CARE HOME ADULTS 18-65
Lindisfarne Church End Leverington Cambridgeshire PE13 5DB Lead Inspector
Mrs Jenny Cangy Unannounced Inspection 15th February 2006 3:00 Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 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 Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Lindisfarne Address Church End Leverington Cambridgeshire PE13 5DB 01945 464817 01945 464817 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) Caretech Community Services Limited Susan Bredbere Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 23rd September 2005 Brief Description of the Service: Lindisfarne is a 10 bed room bungalow for adults with learning and physical disabilities situated at the edge of the village of Leverington, two miles north of the town of Wisbech. All the rooms are single and there are spacious communal areas. There is a large well kept garden to the front, side and rear. It is close to the Village shop and the church. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 15.00. The inspector was admitted to the home by a member of staff. The manager was on duty and time was spent reviewing the requirements made at the last inspection and reviewing the national minimum standards not inspected at the last visit. A tour of the home followed and several staff members and service users were spoken to. The inspection concluded at 17.00. What the service does well: 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. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 7 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Prospective service users or their representatives have the information they need to make an informed choice about the home. They are able to visit and stay before moving in. EVIDENCE: There is a statement of purpose and service user guide with all the information needed to make a decision about living in the home. All service users have a full assessment so the home is able to establish that their needs can be met at every level. Moving in to the home is a gradual process of visits and overnight stays to establish they can fit in with the other service users. All service users have a statement of terms and conditions of residence. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, Service users are included in all aspects of life in the home as far as their disability will allow. EVIDENCE: All service users have monthly individual talk time when they are encouraged to express their views about the home. They are involved with choosing colour schemes for the décor, selecting menus and planning trips, activities and holidays. The staff are compiling a photographic range of activities to enable service users to clearly indicated what activities they want to participate in Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 9 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, Service users are encouraged to develop to the extent that their disabilities will allow. They are enabled to participate in appropriate activities. EVIDENCE: Day service and activities are on a rolling two week rota. They include cinema, zoo, pub trips, ice skating and aroma therapy. Holidays and summer outings are being planned. Structured activities also take place within the home on a one to one basis. A directory of activities in photographic form is being compiled to enable service users to make positive choices about the activities they prefer. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21 There are no service users able to manage their own medication. Staff are aware of service users preferences with regard to care of ageing, illness and after death. EVIDENCE: Service users level of disability makes it impossible for them to manage their own medication. The home has a Monitored Dose System for storage and dispensing of medication with appropriate policies and procedures in place. All staff have medication training followed by an assessment before administering medication. All service users have a care plan regarding ageing, illness and dying. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 11 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse and self harm. EVIDENCE: All staff have Protection of Vulnerable Adult (POVA) training. Some service users wear head protectors and risk assessments are in place for all activities both within and outside the home. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 The home is modern and clean. It presents a homely environment and bedrooms and bathrooms are equipped to promote independence. Some areas of the home need repair and decorative attention. EVIDENCE: The home is suited to the purpose of the service users and has spacious shared lounges and an accessible garden. All specialist equipment needed is provided. Some areas of the home have stained carpets and there is damage to doors, doorframes and walls possibly caused by wheelchairs and hoisting equipment. One area of the home is cluttered with stored or unwanted items that could cause a health and safety and fire hazard. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34,35, There is an effective staff team who are clear in their roles and responsibilities. Service users benefit from effective recruitment procedures and staff training. EVIDENCE: All staff have appropriate job descriptions and contracts of employment. All staff have or are working toward NVQ qualification in care ranging from level 2 to level 4. The provider organisation has a good training programme for staff at all levels. Staffing levels have been increased by new staff recruitment to provide good levels of support to service users. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 14 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40, 41 The home has a full range of policies and procedures developed to protect the best interests of the service users. All records are kept as required. EVIDENCE: Policies and procedures are regularly reviewed and updated at company level. Staff have to sign to acknowledge they have read them. All records are kept as required and the manager regularly audits them to ensure they are up to date. The home has a regular independent quality audit to ensure the standards are met. Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 4 3 X X LIFESTYLES Standard No Score 11 3 12 4 13 X 14 4 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X X X 3 3 X x Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 16 no 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 Standard YA30 Regulation 23(2)(b) Requirement All areas of the home must be maintained inn a good state of repair, clean and reasonably decorated. Action must be taken to make good damaged wood and paintwork and floor coverings must be appropriate and in a reasonably clean state Timescale for action 30/04/06 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 Lindisfarne DS0000057383.V277267.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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