Inspection on 18/04/07 for Lindisfarne Care Home Ltd

This inspection was carried out on 18th April 2007.

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 Care Home Ltd 22/09/05

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Larchfield Manor

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Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lindisfarne Care Home Ltd Bridgehouse Lane Haworth Keighley West Yorkshire BD22 8QE Lead Inspector Ashley Fawthrop Key Unannounced Inspection 18th April 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 Ltd DS0000064238.V326063.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 Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindisfarne Care Home Ltd Address Bridgehouse Lane Haworth Keighley West Yorkshire BD22 8QE 01535 645206 01535 648001 lindisfarnecare@aol.com 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) Lindisfarne Care Home Ltd Mrs Jayne Ricci Care Home 30 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (30), of places Physical disability (1) Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under the age of 65, named on variation dated 7th November 2006, may reside at the home. 22nd September 2005 Date of last inspection Brief Description of the Service: Lindisfarne is a converted extended property situated in the village of Haworth, and is close to local facilities. The home was first registered in 1993 and provides residential and personal care, without nursing, for residents of both sexes over the age of 65. Accommodation is provided in a combination of single and double rooms, the majority of the single rooms have en-suite facilities. Communal areas consist of a lounge, dining room and a large conservatory on the ground floor and a further lounge on the first floor is used as a quiet room. The home is situated in its own grounds with car parking facilities to the front and side of the building. There is a level area at the front of the home where residents may sit. On the 18th April 2007 the charges levied £380.00 to £410.00 per week. Additional charges are levied for hairdressing the charges vary as to what the person has done. Lindisfarne Care Home Ltd DS0000064238.V326063.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 without prior notification and was conducted by one inspector over the course of one day. The inspector would like to thank everyone who took the time to talk to them and express their views. People who live in the home completed sixteen survey forms and relatives, carers or advocates completed nine Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, adult protection issues, reports from other agencies, i.e., the Environmental Health Officer. This information was used to plan this inspection visit. The inspector case tracked tree people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspectors assessed all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspectors spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with external professionals to obtain their opinions about the quality of services provided at the home. What the service does well: The atmosphere at the home is very friendly and we observed a good relationship between staff and people who live there. Where personal care tasks were undertaken it was completed in a professional manner. The staff spent time with people in and among their daily duties. Staff understand and respond to the likes and dislikes of people and wherever possible will go out of their way to make sure that individual tastes are met. The home understands the importance of good nutrition, and hot and cold drinks are always on offer. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 6 The feedback from people who live there and visitors was very positive and people said: - When I ring from my room the staff day or night respond immediately. The home caters for my personal preferences these differ from the set menu. All the staff here are so pleasant and kind which from a personal point of view makes settling in much easier. Relatives of people living at the home said: - Everyone cares about the people who live there and try to get them to live their lives to the full. Nothing is too much and I have been impressed by the care mum receives. The home provides first class care and attention at all times and are always available when needed. The home has a warm and welcoming environment. They have a stable staff team. The meals appropriate and appreciated. What has improved since the last inspection? What they could do better: Where the only evidence that people who live at the home or their relatives have been involved and agree with the care plan is to sign that the agreement sheet. Then this must be in place on all care plans and be replaced when the care plan is updated as evidence that they are aware of the changes. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 7 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 Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 8 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 Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 9 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): 1, 3 and 6 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides good information to people before they move in. They assess the persons needs well to make sure they can deliver the care and the person can visit the home and try the service before they make a decision. This is good practice. EVIDENCE: People wishing to use the service can access good information about the home and the services it provides before making the decision to move in. This information is written in the statement of purpose and the service users guide. Information includes practical information such as how you and your family can become involved in the planning of your care. How your medication Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 10 will be looked after if you can’t manage yourself and what social activities are available if you choose to be involved. There is also information on how much it will cost you and how the home staff will assist you to lead as an independent life as possible. The information comes in pictures as well as written form and is easy to understand. This information is good as it gives the person wishing to use the service sufficient information for them to make a judgement as to whether the home can meet their needs before they make the decision to move in. People who have recently moved into the home said they had stayed at the home for a short time before moving in permanently and had had good information about the home. On the three case records I tracked all the people had a pre moving in assessment. These recorded personal information as well as what the homes staff would need to provide to make sure that the person can continue to lead as an independent life as possible. The records are good practice as it gives the staff good information about the persons needs before moving into the home so that the planning of the care is underway on arrival at the home. There was evidence that people are given the opportunity to visit and in some cases stay at the home for a short time before making a decision to stay permanently. This is good because it gives the person wishing to us the service a chance to try the home without obligation and can go away and make a decision in their own surroundings with the help of their family or representatives. There is record on the care plan that reports on how the person was on the introductory visit but on the care plan I read this was not completed. The introductory visit is part of the pre moving in assessment and good information may be lost if a record is not kept, I recommend that the assessment on the day of the visit is completed in all cases. The home provides opportunities for people to live there on a short stay basis. The home does not provide intermediate care for assessment purposes this is good as the home does not have the facilities to provide such a service. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 11 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 and 10 People who use the service experience excellent.quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care is planned with the input of the person it is written for and makes sure these are individual. They contain good up to date information and are regularly reviewed. Medication practices are seen to be safe, and people were respected as individuals. EVIDENCE: We case tracked three care plans. There was evidence that people who use the service and their family have involvement in care planning, and agree and sign the completed document. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 12 However, on one of the care plans the form had not been completed, as this is the only written evidence that people and their families are involved they should be completed in all cases. I also recommended that these should be renewed each time the care plan is updated On the whole care plans contained good information and included the social interests as well as the physical needs. This is good practice as the person is seen as a whole person rather than only there disabilities. There was information detailing personal preferences, likes and dislikes. Care staff described how they give pressure relief to those residents at risk of developing a pressure sore, and residents identified as being at risk nutritionally are given a nutritious high calorie diet. Turn charts and food diaries were in place. Two care plans related to people who were at risk from pressure sores. The records clearly identified the care needed to minimise and monitor the risk. Pressure area assessments were done and updated regularly and consistently and accurate records were kept relating to nutrition and weight. Pressure relieving mattresses and cushions were in use and regular turning to prevent pressure were recorded. There was evidence that the home has addressed the recommendation from the last inspection and has included social and recreational activities. There was plenty of evidence that people enjoy a good social life within the home, and this is recorded on a daily basis as recommended in the last inspection report We checked the medication system and found drug administration records are well recorded and safe secure storage is provided. Policies and procedures continue to be available to staff and training is provided for staff that handle medication. People said that the staff were very helpful and that the treated them well and that they listen to what they say and it is acted upon. There was further evidence that people are treat with respect I was able to observe staff and people who live their in their daily activities and it was clear that appropriate friendships had developed and people were relaxed and happy. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 13 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 and 15 People who use the service experience excellent.quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable homely environment where choices are respected. Visitors are made to feel part of the home. EVIDENCE: People spoken to said that there were activities organised on a regularly in the home as well as trips out. People said that they could choose whether or not to be involved. Activities are organised by an activity coordinator and there is good information on each care plan about individual pass times. This is good as staff can organise activities on an individual basis at times. Family and friends are encouraged to visit and people said that staff are always helpful and courteous and have a good report with people who live there. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 14 Others said the staff are very caring, the food is good, the home is very clean and staff make it feel like the persons own home. Staff was able to describe the choices available to people and through discussion we felt that there was a good understanding of individual people and their needs such as their favourite TV programmes, preferred milky or alcoholic drink and their past and current interests. Though there are no people with any specific cultural or religious needs people diverse needs are met in many are of their care, for example individual likes and dislikes are recorded and there is evidence that staff try hard to make sure that if an individual likes a certain food it is made available. Meal times are spread out evenly throughout the day, this makes sure that there is not a long time between supper and breakfast. People have input into the menus and their likes and dislikes are recorded on moving into the home and are taken into consideration when planning the menus. We saw staff working at the pace and level of individuals, and saw their decisions respected. People described some of the choices they make, these included times for going to bed and getting up in the morning. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 15 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 and 18 People who use the service experience good. quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The level of staff knowledge and understanding of abuse is good and people are protected. EVIDENCE: There are policies and procedures relating to the Protection of Vulnerable Adults and are available to staff. Staff have undertaken training in this area and is included in the planned future training. Staff are able to describe the different types and signs and symptoms of abuse. They were also aware of the more subtle kind of institutional abuse. Since the last inspection a new policy on abuse has been started that includes details and contact numbers of the multi-agency adult protection unit. She also said that she has also contacted the adult protection unit to arrange training for senior staff on how to use the multi-agency procedures. As was recommended at the last inspection. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 16 All people who use the service have a copy of the complaints procedure. People said that before they entered the home they were made fully aware who to speak to if they had any problems. There has been one complaint since the last inspection, this was investigated by the registered person with a satisfactory outcome. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 17 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, 21, 22, 23, 24, and 26 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides comfortable surrounding that is maintained to a good standard and meets the needs of the people who live there. EVIDENCE: The home is maintained to a good standard and a record of inspections of the building are kept. There has been some refurbishment since the last inspection. Two twin room have been converted into single rooms this has improved the privacy for people using the service while the numbers of people have remained the same. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 18 The lay out of the dining room has been changed to provide more space and a new lounge has been created. There is a shower that has wheelchair access and an additional two toilets have been created so they are closer to living areas and easier for people to get to and use. People said that the home is comfortable and is always clean. People were seen to enjoying the comfort and privacy of their rooms and bedrooms were individually decorated and furnished. People said that they have the opportunity to have their own furnishings and possessions around them giving the feel of individuality and ownership. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 19 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 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Safe recruitment practices are in place and staff are trained and competent to do their jobs. EVIDENCE: The policies and procedures for recruiting staff continue to be good. The records contained all the information required including 2 written references and CRB (Criminal Record Bureau) checks. Information from the pre-inspection questionnaire, completed by the manager, showed that high numbers of care staff have an NVQ (National Vocational Qualification) at level 2 or above. All staff are being provided with individual training records. The records provide information of all the training undertaken by the staff. An annual training plan continues to be in place, which reflects the training identified from the staff meetings and the individual staff training sessions. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 20 Training planned for the future includes Health and safety, Protection of Vulnerable Adults and Palliative care. Staff said that they always have the opportunity to do training on a regular basis. This is good practice and provides the staff with the skills to provide good care. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 21 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 and 38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people living there, they benefit from the ethos, leadership and management of the home. EVIDENCE: The manager has a nursing qualification and many years of experience in the care field. She has undertaken the Registered Manager’s Award. There continues to be clear lines of accountability in the home. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 22 The manager continues to use a quality audit system, which includes a selfassessment audit tool. Questionnaires are being sent out, and regular staff meetings continue to be held with records available for staff to read. No benefit books are held on behalf of residents, however some monies are held for service users. Staff confirmed that supervision takes place. One person said that supervision was constructive, that records are kept, and that staff are given positive feedback. There are records of supervision held on file. The manager and a senior care worker have both attended fire training and are now competent to deliver this training to other staff in the home. This takes place at six monthly intervals. The manager completed a pre-inspection questionnaire that confirmed all the necessary health, safety and maintenance checks have been completed. COSHH (Control of Substances Hazardous to Health) risk assessments are in place for all products used by the home, and the home has information on the safe use of bed rails. The manager continues to audit all accident forms on a monthly basis to help her identify any patterns or trends. As recommended in the last inspection when an accident is not witnessed a record is kept of when the person was last seen, and by whom. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 23 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 4 X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 4 4 X 4 4 4 4 X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 3 X 4 Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 24 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. 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. 1. Refer to Standard OP7 Good Practice Recommendations The confirmation sheet that the person or their relative signs to say that they agree with the plan should be in place on all the care plans. When the care plan is updated these forms should be re signed agreeing with the new plan. Lindisfarne Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Care Home Ltd DS0000064238.V326063.R01.S.doc Version 5.2 Page 26 - 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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