Inspection on 19/09/07 for Lindisfarne Ouston

This inspection was carried out on 19th September 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 Ouston 09/11/06

Lindisfarne Ouston 17/11/05

Lindisfarne Ouston 05/05/05

Lindisfarne Ouston 29/09/04

Lindisfarne Ouston 07/04/04

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 Ouston Institution Terrace Ouston Co Durham DH2 1QW Lead Inspector Unannounced Inspection 10:30 19 September 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 Ouston DS0000046626.V349056.R02.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 Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindisfarne Ouston Address Institution Terrace Ouston Co Durham DH2 1QW 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) 0191 4922891 0191 4922892 ouston@gainfordcarehomes.co.uk CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd Mrs Ann Woodhead Care Home 57 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (57) of places Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 5 persons aged 55 years and over may be placed commensurate with the home’s Statement of Purpose. 9th November 2006 Date of last inspection Brief Description of the Service: Lindisfarne care home is registered to provide care for up to 57 older persons with dementia, five of whom may be under the age of sixty-five. The home is purpose built over two floors, and is situated in the quiet village of Ouston. The building is light, airy and spacious with views over green land. The grounds are pleasant and include an allotment, which is in the process of being developed for people’s use. The home is part of the Gainford Care Home Group. Fees range from £370.00 to £431.00 per week. They do not include hairdressing, chiropody and some of the activities. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Tanya Newton and Jean Pegg carried out the inspection between 10:30am and 3:30pm. The inspection was unannounced. Records were looked at, a tour of the environment took place and staff and relatives were spoken to. Where possible feedback was gained from people living at the service. Comments made during the inspection are reflected throughout the report. All key national minimum standards were looked at. A short observational framework for inspectors (SOFI) was carried out which focuses on interactions between staff and people living at the home. This information is also included within the report. What the service does well: What has improved since the last inspection? What they could do better: Assessments and care plans require further development. The temperature of the treatment room was too high and must be maintained at a safe level. Medication recording systems could be improved upon. The areas of privacy, choice and dignity must be improved upon so that people living at the home are respected and encouraged to make choices wherever possible. Mealtimes should be more relaxed with people supported individually where this is required. A record of all complaints must be maintained and policies and procedures generally need to be reviewed to ensure that they contain the correct information and are up to date. The smoking policy must reflect actual practice within the home. Areas where there are odours present should be addressed and electrical items bought into the home by people, should be Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 6 tested for safety on admission. All staff should receive a minimum of six supervision sessions each year. 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 Ouston DS0000046626.V349056.R02.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 Ouston DS0000046626.V349056.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. No person is admitted to the home without having his or her needs met. EVIDENCE: The home carries out its own assessments before admission, meeting people either in hospital, their own homes or Lindisfarne. Three assessments were viewed as part of the inspection, all contained very basic information and there were some gaps in the recording. One of the staff members said “People are assessed by a Care manager, when people are admitted we have access to the assessment information”. The home does not provide intermediate care, although people may be admitted for short periods of respite care before going home. Lindisfarne Ouston DS0000046626.V349056.R02.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. Care plans require further development. Feedback regarding the way in which people’s health was monitored was positive. The home must take action to address issues regarding people’s privacy and dignity. Medication recording should be improved. EVIDENCE: The home has is in the process of implementing a new standex care plan. Three care plans were viewed, each contained very basic information and there were lots of gaps in the recording. The section on risk management was the same as the care plan. It should reflect how the concerns raised within the care plan would be managed by the home. Care plans still require work to get them up to date so that they provide sufficient information for staff to meet people’s needs. All of the staff spoken to were able to describe how they use the care plan and gave examples of what may be found within them. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 10 A discussion took place with staff regarding people’s health needs. One GP commented “the home was of a good standard in terms of patient care and in its dealings with the GP practice”. The home has support from district nursing staff where this is required. Five relative questionnaires were received all had ticked to say that they were satisfied with the overall care provided. Medication systems were looked at. There were a number of missed signatures on the drug-recording sheet, although medication was not left in blister packs. The staff member in charge on the day said that sometimes staff forgot to sign. Storage systems were well organised. The temperature of the treatment room still needs to be addressed. The home said that they had received quotes regarding this. To gain feedback on issues of privacy and dignity a short observational framework for inspection (SOFI) was carried out. SOFI provides inspectors with information about interactions between staff and people living at the home. These observations were carried out for one hour. Some examples of good and bad interactions were seen. These included a staff member supporting someone to have a drink. The staff member gave encouragement and support to the individual ensuring that they were able to have a drink. Poor examples were a district nurse telling someone that they needed an injection and a staff member telling someone that they needed to get changed in front of visitors. One lady was hoisted from her wheelchair to a comfy chair, although staff explained what they were doing, more could have been done to respect the ladies dignity. A staff member collected the cups following morning coffee without speaking to anyone. There were lots of occasions where staff stood in the doorway to the lounge talking to each other and fewer examples of interactions between staff and people living at the home. Lindisfarne Ouston DS0000046626.V349056.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. In the main there are good arrangements for daily life and social activities, including leisure, personal development and catering. People must be supported and encouraged to make decisions and choices wherever possible. EVIDENCE: There is no restriction on visiting and all visitors said that they could come and visit the home at any time, this included mealtimes. The home has an activities co-ordinator who was on duty during the inspection. Activity records were well maintained with each person having their own social assessment and life story, which included a list of their like’s and dislikes. A range of activities are available, these include outings on the homes minibus, which take place at least once a week. A summary was also kept of how successful or enjoyable an activity had been. People are supported in attending church and there are weekly visits to the local chapel. Although a list of activities for the home was displayed in the foyer, the ones recorded for the day of the inspection did not take place. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 12 People were supposed to be going on an outing during the afternoon. This was cancelled due to the driver transporting staff to another home. The staff were asked about the activities provided, some of their comments included “I haven’t seen many, we had a band in and people had a dance. I haven’t been asked to play games or anything” another said “we have an activities co-ordinator she takes people on trips and plays games with residents, she also does things like knitting, its nice”. People are encouraged to make some choices, this included a choice of meal, a staff member spoke to each person and asked them what they wanted explaining fully the choices available. Other choices were very limited, staff members were observed on two occasions to turn off or to change the music without asking people if they wanted this to happen. An inspector observed mealtime. The interactions between staff and people living at the home were poor during mealtime. One staff member stood between two people who needed support with eating. They should have been sat down and should have supported each person in turn. Comments from staff included “have you finished?” and “don’t you want your dinner?” There were menus on display and food was nicely presented. Comments about the meals were good. Lindisfarne Ouston DS0000046626.V349056.R02.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and systems for managing complaints and adult protection referrals. These procedures must be followed at all times. EVIDENCE: The complaints book was looked at. There were two recorded complaints. One complaint, which had been made to The Commission as well as the home, had not been recorded. A log of all complaints must be maintained and this must include a list of any action taken. The majority of staff had received training in adult protection and there are policies and procedures to support staff. The whistle blowing policy had been read and signed by all staff. Although some of the policies and procedures were recorded as having been reviewed by the manager, many did not contain contact numbers of the relevant authority. In some areas there were two or three different policies in place, this may lead to confusion for staff. It is recommended that all policies and procedures are reviewed and updated. Lindisfarne Ouston DS0000046626.V349056.R02.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 good. This judgement has been made using available evidence including a visit to this service. The standard of décor and furnishings within the home are good, providing people with an attractive and homely place to live. EVIDENCE: The home is purpose built and has a range of large and small lounge and dining areas. There is an enclosed patio area on both floors. Suitable toilet and bathing facilities are provided throughout the home, many of which have aids to support people. Bedrooms are decorated to individual taste and many are furnished with people’s own possessions to make them more homely. In some areas of the home there were odours present. This must be addressed. The home now has a smoke free policy. The policy does not reflect actual practice within the home, as people living at the home are still able to smoke Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 15 upstairs if it is raining. The policy must reflect actual practice taking place within the home. Lindisfarne Ouston DS0000046626.V349056.R02.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. There are sufficient numbers of staff, with the right skills, for the needs of the people accommodated. The home’s recruitment policy and practices support and protect people living at the home. EVIDENCE: There were nine staff on duty on the day of the inspection. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. Of the thirty-six care staff employed at the home, 79 have gained an NVQ at level 2 or above. Training files were looked at. There is a training matrix, which details all of the training, which has taken place within Lindisfarne. Although there were a number of gaps in the training for some staff, training had been booked. The company has recently changed its training provider. There are a number of policies in place to support staff. Pre-employment checks are carried out on staff, which includes enhanced checks with the Criminal Record Bureau plus Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to try to ensure that unsuitable people are not employed to care for vulnerable adults. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The manager of the home is experienced. People’s financial interests are safeguarded in situations where the home is involved. The health, safety and welfare of people living, working and visiting the home are in the main promoted and protected. EVIDENCE: The registered manager is experienced and competent in her role. She has many years experience and staff spoke well of her leadership skills. Comments included ““Ann doesn’t ask anyone to do anything that she wouldn’t do herself”. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 18 The home has a variety of quality assurance systems in place, which include surveys and questionnaires for people living at and visiting the home. They also include Regulation 26 visits from the provider and meetings for staff and people living at the home. Appropriate accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving people’s personal monies. Audits are carried out on a regular basis. Some staff are still not receiving the required six supervision sessions each year. Health and Safety records were looked at during the inspection. Regular checks are carried out to ensure the safety of the premises. For those people admitted to the home with their own equipment such as TV’s or stereos, the equipment must be checked on admission. It is not sufficient to wait until the next portable appliance test (PAT). Other certificates examined were up to date. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 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 3 X 3 X 3 2 X 3 Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 20 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 OP3 OP7 Regulation 14 15 Requirement Assessments must contain detailed information. Care plans must contain detailed information, which demonstrates how the home will meet people’s needs. The temperature of the treatment room must be kept within safe limits so that medication is stored in line with pharmacist directions. Previous timescale of 31/12/06 not met. Recording on medication MAR sheets must be improved. The care home must be conducted in a way that respects service users privacy and dignity at all times. Previous timescale of 31/12/06 not met. The home must be run in a way, which enables people to make choices and decisions as far as possible. Support and assistance should be provided where required during mealtimes in a sensitive and respectful manner. DS0000046626.V349056.R02.S.doc Timescale for action 30/11/07 30/11/07 3. OP9 13(2) 31/12/07 4. OP10 12(4) (a) 31/10/07 5. OP14 12(2) 31/10/07 6. OP15 12 31/10/07 Lindisfarne Ouston Version 5.2 Page 21 7. 7. OP16 OP30 22 18(1) All complaints must be recorded with any investigation and outcome. Staff training must be kept up to date and be suitable to the job being performed. Previous timescale of 31/01/07 not met. 31/10/07 31/10/07 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. 2. 3. 4. Refer to Standard OP26 OP36 OP37 OP38 Good Practice Recommendations The home should take the necessary action to address any odours within the premises. Supervision should take place for all staff at least six times each year. Policies and procedures should be reviewed and updated and reflect practice within the home. The home should consider ways in which electrical items bought into the home can be tested on admission. Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Lindisfarne Ouston DS0000046626.V349056.R02.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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