someone is at risk of developing pressure sores, there is a care plan to showing how this risk will be reduced. The care plans of two people showed that they are nutritionally at risk because of weight loss. In one case the GP had been consulted and prescribed diet supplements, in the other the GP had not yet been involved. The daily notes did not have enough detailed information to show what people are actually eating. The manager said she was aware of this and was planning to change the format used for daily notes. For people who are nutritionally at risk food charts should be considered to make it easier to monitor exactly what people are eating. People living in the home are satisfied that they get the care and support they need. One visiting health care professional said “the standard of care at St Luke’s is tip top, sometimes under difficult circumstances”. The records showed that people have access to NHS services. One relative said they would like to see opticians and dentists visit people in the home. The manager said NHS dentists are no longer funded to do home visits and the company is considering offering the services of a private dentist. The home employs a physiotherapist but one person said, “the physiotherapy services offered within the home leaves a lot to be desired, it is often nonexistent”. Medicines are safely managed in the home. On occasions we heard staff talk about people over their heads in a way that did not show consideration for their dignity. For example when a carer was wheeling a lady in a wheelchair into the dining the nurse said to the carer “where is she going”. Another example was before lunch when the cook came into the lounge/dining room and instructed one of the new care staff to “put bibs on them all”. The carer then put protective bids on everyone without considered whether people wanted or needed them and without any discussion with people. This was discussed with the manager and she said she would deal with it. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home offers people the opportunity to take part in a variety of social activities and is continuing to look at ways of improving this aspect of the service. EVIDENCE: Information about people’s past lives and interests is recorded in the care records and social care plans have been developed for most people. Over the past year the home has been working to improve the way people’s social care needs are addressed. They now have a designated activities organiser in the afternoons and have started a newsletter. The manager is aware that more needs to done to meet the social needs of everyone living in the home and she is looking at how to encourage more evening activities. Most people living in the home said they are satisfied that there are activities for them to take part in. However, some relatives and staff felt this could be improved. DS0000062254.V370192.R01.S.doc Version 5.2 Page 12 An activities programme is displayed and range of activities offered includes motivation sessions, games, visits to a local community centre, and hand massages. During the day we saw some people looking at photographs in the morning and another group of people were playing dominoes in the afternoon. The home has a regular church service for people who want to attend. The home welcomes visitors at any time and people said the home is friendly. One relative said it would be nice if the home had a telephone trolley so that they could ring people. During the visit we observed the meal service at lunchtime. The tables were set with tablecloths and cold drinks were available. There were no condiments on the tables. One person asked for salt and was given it but condiments were not offered to other people. The manager served the meal; she said the nursing staff always serve the meals so that they know whether people are eating or not. There was a choice of main course and pudding and the meals looked appetising. People said they enjoyed the food. Staff were available to help people as needed. Overall the mealtime was a relaxed occasion for people. We saw that people are regularly offered drinks throughout the day. One of the nurses started to give out medicines while people were eating. Consideration should be given to whether this is the most appropriate time to give out medicines or whether it would be better to wait until people had finished eating. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home. People living in the home told us they know how to make a complaint if they need to. One relative said they are not aware of how to make a complaint. Staff told us they know what to do if people have any concerns. Complaints are recorded and the home has received two complaints since our last visit, one of them is still being dealt with. The home has procedures in place to make sure people are protected from abuse. Training on the protection of vulnerable adults and whistle blowing procedures is now included in induction training for all staff. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a clean, pleasant, and suitably equipped place for people to live. EVIDENCE: When we visited the home was clean and people living there said it is always clean and fresh. Work is being done to upgrade the bathrooms and this will include improving the hairdressing facilities. People’s bedrooms are suitably equipped to meet their needs, every room has an overhead track hoist which can be used to help people with mobility DS0000062254.V370192.R01.S.doc Version 5.2 Page 15 problems to get in and out of bed. In the rooms we looked at people had lots of their personal belongings around. Since our last visit the home had improved storage facilities making the home less cluttered and safer for people. Signs have been put on doors to help people find their way around. The communal rooms are suitable furnished and there is easy access to a pleasant and well-maintained garden. The corridor carpets are starting to show signs of wear and tear and this was discussed during the visit. Since the last inspection all staff have had training on the control of infection. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are not always enough staff to meet people’s needs in a timely way. People are protected by good recruitment procedures and staff are supported in getting the knowledge and skills they need to meet people’s needs. EVIDENCE: People living in the home said staff are usually available when they need them. One person said she gets frustrated because she is dependent on staff and they always say, “wait a minute” when she needs something. Other people said staff are friendly, one person said the home would benefit from “better staffing levels” and other comments included: “Often short staffed at weekends, sometimes agency staff who do not know residents at weekends” “Some care staff would benefit from more supervision and training” Staff also told us that because of sickness and holidays there are not always enough of them on duty. DS0000062254.V370192.R01.S.doc Version 5.2 Page 17 The manager told us that since the last inspection the staffing levels on the evening shift have been increased. She said she has employed one person to work evenings and is trying to recruit another. The home had planned a recruitment open day to take place on the weekend following our visit. The home told us that over 56 of care staff have achieved an NVQ (National Vocational Qualification) at level 2 or above. Three more staff are currently working to achieve this qualification. The records showed that the home provides staff with the training they need to meet people’s needs and staff confirmed this. We looked at four staff files and they showed that all the required checks are completed before new staff start work in the home. DS0000062254.V370192.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is appropriately managed. People are able to share their views and contribute to the development and improvement of the service. EVIDENCE: The registered manager is a nurse who has worked at St Luke’s for 18 years. The company sends questionnaires to people involved with the service every year, this includes health care professionals. The most recent questionnaires were sent in April 2008 and the results are summarised and displayed in the home. The manager said any individual issues had been dealt with. There are also meetings twice a year for people living in the home and their relatives DS0000062254.V370192.R01.S.doc Version 5.2 Page 19 where people have an opportunity to share their views of the service and make suggestions for improvements. The regional manager visits the home at least once a month to audit various aspects of the service; we receive copies of the reports from these visits. The home has staff meetings every 2 months, appraisals are done once a year, and staff have regular supervision. The home holds small amounts of spending money for some people. All transactions are recorded and receipts are obtained for any money spent on people’s behalf. The home does not have any other involvement in managing people’s personal finances. In their self-assessment the home told us they have appropriate systems in place to manage health and safety. We looked at a selection of maintenance records, they were up to date and showed that equipment, and installations are serviced and maintained at the required intervals. DS0000062254.V370192.R01.S.doc Version 5.2 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 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X 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 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000062254.V370192.R01.S.doc Version 5.2 Page 21 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 OP27 Regulation 18 Requirement There must always be enough staff on duty to make sure that people’s needs are be met in a timely way. Particular attention must be given to weekends and the arrangements for covering staff absence due to holidays or sickness. Timescale for action 28/11/08 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 DS0000062254.V370192.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000062254.V370192.R01.S.doc Version 5.2 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!