Inspection on 28/06/07 for Lindisfarne Care Home

This inspection was carried out on 28th June 2007.

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 13/11/08

Lindisfarne Care Home 14/06/06

Lindisfarne Care Home 15/12/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Lindisfarne Care Home Masefield Road Hartlepool TS25 4JY Lead Inspector Mrs Tanya Newton Key Unannounced Inspection 28th June 2007 09:30 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 DS0000062328.V343266.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 DS0000062328.V343266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindisfarne Care Home Address Masefield Road Hartlepool TS25 4JY 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) 01429 244020 CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd Wendy Moses Care Home 53 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (30), Physical disability (2) Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 Brief Description of the Service: Lindisfarne is a purpose built, 53-bed residential care home, owned by Gainford Care Homes Ltd. It has bedrooms on two floors and further facilities, including an activity room and a hairdressing salon, on a lower ground floor. The home is situated on Rift House housing estate, on the outskirts of Hartlepool, and is on a major bus route with small, local shops and community facilities nearby. The home opened in August 2005 and is registered with the Commission for Social Care Inspection to provide care and accommodation with nursing care. The current scale of charges is £357 and does not include the cost of hairdressing, chiropody and newspapers. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home was unannounced and carried out over seven hours. People living at the home, relatives and staff were spoken to during the inspection. Some information was received prior to the inspection. This included a pre-inspection questionnaire that was completed by the previous manager. Some of this information is included within this inspection report. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to include more detail particularly where any form of restraint is being used to safeguard people. The complaints file must be made available to everyone and staff should receive training in its use. Staffing numbers require review. Issues around staff morale and allocation of staff need to be addressed. Staff training must be kept up to date so that staff can maintain the skills necessary to carry out their roles effectively. There must be clear lines of management at all times with delegated responsibilities in the absence of the manager. A gas safety certificate is required and bed rail assessments must be in place in all cases where bed rails are used. This helps to protect people. Policies and procedures should be read and signed by staff. Lindisfarne Care Home DS0000062328.V343266.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 Care Home DS0000062328.V343266.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 DS0000062328.V343266.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. A detailed assessment is provided before admission. Assessments demonstrate how the home is able to meet people’s needs. The home does not provide intermediate care. EVIDENCE: The home carries out its own assessments before admission, meeting people either in hospital, their own homes or at Lindisfarne. People are invited to visit the home prior to admission. The home requests a copy of the care management assessment for service users funded by the local authority. The assessments viewed in the main contained detailed information and were up to date. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care. However the manager did say that if there were vacancies within the home people could be admitted for short periods of respite care before going home. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. People’s health needs are in the main well managed by the home. Systems to store and administer medication are safe. People living at the home in the main say that they are treated well and that the standard of care is high. EVIDENCE: Care plans were generally well written. Some needed to include more detail. Care plans provide information, which sets out the way in which the home will meet people’s needs. There was clear evidence of input from other health professionals where this was required. Records held at the home showed that people’s health care needs were being met. People’s care notes contained a record of visits to and from their own doctor and by district nursing services in addition to the home’s nursing staff. The homes policy on restraint needs to be reviewed to reflect practice within the home. One person was being restrained in a chair with the use of a Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 11 wheelchair lap strap. Restraint should not be being carried out unless advice has been sought and agreement made from a multidisciplinary team. Having the approval of a relative is not sufficient. An alternative recliner chair should be considered so that people are comfortable and safe. Medication systems were viewed. The home has a policy on the handling and administration of medication that is followed by staff members. Medication records for each service user were well documented and accurate. None of the people living at the home are currently looking after their own medication. People were asked if they felt that they were treated with dignity and respect, the responses to this were mixed. One gentleman said that he did not get a drink throughout the night despite asking staff for one. Other people said that staff knocked on doors and spoke nicely. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 12 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. In the main there are a range of activities available to support most people’s social needs. Visitors are made welcome to the home and there is a varied menu which people enjoy. EVIDENCE: People living at Lindisfarne said that there were good social opportunities available within the home. On day one of the inspection a group of people had gone out on the home’s minibus to the marina. People said that there were good opportunities to participate in activities within the home. Some staff felt that there should be more activities available. The home has an activities coordinator who provides a range of activities, which include bingo, sing longs and a range of outings to different places. Friends and relatives are encouraged to visit the home. Comments from visitors were positive and included “I am very happy with the home, it is so relaxed with quite a lot of social activities taking place, lots of singing, dancing. Staff are very good at keeping families up to date”. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 13 People were asked if they were able to make choices in the home. Some said that they regularly had breakfast in bed. Other choices included meals and activities. Comments about the food were good. The home has recently gained a five star rating for “safer food better business” which is an initiative put in place by the local environmental health department. The chef said that a cooked breakfast was available on a daily basis to those who wanted it. Lunch and tea was a choice of two items and sandwiches, light snacks and drinks were available at any time. Comments about the food included “ Lunch was lovely, I had an omelette” and “I enjoyed lunch today it was lovely and “The food looks beautiful lots of choice”. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy must be accessible to all staff. Adult protection matters are dealt with appropriately. EVIDENCE: Although the home does have a complaints policy, some staff did not know where the complaints file was kept. A complaint was made during the inspection. However in the manager’s absence staff did not seem clear about the action to be taken. All staff should be clear about the way in which complaints are managed. Some additional training in this area may be required. There is a policy for referring allegations of abuse, all staff spoken to say that they would whistle blow (tell someone) if they saw or heard something inappropriate. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and furnished and decorated to a high standard. EVIDENCE: The home is a new building and is well maintained. Individual bedrooms were seen to be bright and comfortably furnished. There is a range of communal areas where people can sit and relax in addition to the main lounge areas. The home was clean and free from odour, much to the credit of the domestic staff. Positive comments were received from relatives regarding the cleanliness of the home. Lindisfarne Care Home DS0000062328.V343266.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers, allocation and training need to be reviewed. Staff recruitment systems are safe and protect people. EVIDENCE: Staff said that the numbers of staff on duty were no longer adequate to meet the needs of the people living in the home. Staff felt that people’s care needs had increased and that the number of staff on duty should be increased to reflect this. Staff worked long shifts out of choice but many were not taking their allocated breaks. Staffing numbers must be reviewed. Staff also said that morale was not always good, staff tended to work purely on one floor and there seemed great reluctance for them to cover other floors. Some staff said that there was a divide between the two teams working on each floor. The owner said that the staff were employed to work in the home, not on a particular floor. This matter was discussed with the manager and must be addressed. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 17 Staff training files were looked at. Not all mandatory training was up to date although a number of courses had been booked to address this. Eighteen of the thirty-three staff employed had an NVQ at level 2 or above. A further fifteen staff are working towards this award. Recruitment files were looked at during day two of the inspection. All those viewed contained two references and a police check, this helps to protect people living at the home. Lindisfarne Care Home DS0000062328.V343266.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements in the absence of the registered manager are unclear. Financial arrangements are sound and health and safety systems and practices protect people. EVIDENCE: The home has a registered manager who is a nurse. Comments about the management arrangements were mixed. Some staff felt that there should be better support available to them. Proper arrangements need to be made in the absence of the manager as during day one of the inspection the manager was absent and a number of records were unavailable. Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 19 Quality assurance audits are carried out to ensure that the home provides a good level of care to the people living there. The manager has sent out surveys to people’s families and is available to discuss any issues raised at any time. Regular checks of the building and surroundings are also carried to ensure the environment is appropriately maintained. The manager said that relatives managed people’s financial affairs although the home did provide a facility to safeguard and record people’s personal allowances. The health and safety of service users, staff and visitors to the home must be monitored. Risk assessments had been conducted covering a variety of issues and included regular checking and servicing of equipment and fittings. However, the gas safety certificate was dated 2005, an up to date certificate is required. One person had bed rails fitted to their bed without a risk assessment, other bed rails were left lying around the home and one risk assessment on bed rails said that staff should fit a pillow between the gap. This practice is dangerous and must stop. There are a range of policies and procedures to support staff working within the home, although there is no evidence that staff are accessing these. These should be read and signed by staff. Lindisfarne Care Home DS0000062328.V343266.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 3 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 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 X X 2 Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 12 Requirement The home must ensure that the health and welfare of service users is maintained. Where restraint is used the reason for doing so must be fully documented and advice sought from other professionals. The complaints procedure in the home must be available at all times. Staff may require training in its use. Staffing numbers must be appropriate to the assessed needs of service users. Staff training must be kept up to date. Management arrangements within the home need to be clear. Issues around staff morale and allocation of staff must be addressed. A gas safety certificate is required. Bed rail assessments must be carried out and must be based on the MDA guidance 2002. Timescale for action 31/08/07 2. OP16 22 15/09/07 3. 4. 5. OP27 OP30 OP31 18 (1)a 18 ©i 9(2)i 15/09/07 30/09/07 15/09/07 6. OP38 13(4)c 15/09/07 Lindisfarne Care Home DS0000062328.V343266.R01.S.doc Version 5.2 Page 22 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 OP38 Good Practice Recommendations Staff should read and sign all policies. Lindisfarne Care Home DS0000062328.V343266.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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