Inspection on 05/05/05 for Lindisfarne Ouston

This inspection was carried out on 5th May 2005.

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 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 Ouston 19/09/07

Lindisfarne Ouston 09/11/06

Lindisfarne Ouston 17/11/05

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 Tanya Newton Unannounced 5 May 2005 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 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 B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Lindisfarne Ouston Address Institution Terrace, Ouston, Co Durham, DH2 1QW 0191 4922891 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Gainford Care Homes Limited Mrs Ann Woodhead Care Home 57 Category(ies) of Dementia (5), registration, with number Dementia - over 65 years of age (57) of places Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Up to 5 persons aged 55 years and over may be placed commensurate with the home`s Statement of Purpose. Date of last inspection 29 September 2004 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 service users use. The home is part of the Gainford Care Home Group. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. CSCI has a statutory duty to inspect all care homes at least twice a year. This unannounced inspection was carried out in accordance with this duty. The inspection took place on the 5th May 2005 between the hours of 9.30 and 4.00. During the inspection, time was spent talking to eleven service users, two staff and five relatives. Records were examined and a tour of the building took place. In line with current CSCI policy on Proportionality, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion will be raised during the next inspection of the home. Issues raised in the last inspection were also examined. What the service does well: What has improved since the last inspection? The standard of assessments and care planning has improved, the complaints procedure and adult protection procedure has been updated. Policies on whistle blowing and physical aggression have been reviewed and updated. The garden area has been made safer as a fence has been fitted and the home is buying furniture so that service users can sit outside. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Admissions are managed well by the home, however the home should evidence any involvement from service users and/or their relative/supporter. EVIDENCE: New service users are admitted, only when an assessment has been carried out by the home. Care management assessments are also requested prior to admission but are not always received. Evidence of service user/relative input should be included within the assessment process where possible. Five relatives provided feedback cards which all confirmed that they were kept informed of important matters which affected their relatives. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 and 11. There is a clear consistent care planning system in place, which provides staff with the information they need to satisfactorily meet service users needs. There is limited evidence of service users involvement within these plans. EVIDENCE: The four care plans examined contained detailed information on how each service users needs were to be met by staff. The care plans include risk assessments and are reviewed regularly by the manager. The care plans have improved since the last visit to the home. In order to improve these further, it is recommended that service users and/or their relatives/supporters sign their agreement with the care plan. It is acknowledged that this has begun. Service users spoken to during the inspection confirmed that both their health needs and their privacy was being maintained, comments such as “I am looked after really well” “they go out of their way to look after you” and “they always knock on your door and are polite” were received. Two service users required changing after their meal, this was not done; this was discussed with the manager during the inspection to ensure that service users dignity is maintained at all times. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 10 Relatives also offered positive feedback about the standard of care being provided. Service users care plans contained written evidence of input from other health professionals and each service user is registered with a G.P. Information regarding people’s wishes in the sensitive area of death and dying is being collated and will be included within the care plan where appropriate. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these outcomes/standards were assessed on this occasion. They will be examined during the next inspection of the home. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18. The home has a satisfactory complaints procedure in place, with some evidence that relatives are aware of the process. Service users have access to information on advocacy services in the area if they needed someone to speak on their behalf. EVIDENCE: The complaints procedure and adult protection procedures had been updated following requirements in the previous inspection report of the home. Out of the 5 feedback cards received from relatives 4 confirmed that they knew how to make a complaint. Service users legal rights are supported, a postal voting system is in place. Policies on physical aggression and whistle blowing had been implemented; the policy on managing aggression needs to be further developed to reflect the “no restraint” practice operated within the home. The manager stated that there was a lack of training in adult protection particularly within the reporting process, although in house training had been provided for staff in this area. Service users spoken to during the inspection made comments such as “no concerns at all” and another confirmed, “I could tell someone if I had a problem”. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26. The standard of décor and furnishings within the home are high, providing service users with an attractive and homely place to live. EVIDENCE: The home is purpose built; it is well maintained with a range of large and small lounge and dining areas. The upper floor has a lounge, which leads, onto an enclosed patio area. A fence has been installed to the rear garden following requirements made in the previous inspection report for the home and some seating has been provided. The manager confirmed that additional garden furniture would be purchased; an allotment was also being developed for service users use. Suitable toilet and bathing facilities are provided throughout the home with aids to support service users. Service users rooms are furnished to individual taste with personal possessions being used to create a more homely environment. Service users spoken with confirmed that “the home was a very comfortable place to be” and that “rooms were nice and the home is clean”. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these outcomes/standards were assessed on this occasion. They will be examined during the next inspection of the home. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35,38 There are basic procedures for the safekeeping of service users monies; further work should be undertaken in this area. Health and safety records are maintained. EVIDENCE: The home is still awaiting a business plan from the financial director who has been in post since October 2004. Five service users monies were checked randomly during the inspection, systems and policies require amendment as a number of service users had large sums of money. Receipts must be held for all transactions with an audit trail, where sums of monies do not tally this must be fully investigated with a record held. Health and Safety records are maintained within the home, there have been 11 fire drills since the home opened. Training is provided for all staff and includes manual handling, first aid, dementia awareness, swallowing difficulties, food hygiene, adult protection and NVQ’s. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x x 2 2 x x 3 Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 17 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP34 Regulation 14(1)c & 15(2)c 25 Requirement Service users/relatives must be consulted regarding their assessments and care plans. The home neeeds to implement a business plan which details information as to the financing and financial resources of the care home. The registered person must ensure that financial records are maintained and kept up to date. Timescale for action 30th July 2005 30th July 2005 3. OP35 25(3)a 30th July 2005. 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. Refer to Standard OP18 OP18 Good Practice Recommendations Training in adult protection referral procedures should be provided for management. The policy on managing aggression should be further updated to reflect current practices within the home. Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 18 Commission for Social Care Inspection No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lindisfarne Ouston B54 X00015 S46626 Lindisfarne Ouston V217381 050505 Stage4.doc Version 1.20 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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