St Lukes Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from avoidable harm. At our last inspection this key question was rated requires improvement. At this assessment this key question remains at requires improvement. We identified shortfalls with training compliance for staff and people having their mental capacity and best interest assessed and recorded appropriately. However, the provider was responsive and took immediate action during and after our visit. This was a breach of Staffing and Need for consent.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives, we spoke with told us they felt listened to. If they had any concerns, they felt comfortable raising them. Relatives told us they felt involved and if changes were required, they would be done. Comments included, “[Name] care plan was updated recently, any change in medication is discussed” and “Always informed of any changes.”

Feedback from staff supported the improvements in a positive learning culture. Staff felt confident to raise concerns and suggestions for improvement. Not all staff had received training on dementia but were aware of how dementia impacted people. Comments included, “[Name] office door is open. [Name] come on to the unit speaks to staff. I have their email. [Name] is friendly, fair and firm” and “Manager is, friendly, they are great, very pro-active in their approach, Home is run very well from what I can see.”

The provider had a proactive and positive culture of safety, based on openness and honesty. The management listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, the manager and provider showed us how falls were analysed and what improvements had been implemented. One relative told us, “I know the manager, I can go to the office, staff will always phone me back, all are friendly and approachable.”

People told us they felt safe in St Lukes Care Home and knew they could raise any concerns they may have. Relatives confirmed they felt their loved one was safe and could raise concerns with management and staff. One relative told us, “[Name] care plan was completed with staff, social worker and some other people, they initially went in for respite but as mobility poor is now in permanently.”

The manager told us about the systems they had in place to ensure continuity of care at the service. This included staff having access to people’s care plans and families being involved in care planning because they knew people best.

We received positive feedback from health professionals. A health professional told us, “Staff are receptive and there is a focus on collaboration.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. We saw new admissions into St Lukes and they made sure there was continuity of care, including when people moved between different services.

People were safely looked after, and relatives told us they felt their loved ones were safe at St Lukes. Relatives told us, “Staff are very careful and caring”, “Staff keep [Name] safe, everything I have seen here tells me that. All are polite and friendly” and “Yes I feel [Name] is kept safe; the staff are very good.”

Staff were aware of the safeguarding procedures and knew how and when to raise a safeguarding concern. A staff member told us, “I have learnt to ensure the right things are done at the right time to enable people to live free from harm, abuse and neglect.”

People were able to express their views and choices without fear. We observed people came close to staff when they wished to and felt comfortable around staff. People asked staff for support and assistance when they needed it, for example, to make a cup of tea.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Safeguarding adults’ policies and procedures were in place. Staff followed processes to ensure any safeguarding concerns were reported and recorded. There were systems in place for the management team to review safeguarding adults’ concerns to ensure they were learnt from.

People and relatives told us they were kept informed and included in changes that had an impact on the person living at St Lukes Care Home. Relatives we spoke with told us they made suggestions and were involved in the care and support. Relatives said, “I was involved in her care plan as [Name] needs 24-hour care, it gets updated as necessary.” Although people and relatives gave us positive feedback, people at St Lukes had restrictions put in place that were not appropriately assessed or recorded.

Staff demonstrated awareness of people's risks and knew where to find personalised guidance on how to support people safely. Staff were knowledgeable and knew people risks assessment were mostly positive.

Staff knew people well; we saw staff supporting people safely.

The provider did not always work well with people to understand and manage risks. For example, where bedroom alarms had been put in place to monitor movements of people, we saw these had not been assessed or documented appropriately or involved the people living at St Lukes. The management were open to this feedback and immediately took action to address this shortfall.

People and relatives told us they felt the environment was safe at St Lukes and made sure equipment, facilities and technology supported the delivery of safe care. One person said, “Yes, I feel safe” and a relative told us, “Equipment is used safely I feel, no sign of any abuse ever.”

Feedback from staff and the manager confirmed effective systems were in place to ensure the safety of the premises and equipment. Staff confirmed that they completed fire safety training and had taken part in simulated fire drills. Comments included, “We have regular fire training, either on e-learning or we come in to do fire training course. We have regular fire drills” and “I have had a few fire drills and know what if there ever is a fire emergency, for example, leaving the unit to check where it is, using the back of your hand on doors to check where the fire is, and to move our clients to a safe distance.” The manager told us about the recent redecoration of the home including people bedrooms doors, new wallpaper in people bedrooms and communal areas.

The home was spacious and had plenty of natural light and was clean, and equipment had been appropriately maintained. We observed the communal areas being well furbished and there were no trip hazards.

The provider detected and controlled potential risks in the care environment. We saw evidence in the maintenance records that environmental checks had taken place, and any issues had been reported and fixed. People’s bedrooms and corridors were wide enough to ensure adapted wheelchairs and hoists could fit.

Feedback from people’s relatives about staffing numbers was mixed. Comments included, “More full-time staff needed and less agency, especially at weekends, the majority are well trained and caring” and “Regular staff make the atmosphere more of a home, some agency staff not very approachable.”

Staff we spoke with told us there was enough staff to meet people’s needs. Staff told us, “Staffing levels are a lot better and has improved” and “In an ideal world of course I would like staff numbers to increase. A lot of the residents need support by 2 staff. Mealtimes are the busiest.” However, some staff told us staff numbers were low and this should be improved. Staff told us, “I feel the staffing levels can improve. Sometimes when staff are assisting with service users in the bedrooms and in the afternoon can be difficult” and “The staffing level is below par.”

Staff were available at all times when people needed their assistance. We observed staff being knowledgeable about people's care and support needs, including knowing how to manage their anxieties. However, on day one of the site visit we did observe an agency staff member standing over a person supporting them to eat their food. This did not meet the person needs in a person centred way.

The provider did not always ensure staff received sufficient training for their roles. For example, there were shortfalls in some key training areas such as person-centred care, moving and handling, first aid, risk assessments, preventing falls, pressure ulcer prevention, incontinence, mouth care matters, dementia, deprivation of liberties (DoLs), mental capacity act (MCA) and fluid and nutrition. The manager told us there was work to improve the training for staff and this was an ongoing piece of work. Safe recruitment processes were in place to ensure suitable staff were employed at the service.

Relatives told us the home was clean and told us about their personal observations when visiting St Lukes. Comments included, “The home is kept very clean and recently decorated”, “The home is always clean and tidy with no nasty smells” and “Home always looks clean and tidy, my niece commented that she had never seen such a clean Home.”

Housekeeping staff told us about the cleaning schedules and showed us the audits. Housekeeping staff told us that communication was good and felt supported by the manager. Comments included, "We have enough of everything and never run out. The Manager is really good, and we never have any issues with getting cleaning products or making suggestions."

We observed the home was clean and well maintained. We observed housekeeping staff working hard to keep the home clean and protect the people from risk of infection.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had personal protection equipment situated throughout the service giving them easy access to wear when needed. However, some staff had not completed or updated their infection prevention and control training as far back as 2021.

Most of the feedback from relatives about their loved one’s medicines was positive. Comments included, "[Name] does understand their medication, no concerns around administration”, "Most of the time staff discuss any changes in his medication, his blood sugar levels are managed well, permission sort before jabs given, always informed of any changes” and "All of [Name] medication is given correctly." However, one relative told us, “Not always informed of any changes in [Name] medication but given on time.”

Staff were trained and had their competency assessed in handling medicines. Staff understood policies and procedures to ensure people had their medicines reconciled when they move between services.

Medicines were stored securely, and use of medicines was recorded appropriately including the use of topical medicines and patches. Covert medicines (medicines that are hidden in a person’s food or drink) were managed well and the provider ensured they had instructions from a pharmacist so staff could administer medicines in a safe way. Staff were recording when thickened drinks were being given to people at risk of choking and aspiration. Person centred guidance was in place to support people to have their when required medicines. People were supported to access monitoring relating to medicines such as blood monitoring for diabetes, however, for one person, we found this was not always being carried out as often as required by the medication plan. The time a medicine was administered was documented for time sensitive medicines, however, we found for 2 people incidents when paracetamol containing products had been given within the safe 4-hour time interval.