Inspection on 15/03/07 for Lindisfarne Care Home

This inspection was carried out on 15th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lindisfarne Care Home 10/11/08

Lindisfarne Care Home 02/11/07

Lindisfarne Care Home 01/11/05

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 Tanya Newton Unannounced Inspection 10:00 15 March 2007 th 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.V330925.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 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.V330925.R01.S.doc Version 5.2 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) CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd Position Vacant Care Home 56 Category(ies) of Dementia (56), Dementia - over 65 years of age registration, with number (56) of places Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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, quiet rooms and a dining area on each floor. 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-le-Street, and is easily accessible by car and public transport. Fees range between £412.00 and £576.00. Fees do not include personal items such as clothing, toiletries or newspapers. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on the 15/03/06 between the hours of 10:00 and 3.30. A tour of the building was taken and the inspectors spent time talking to service users, visitors and staff. Some of their comments have been included within the report. The provider of the home also provided the Commission with information about the home earlier in the year. Records were looked at and a number of surveys were received which provide the inspector with people’s views of the service. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be more detailed to reflect the individual residents needs, particularly where there may be a risk to their health and well being. Risk assessments should be included within care plans, these tell staff how to avoid or minimise risks within the home. Medication has been moved to a different room. On the day of the inspection systems were still fairly chaotic, as the move had not been completed. The home was advised to record the number of tablets when booking them into the home so that audits could be carried out. Policies on the disposal of medication need to be updated to reflect actual practice within the home. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 6 Staff were overriding window restrictors, this is dangerous and must not happen. Some of the equipment in the home was dirty and needed cleaning and there were some odours in parts of the home. This needs address. Fire exits should not be used as storage areas and the fire risk assessment should be reviewed to ensure its compliance with current fire safety legislation. Some staff training needs to be updated as it had run out. The health and safety audit tool should be updated to reflect what action has been taken where problems are identified. Records of any restraint must be maintained. Staff should receive training in this area. 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 Care Home DS0000000727.V330925.R01.S.doc Version 5.2 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.V330925.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are managed well by the home. EVIDENCE: New service users are assessed before being admitted to the home. There is some evidence of service user and relative involvement within the assessment process. Assessments form the basis from which the care plan will be written and demonstrate how the home will meet individual needs. The home does not admit residents for intermediate care. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the care plans need updating to ensure that there is a clear consistent care planning system in place to provide staff with the information they need to meet service users needs. There is some evidence of service users involvement within these plans. Service users health needs are well met. Medication policies need to be reviewed and updated to reflect practice within the home. EVIDENCE: Each service users has an individual plan of care (care plan). Care plans were at varying levels. Some were well written and detailed, others did not contain sufficient information or risk management to demonstrate how the home would meet an individual service users needs. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 10 Risk assessments for dealing with difficult or challenging behaviours were not up to date, and the home were not providing written accounts of any restraints being used. The manager designate stated that the home were in the process of moving the care plans over to a new kardex system. Service users and relatives were asked for their views about the standard of care provided in the home. The following are some of their comments “I am very satisfied with the care and attention my relative is receiving”, “my wife is so well cared for with lots of TLC” and “my sister and I have always felt that our father is well looked after. The nurses and staff are always pleasant and dad always seems to be happy”. The medication systems in the home were looked at. The medication room has recently been moved and staff were still in the process of trying to reorganise this. It is recommended that the number of tablets being booked into the home be counted so that full audits can be carried out. Two needles had expired. The home should develop a system for monitoring their stock so that out of date items are returned to the pharmacy. It is also recommended that the policy for the disposal of medicines is reviewed and updated to reflect current practice within the home. To ensure that service users needs are met and their privacy maintained, the home provides training, which focuses on the needs of the residents, accommodated. All staff spoken to during the inspection said that residents were well looked after and that standards of care were high. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for its resident’s, and records in this area were well maintained. Service users are given a choice of activities and are able to choose what they would like to eat. EVIDENCE: The home has an activities co-ordinator and there are a range of activities provided. The home has introduced a Clipper questionnaire, which focuses on each service user’s ability to be involved in daily living tasks and social activities. This is positive as the emphasis is on retaining skills and providing positive experiences for service users. Some of the comments from residents included “ outings, yes, picnics and fish and chips at the coast I always go. The little dogs are lovely and we watch a film on a Tuesday”. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 12 Contact with family and friends is encouraged and visitors said that they were made welcome to the home. There are a wide range of activities available, which include music, trips out, theatre, pub, massage, church visits and reminiscence. The home also arranges for external entertainers to come into the home and entertain service users. One of the visitors said, “staff speak nicely and are friendly and pleasant, there’s plenty going on and they look after the visitors too”. The records maintained by the activities co-ordinator were of a high standard. Comments about the food were also good and included “there’s plenty to eat and whatever they want they get” and “the meals are good, there’s an unlimited amount of choice”. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with effectively and there are clear systems to protect residents from abuse. Any restraint carried out by the home must be recorded. EVIDENCE: The home has received four complaints since the last inspection. There are clear policies for managing complaints and the home refers any concerns relating to adult protection appropriately. 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 that all staff receive training prior to them carrying out any type of restraint. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the environment in the main is kept clean and tidy, there were some concerns, which need to be addressed to ensure the health, safety and well being of service users and staff. EVIDENCE: A tour of the home was taken. Domestic staff are on duty throughout the day and areas such as toilets and sluices and residents bedrooms and communal areas were kept clean and tidy. The home has developed a multi sensory room for residents to relax in. The temperature of this room must be monitored, as it was very hot. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 15 It was concerning that a number of windows had been opened wide by staff who had disabled the window restrictors. This may put residents at risk of a potential fall. Cleaning materials were being stored at the rear of the ground floor stairway, which may be a fire risk as the area is used as a fire escape route. The studs and slings used for the Kingcraft bath were filthy and must be cleaned regularly. The toilet light cord next to the upstairs sluice was broken. Management checks of the home should be carried out to identify matters such as this. Some areas particularly the top corridor smelt of urine. Relative comments included “The home is always clean and free from nasty odours” and “I visit regularly, the domestics keep the place clean and nice. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty are sufficient to meet the needs of the residents living within Lindisfarne. Staff recruitment systems protect service users. Some staff training needs updating. EVIDENCE: Staff rotas were looked at. The number of staff on duty is sufficient to meet the needs of the residents living within Lindisfarne care home. Comments about the staff included “The staff are very friendly and helpful, over the years I have built up a very good relationship with everyone who works at the home, I can’t praise them enough and would recommend the home to anyone”. Staff recruitment files were looked at, all contained sufficient information to protect service users. This included a police check and two references. Induction is provided for all new staff. Training files were also looked at. Some staff had gaps in their mandatory training this needs to be updated. Mandatory training includes First Aid, Fire, Manual handling, H&S, POVA and food hygiene. Out of the 4 files looked at 3 staff required fire training, 3 required food hygiene 1 required manual handling and 1 required first aid. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 17 It is important that staff training is kept up to date. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager at present. The home does have systems to monitor quality, which seek the views of relatives and other professionals. Staff supervision should take place more regularly. Some health and safety systems need updating, to ensure the safety and well being of service users and staff. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home does not currently have a registered manager. The acting manager said that a new manager had been employed and was due to commence work once a satisfactory CRB and references had been obtained. Quality assurance systems were looked at. Relative questionnaires were sent out by the home in March 2007, thirty-seven had been returned to the home. The manager designate said that action would be taken to address any concerns raised within these. The home has achieved the Investors in People award and has also been accepted as an adaptation centre for overseas staff wishing to update their skills. The home does not act as an appointee for any of the service users, although regular checks are carried out internally, the home should also have external audits. Of the 57 staff employed by the home (32 of which are carers) 19 had received supervision in the last two months. All staff should receive a minimum of 6 supervision sessions each year. Health and Safety systems were looked at. Audits are carried out on a monthly basis. Some areas of maintenance, which are being reported to head office, are not being dealt with. Regular maintenance checks are carried out and include fire and emergency light checks. The home also has in place contracts to ensure the safe working order of equipment within the home. Bed rail assessments must be signed by the person completing them and be detailed in the way they are recorded. The form needs to be updated, as it does not make sense. It was concerning that a number of windows had been opened wide by staff who had disabled the window restrictors. The window restrictors were easy to override and one-service user had managed to climb out of a ground floor window. The home must ensure that safe restrictors are in place and that risk assessments are provided. Cleaning materials were being stored at the rear of the ground floor stairway. This may be a fire risk as the area is used as a fire escape route. The fire risk assessment was dated 2005, this must be reviewed to ensure that it complies with current legislation. Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 20 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 2 8 3 9 2 10 3 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP7 OP18 Regulation 15(1) 13(8) Requirement Each service user must have a care plan which reflects their needs fully. 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. Previous requirement of 01/11/05 unmet Fire escape routes must be kept clear and must not be used to store cleaning materials. Studs and slings must be kept clean to ensure that infection control policies are adhered to. Staff must not override window restrictors. All areas must be kept clean and free from odour. Staff training must be kept up to date The home must employ a manager who is registered with the commission. The person completing them must sign bed rail assessments and the form needs to be DS0000000727.V330925.R01.S.doc Timescale for action 30/06/07 30/05/07 3. OP19 OP26 OP38 23(2) 30/05/07 4. 5. 6. OP30 OP31 OP38 18(1) i 9 13(4) 30/05/07 30/06/07 30/06/07 Lindisfarne Care Home Version 5.2 Page 22 updated. Risk assessments must be carried out on the current window restrictors and staff must not override these when cleaning the home. The fire risk assessment needs to be reviewed to ensure its compliance with fire safety. Escape routes should not be used to store cleaning materials. 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 OP9 Good Practice Recommendations The home should count the number of tablets, which are booked into the home so that proper audits can be completed. Systems to monitor stock should also be developed so that out of date items are disposed of. The policy for the disposal of medicines should be updated. Staff should receive at least six supervision sessions each year. Someone external to the home should audit resident’s money. 2. 3. OP36 OP35 Lindisfarne Care Home DS0000000727.V330925.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. 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