Inspection on 01/11/05 for Lindisfarne Care Home

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Care Home 10/11/08

Lindisfarne Care Home 02/11/07

Lindisfarne Care Home 15/03/07

Lindisfarne Care Home 12/05/05

Lindisfarne Care Home 26/10/04

Lindisfarne Care Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Lindisfarne Care Home Gainford Whitehill Park Chester Le Street Durham DH2 2EP Lead Inspector Mrs Tanya Newton Unannounced Inspection 1st November 2005 09.15a 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 Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 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. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lindisfarne Care Home Address Gainford Whitehill Park Chester Le Street Durham DH2 2EP 0191 3883717 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) Gainford Care Homes Limited Mrs Margaret Roe Care Home 56 Category(ies) of Dementia (56), Dementia - over 65 years of age registration, with number (56) of places Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 2005 Brief Description of the Service: Lindisfarne Care Home is registered to provide nursing and residential care for up to 56 service users aged 65 years and over, who experience mental health problems. The home is a purpose built unit, with two floors (ground and first). Each service user has their own bedroom, and there are a number of lounges, quite rooms and a dining area. The garden area provides a pleasant enclosed area, and the general presentation of the home is friendly and welcoming. The home is located within the community in a residential area of Chester-leStreet, and is easily accessible by care and public transport. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on the 1st of November between the hours of 9.15 and 3.15. This was the second annual inspection of the home. The manager, eight staff, six residents and seven visitors/relatives were spoken to during the inspection and some of their comments have been included within the report. In line with current CSCI policy on “proportionality” the inspection focused on a number of core standard outcomes for service users. What the service does well: What has improved since the last inspection? Admissions are well managed by the home and the home does not admit any resident unless their needs can be met. Each resident has a care plan, which is a document, which tells people how to care for each resident. Medication systems have improved and checks are carried out on equipment, which is used to monitor the health needs of residents. . Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 6 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 Care Home DS0000000727.V261045.R01.S.doc Version 5.0 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 Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Admissions are managed well by the home. EVIDENCE: New service users are admitted, only when an assessment has been carried out by the home. Evidence of service user/relative input is included within the assessment process where possible. Assessments form the basis from which the individual plan of care will be written and demonstrate how the home will meet an individuals needs. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 There is a clear consistent care planning system in place, which provides staff with the information they need to satisfactorily meet service users needs. There is some evidence of service users involvement within these plans. EVIDENCE: The care plans examined contained detailed information on how each service users needs were to be met by staff. The care plans include risk assessments and are reviewed regularly by the manager; the home are encouraging relatives to be involved within the care planning process. The qualified nurses have received training in care planning. The manager confirmed that she carried out a monthly audit on medication systems and that these had improved. Equipment to monitor resident’s health, for example equipment to monitor blood sugar is checked regularly in line with the manufacturers instructions. Relatives spoken with confirmed that resident’s health needs were met and comments included “my mam is looked after well, she is improving all the time, personal care is of a high standard, I can’t fault it” and “my wife is eating better and is getting her medication since moving in, I’ve no concerns”. Staff training is based around meeting the needs of the residents accommodated, Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 10 staff stated that “residents are well looked after and the standard of care is high”. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 A variety of activities are provided to provide stimulation and social support to residents. A choice of meals is provided for residents. EVIDENCE: A wide range of activities is provided and the home has an activities coordinator. A record of all of the activities provided is held. Residents choose whether or not they want to participate in activities, the home has a flexible approach to meeting each residents needs. A relative commented, “I am invited to relative meetings, there lots going on socially”. Contact with friends and family is encouraged and all visitors spoken with confirmed that they were made to feel very welcome. Choice making is encouraged in as many areas as possible, this was confirmed by staff and relatives, pictorial menus have been developed to support residents in choosing menus and one resident commented “nobody makes me do anything I don’t want to”. Menus are provided and residents are given a choice at mealtimes, there are home baked goods and a cooked breakfast is available. Comments from relatives included “the meals look lovely, they are given a choice” and one of the residents said “the food is alright, you get to choose”. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints are dealt with effectively and there are clear systems to protect residents from abuse. EVIDENCE: Two complaints had been made to the home since the last inspection, both complaints were upheld. Training has been provided to staff in the referral process as one of the complaints also related to adult protection and should have been referred to Durham Social Services prior to the home starting its own investigation. The majority of staff have now received training in adult protection and all staff spoken with during the inspection had heard of whistle blowing (where staff are able to report any concerns, and are protected in doing so). There are clear policies in place to support staff in this area. The home has a policy on restraint and on occasions does have to intervene to protect service users, when this happens the home must ensure that clear records are maintained and staff receive training. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home provides a safe, clean, pleasant and comfortable environment for residents. EVIDENCE: An ozone machine has been purchased for the upper lounge to reduce odours, it is hoped that an additional machine will be purchased for the reception area. The home’s domestic staff work very hard to maintain a clean and odour free environment. Carpets are being replaced in fifteen of the bedrooms. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staffing numbers are sufficient to meet the assessed needs of the service users. Training for staff is ongoing and based around meeting the needs of the service users accommodated. EVIDENCE: The homes staffing rota demonstrates that the home is staffed in a way that supports them to meet the needs of residents. Comments were made such as “the staff are canny” and “the staff are lovely”. Four staff files were looked at, where staff are employed from overseas by an agency, copies of references should be held on their personnel file. Some staff files had no photo; otherwise all contained the required information, which helps to protect residents. Induction is provided for all staff, which is based on TOPSS guidance. All new staff attends training in induction and foundation and can then go on to NVQ. The home has already achieved 50 of staff gaining NVQ 2 or above and hopes that it will reach 70 . The fire training is out of date and must be provided for all staff. The manager and staff confirmed that courses were on going and that there was a high commitment to staff training. Comments from relatives included “the staff are really nice, I am kept up to date, they are really good”. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 34, 35 & 38. The home has clear systems to support and protect staff and residents living at Lindisfarne. EVIDENCE: Staff confirmed that they received good support from the manager, the following are some of the comments were made “the management are really approachable” and “the manager is great”, comments from relatives and visitors were also positive about the approach of the manager and staff working at the home. A random check was carried out on resident’s finances; it is recommended that someone other than the administrator audit resident’s monies at least annually. The welcome letter, which is sent out to prospective residents, should be updated to reflect the changes in costs for things like hairdressing. Resident’s monies should be held in the safe. Health and safety audits are carried out, where problems are identified these should also reflect what action has been taken, the date and by whom. The Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 16 home has policies in place to support staff with health and safety, training should also be provided to all staff in this area. The fire risk assessment covers both homes on the site, this should be updated and reflect each home individually. Lindisfarne Care Home DS0000000727.V261045.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 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 2 Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 18 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 OP18 Regulation 13(8) Requirement On any occasion on which a service user is subject to physical restraint, the registered person shall record the circumstances, including the nature of the restraint. All staff must receive regular training in fire evacuation Timescale for action 01/11/05 2. OP38 23(4)d 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP35 Good Practice Recommendations Resident’s monies should be audited and the welcome back should be updated to reflect current costs. Lindisfarne Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 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 Care Home DS0000000727.V261045.R01.S.doc Version 5.0 Page 20 - 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. 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