CARE HOME ADULTS 18-65
Lindisfarne Church End Leverington Cambridgeshire PE13 5DB Lead Inspector
Mrs Jenny Cangy Unannounced Inspection 23rd September 2005 14.30 Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 1 Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 2 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.V250895.R01.S.doc Version 5.0 Page 3 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.V250895.R01.S.doc Version 5.0 Page 4 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.V250895.R01.S.doc Version 5.0 Page 5 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st February 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.V250895.R01.S.doc Version 5.0 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection commenced at 14.30. The inspector was admitted to the home by a member of staff who introduced himself as an agency worker. The manager was on duty and time was spent going through records, discussing the National Minimum Standards and how the home is progressing with regards to service users and staff. During the time spent in the manager’s office a service user was present for some of the time only leaving when staff took him to get a drink. A tour of the home followed and several staff members and service users were spoken to. The inspection concluded at 17.45. What the service does well: What has improved since the last inspection?
Building work has been completed changing the kitchen to a bedroom and a bedroom. to the kitchen. Excessive gaps under bedroom doors have been rectified. The manager has been registered with the CSCI. Staffing levels have been increased as the number of service users has increased. Attractive nonslip cushion flooring has replaced the carpet in one service user’s bedroom eliminating the unpleasant odours caused by his behavioural problems. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 7 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.V250895.R01.S.doc Version 5.0 Page 8 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.V250895.R01.S.doc Version 5.0 Page 9 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): 4&5 The home does not currently fully meet standards four and five therefore not ensuring service users and their representatives have all the information needed. EVIDENCE: Not all service users have been given the opportunity to visit the home and have an overnight stay before moving in. They have not all had the opportunity to meet the other service users and staff before moving in. The manager stated that one service users was not able to do so due to the nature of his disability. She also stated that during the assessment process staff took photographs of service users and staff for the prospective person to see. There are no service user or their representatives signatures on the contracts of residence. The manager stated these would be obtained at each of their reviews over the next few months. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 10 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): 6,9 &10 Care plans and risk assessments are in place and the information is. confidential EVIDENCE: The manager and senior staff assess all prospective service users. The assessment forms part of the basic care plan. As much knowledge as possible is gathered prior to service users moving into the home. Risk assessments form part of the care plan and are reviewed frequently as the service users settle into the home. All information about service users held by the home is confidential and staff are aware of the confidentiality policy. Agency staff have as much information as they need to meet the service users’ needs. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 11 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): 13,15,16 &17 Service users have a high quality of life at Lindisfarne. EVIDENCE: All service users access the local community, using local shops and community facilities. Family links are maintained and friendships supported. Service users rights are upheld and they have choice in all aspects of their lives. Mealtimes are relaxed and service users main meal is staggered to ensure those who need support in eating have staff undivided attention. Service users are involved in planning the menu and have a choice at each meal. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 12 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): 18,19,21 Service users are cared for in the way they demonstrate they prefer and all their needs are met. EVIDENCE: Personal support is individualised to each service user and their preferences recorded in their care plan. All aids and equipment is provided as appropriate and the advice of outside professionals is sought. The local community health services are involved and the service users registered with a local GP practice. There is a care plan in place for preferences in final illness and after death. These are not fully complete and information is still being gathered. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 13 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): 22 All concerns and complaints are recorded and investigated. EVIDENCE: There is a complaint procedure for staff, family and others to follow. Service users are enabled to voice concerns in one to one talk time and any issues are followed up and recorded. Outside advocacy is sought when appropriate. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 14 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): 25 The home meet its stated purpose EVIDENCE: The size and layout of the home meet the requirements of the Care Home Regulations and national minimum standards. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 15 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): 33&36 The staffing level needs to be reviewed to ensure it is sufficient for the needs of the service users and to give them continuity of care. EVIDENCE: The home is registered for 10 people and on the day of inspection there were nine service users. Staffing levels can only be maintained by the use of agency and bank staff. Two of the team, 50 of the staff on duty on the afternoon of the inspection were agency staff although these staff are regular to the home. The rota shows only 12 day staff including the manager and not all are full time. The manager stated some service users needed one to one or two to one support for some activities. Evening social activities outside of the home cannot be supported on the current levels. Staff all have a good basic induction and intermediate training. They have regular formal supervision and training is freely available. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 16 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): 37,38,39,42&43 The home is well managed to the benefit of the service users. EVIDENCE: The manager is registered with the CSCI and is currently undertaking NVQ level 4 and the registered managers award. The manager is open and accessible to both staff and service users and has a good rapport with outside professionals. She is supported by a deputy and two senior carers. The home has recently undergone a quality assurance review conducted by an outside assessor and increased their score from 81 to 91 since February 2005. All health and safety monitoring is conducted as required and staff are aware of their responsibilities an have had training. All fire safety equipment is maintained under an outside contract. Staff are booked to attend Protection of Vulnerable Adult training. Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 2 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3
x Standard No 24 25 26 27 28 29 30
STAFFING Score X 4 X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Lindisfarne Score 3 3 X 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 3 3 DS0000057383.V250895.R01.S.doc Version 5.0 Page 18 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 YA4 Regulation 12(2)(3) Requirement The registered person must ensure that all prospective service users have the opportunity to be gradually introduced to the home before moving in. The registered person must ensure that all service users have a statement of terms and conditions of residence and/or a contract of care that has a signature acknowledging agreement either by the service user or their representative. The registered person must ensure that the wishes of service users with regard to final illness and death are known and recorded. The registered person must review the staffing levels and ensure that all the service users needs can be met at all times and with Timescale for action 30/10/05 2 YA5 5(1(b)(c)) 01/01/06 2 YA21 12(3) 30/11/05 3 YA33 18(1(a)) 30/12/05 Lindisfarne DS0000057383.V250895.R01.S.doc Version 5.0 Page 19 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.V250895.R01.S.doc Version 5.0 Page 20 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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