Inspection on 31/10/06 for Lindisfarne

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Lindisfarne 11/07/08

Lindisfarne 30/01/08

Lindisfarne 25/04/07

Lindisfarne 15/02/06

Lindisfarne 23/09/05

Lindisfarne 21/02/05

Lindisfarne 29/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Lindisfarne Church End Leverington Cambridgeshire PE13 5DB Lead Inspector Mrs Jenny Cangy Unannounced Inspection 31st October 2006 3:30 Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 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.V318292.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 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.V318292.R01.S.doc Version 5.2 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 Dementia (3), Learning disability (10), Physical registration, with number disability (10) of places Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three named service users with dementia under 65 years of age Date of last inspection 15th February 2006 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. The home has a disabled access vehicle. Fees are from £1,319 t0 £2,075 per week according to the level of disability and support needed. Service users fund their own social activities and admission for their carer if required. They pay for their own holidays, any extra day services beyond those as part of their care plan (eg aromatherapy) personal clothing and hairdressing. The report from the CSCI is kept in the office and is available to service user representatives on request. The manager does not currently actively discuss the report and its contents with the service users as the level of their disability makes the report format difficult to understand. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 15.30. The inspector was admitted to the home by a member of staff. The manager was on duty but out of the home returning after about 45 minutes. The inspector spent time with the senior carer on duty reviewing the requirements made at the last inspection and reviewing the key national minimum standards and those not inspected at the last visit. She was helpful and knowledgeable and conducted herself with confidence. A tour of the home followed and several staff members and service users were spoken to. The staff and service users were enjoying a Halloween/ service user’s birthday party. Staff and service users were dressed up and the home was decorated. Those service users who find it difficult to cope with the noise and activity of such a social occasion had been taken on a trip out and returned during the inspection in time for tea. The inspection concluded at 17.30. What the service does well: What has improved since the last inspection? What they could do better: There are some carpets in service users bedrooms that are unacceptably stained and in need of replacement but the manager stated this is in hand. There were no requirements made following this inspection. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 6 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. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 7 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.V318292.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. The needs and aspirations of service users are known and documented This judgement has been made using available evidence including a visit to this service and reviewing service user care plans and files. EVIDENCE: Needs led assessments were evident on service user files and care plans reflected the activities observed. It was noted that alternative activities were in place for service users unable to cope with the noise and activities of a birthday party so they had been taken out on a trip. Family contacts are maintained including taking service users to visit families. All cultural needs are met including special diets and religious festival observance. There are clear records of healthcare needs being met. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards6, 7, 9, 10. Quality in this outcome area is excellent Care plans contain detailed information about service users daily lives and service users are involved in compiling and reviewing these plans. This judgement has been made using available evidence including a visit to this service, checking service user records and discussing care with staff, service users and the manager. EVIDENCE: All care plans are detailed and have been recently reviewed and updated. There is a key worker system and key workers have responsibility to review care plans monthly. The senior staff do weekly audits of the care plans. Service users’ involvement and choice is assured by using symbols and pictures, makaton and the use of independent advocates. Some service users are profoundly disabled and staff share their knowledge of each individual to assure continuity of care. Menus are compiled with service users using pictures Four weekly. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 10 All areas of the service users lives are risk assessed and acceptable risks accommodated. Confidentiality is part of new staff induction training and is constantly reinforced. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent Service users have an excellent quality of life with daily activities that they help to plan. Those with family have contact maintained. This judgement has been made using available evidence including a visit to this service, speaking to staff and service users and checking records EVIDENCE: All service users have a mixture of in house and external day services. The manager and staff are also involved in looking for additional activities to suit the needs of the service users. The facilities in the local community are accessed including pubs and the church. Recent social activities have included bowling, swimming and ice skating. Trips to the theatre and a pantomime are planned and all service users have been away on a holiday. There is a comprehensive programme of trips out with all service users having the opportunity to participate. Family contact is maintained and staff enable service users to visit their families. Service users daily routines are planned to suit them and are detailed in the care plans. Service users help with menu planning using picture based menus. Meal times are treated as social Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 12 occasions. The evening meal was observed during the inspection. Special dietary needs are met. Two service users have ethnic dietary needs Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good Personal and emotional support is provided appropriately and medication is stored and recorded as required. This judgement has been made using available evidence including a visit to this service, inspection of care plans and records and discussion with staff. EVIDENCE: All service users have personal care in the privacy of their own rooms or the bathroom. All service users need support to meet their personal and physical healthcare needs. Care plans clearly identify what these needs are and the service users preference in the way they are carried out. There is evidence recorded of regular general health check ups including chiropody and dentistry. If service users are admitted to hospital then staff will accompany them to ensure their needs are fully met and they are emotionally supported. The home has a Monitored dose system of medication and this was found to be in order. No service users manage their own medication. All staff are trained in the administration of medication and rectal anti-convulsion drugs. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. The home has an appropriate method of dealing with complaints and the protection of the service users from any form of abuse is paramount. This judgement has been made using available evidence including a visit to this service review of records and discussion with staff. EVIDENCE: A complaint record log is kept and was seen as part of the inspection. There are no recent complaints but those dealt with in the past were responded to appropriately and in the required time scale. Staff records show that Protection of Vulnerable Adult training is in place and the contact number for the PoVA team is prominently displayed on the office notice board with guidance noted for staff to follow. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. The home is clean and free from hazards and provides a homely environment. This judgement has been made using available evidence including a visit to this service and a tour of the building. EVIDENCE: The home has a spacious lounge and dining room. The corridors are wide and give the service users plenty of space to move around. Bedrooms are personalised and reflect the personality of the occupant. On the day of inspection the lounge and dining room was decorated for a Halloween party to celebrate the birthday of a service user. There has been some redecoration since the last inspection and cluttered areas have been cleared. Some carpets in service user bedrooms were in need of replacing and the manager stated that this is in hand. The home was found to be clean and fresh through out. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. Service users are supported by a diverse staff team who have a good level of training. They undergo a rigorous recruitment process followed by a detailed induction and regular supervision. This judgement has been made using available evidence including a visit to this service, discussion withy staff and the manager and inspecting staff records. EVIDENCE: The staff have access to regular and relevant training and this was evident in the staff training records. NVQ training is on going with staff qualified to levels 2, 3 and 4. New staff begin NVQ training when they have completed their induction and foundation training. All new staff have evidence on file of proof of identity, two written references and PoVA and Criminal Record Bureau enhanced record checks. All staff have monthly formal supervision and records are kept. Extra supervision is given when needed. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good. The provider and the manager ensure the service users benefit from a well managed home. This judgement has been made using available evidence including a visit to this service, inspection of records and discussion with the manager and staff. EVIDENCE: The manager holds NVQ level 4 registered managers award and her deputy is an NVQ assessor. The manager is supported by regular visits from her line manager. Staff were clear that the manager is approachable and supportive. The area manager visits the home at least monthly. Quality audits are conducted by the area manager or a manager from another home monthly. These audits are submitted to the CSCI. There is an annual unannounced quality audit conducted by an outside agency on behalf of the company. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 18 All health and safety records were found to be in place and up to date. A fire contingency plan is in place as is a fire safety risk assessment. Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 19 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 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 3 4 X X 4 x Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action 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.V318292.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Lindisfarne DS0000057383.V318292.R01.S.doc Version 5.2 Page 22 - 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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