Inspection on 09/11/06 for Lindisfarne Ouston

This inspection was carried out on 9th November 2006.

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 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 19/09/07

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 Mrs Tanya Newton Unannounced Inspection 9th November 2006 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 Ouston DS0000046626.V301108.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 Ouston DS0000046626.V301108.R01.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 4922897 Gainford Care Homes Limited 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.V301108.R01.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. 17th November 2005 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 service users use. The home is part of the Gainford Care Home Group. Fees are £398.50 per week. They do not include hairdressing, chiropody and some of the activities. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Tanya Newton and Susan Lowther carried out the inspection between 9:30am and 3:15pm. The inspection was unannounced. Records were looked at, a tour of the environment took place and service users, staff and relatives were spoken to. Comments made during the inspection are reflected throughout the report. All key national minimum standards were looked at. What the service does well: What has improved since the last inspection? What they could do better: The temperature of the treatment room was too high and must be maintained at a safe level. Although service users dignity was maintained the interaction between staff and residents could be improved upon. Service users should be consulted about their social likes and dislikes. Menus are being updated and must be based on good nutritional guidance. A record of all meals should be maintained as this helps staff to monitor diet. The complaints procedures displayed within the home should be checked to ensure that they reflect the correct information, as one made reference to NCSC and the other to a different CSCI office. The policy on managing aggression should also be updated to reflect current practices within the home. Staff training is out of date in some areas and the number of staff with an NVQ 2 or equivalent should increase so that a minimum of 50 of staff working at the home has gained this award. This is in line with national guidance. The home needs to implement a business plan, which reflects how the home is to be maintained. The company should arrange for a second person to audit the pocket money of service users on a regular basis. Staff supervision needs to take place more regularly, the manager is aware of this. The home must have Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 6 an up to date electrical wiring certificate and a record of portable appliance testing (PAT). 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. Lindisfarne Ouston DS0000046626.V301108.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 Ouston DS0000046626.V301108.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 at least once during a 12 month period. 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. Service users’ needs are thoroughly assessed prior to admission. Admissions to the home are well managed. EVIDENCE: Comprehensive and detailed assessments were found in service users’ case files. The manager and staff confirmed that the home’s admission policy is followed, so that only people whose needs are known and whose needs can be met are admitted to the home. There is evidence of service users/relative involvement within some of these assessments. The home does not admit service users requiring intermediate care. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. 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. Each service user has a care plan which sets out the way in which the home will meet their needs. Medication systems are sound although the temperature of the treatment room needs to be lowered. EVIDENCE: The care plans examined contained detailed information on how each service users’ needs were to be met by staff. They include risk assessments, which set out how the home will minimise risks for service users. The manager reviews care plans regularly. The home encourages service users and their relatives to be involved within the care planning process. A visiting GP said, “Patients seem well cared for”. Medication systems were looked at during the inspection. In the main these systems were good. However the temperature of the treatment room was too high and must be kept within safe limits. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 10 Service users and staff were asked about the ways in which the home maintains people’s privacy and dignity. Staff knock on doors before entering a service users bedroom and some of the residents hold their own keys to their room. However throughout the day, some staff were observed to be talking amongst themselves rather than spending time with service users. This can have a negative impact on people living at the home. One staff member said that the way in which some service users were spoken to could sometimes be poor and that the level of respect should be improved. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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. Records of food must be maintained and menus based on good nutritional guidance. EVIDENCE: The home has an activities co-ordinator who provides a range of activities to service users. Planned activities include trips to the theatre, shopping trips, and a visit to Fenwick’s window. Comments about the activities were mixed and include “ there’s not much going on, some things now and again but we don’t get to go out much” and “I like it here, there’s plenty going on”. Other comments included “I like the company and the entertainment here, we go to all sorts of places on the bus”. Social assessments and or life histories should be included as part of the care plan so that the home gains a better understanding of peoples interests prior to entering the home. One staff member said “there’s not enough stimulation for residents, staff don’t have the time”. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 12 Relatives and friends are encouraged to visit the home and many do so on a daily basis. The home supports this by providing transport to those who would otherwise be unavailable to visit. Comments from relatives were positive and include “I visit the home regularly, the home is grand everyone is friendly”. The menus and meals being provided at the home were being reviewed. The home must ensure that they include at least five portions of fruit and vegetables each day. One of the residents said, “I had bacon and tomato for breakfast, there is a cooked breakfast available every day”. Other service users said how good the food was. There were no records available detailing what individuals were eating. These should be maintained so that peoples diet can be adequately monitored. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and systems for managing complaints. The complaints policy and requires updating to contain accurate information. The policy on managing aggression should also be updated to reflect current practices within the home. EVIDENCE: The policy on complaints needs updating as it makes reference to NCSC and not CSCI. There have been two complaints made to the home since the last inspection both of which were unsubstantiated. Most of the residents spoken to said that they were able to raise concerns if they had any. Most staff had received training in adult protection and all said that they were aware of the whistle blowing procedure. However the policy on managing aggression should be updated on managing aggression requires review to reflect current practices within the home. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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 high, providing service users with an attractive and homely place to live. EVIDENCE: The home is purpose built and is well maintained with a range of large and small lounge and dining areas. There is an enclosed patio area on both floors. Communal areas of the home were being decorated on the day of the inspection. Suitable toilet and bathing facilities are provided throughout the home to support service users. Bedrooms are decorated to individual taste and many are furnished with service users’ own possessions to make them more homely. The home is kept clean and there were no odours present. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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 residents. Residents are in safe hands most of the time, although more care staff require NVQ level 2 or above, to confirm competence. The home’s recruitment policy and practices support and protect residents. EVIDENCE: The numbers of staff on duty seemed sufficient to meet the assessed needs of the residents living within Lindisfarne. The home normally has the following staff on duty, ten or eleven staff work on a morning and nine or ten staff work on an afternoon. There are five staff on duty throughout the night. Service users and relatives said that the staff are friendly. One resident said, “Everyone is friendly enough, any time you want the staff they are there”. One staff member said that afternoon shifts were hard, as they had to get all of the residents ready for bed before the night staff came on duty. Pre-employment checks are carried out on staff, including 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.V301108.R01.S.doc Version 5.2 Page 16 New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. Most care staff members have completed Protection of Vulnerable Adults training. Residents reported a caring, supportive atmosphere in the home, which is well established. Seventeen of the forty-three care staff employed had an NVQ at level 2 or above. This means that forty per cent of staff had achieved this award. The national target is for a minimum of fifty per cent of staff to gain this award. Some other training for staff was required, this included first aid and manual handling. Lindisfarne Ouston DS0000046626.V301108.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of the home is experienced and the home is run in the best interests of residents. Residents’ financial interests are safeguarded in those situations where the home is involved. The health, safety and welfare of residents and staff are in the main promoted and protected. Some certificates need updating and the home needs to update their fire risk assessment and signage. 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 “she is very approachable and has an open door policy”. Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 18 The home has a variety of quality assurance systems in place, which include surveys and questionnaires for service users and visitors to the home. Regulation 26 visits from the provider and service user and staff meetings. Appropriate accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving residents’ personal monies, in which the home is involved, wherever practicable. However the company should arrange for a second person to audit the pocket monies of service users on a regular basis. Relatives look after the personal monies of many residents. The home needs to implement a business plan, which reflects how the home is to be maintained. (Previous requirement of 30/07/05 not met). Some of the staff supervisions were out of date the manager is going to provide training to other senior staff working at the home so that these are updated. Health and Safety records were looked at during the inspection. The home needs to carry out a fire risk assessment, the home were advised to access the fire safety website for information regarding this. Fire drills had been provided recently for all staff. The home should have some additional fire signage in place to safeguard residents and staff at the home. There was no evidence of portable appliance testing (PAT) the home must ensure that this is carried out. The certificate for the electrical wiring was also missing. A copy of this and the PAT test should be forwarded to CSCI. Other certificates examined were up to date. Lindisfarne Ouston DS0000046626.V301108.R01.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 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 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 X 2 Lindisfarne Ouston DS0000046626.V301108.R01.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. Standard OP9 Regulation 13(2) Requirement The temperature of the treatment room must be kept within safe limits so that medication is stored in line with pharmacist directions. The care home must be conducted in a way that respects service users dignity at all times. Menus must be based on national recommended nutritional guidance and a record of all food eaten must be maintained. Staff training must be kept up to date and be suitable to the job being performed. The home needs to implement a business plan, which details information as to the financing and financial resources of the care home (previous requirement of 30/07/05 and 30/11/05 not met). Health and Safety records must be maintained and include an electrical wiring certificate and PAT testing. Timescale for action 31/12/06 2. 3. OP10 OP15 12(4) (a) 16(2)(I) 31/12/06 31/12/06 4. 5. OP28 OP30 OP34 18(1) 25 31/01/07 28/02/07 6. OP38 13(4) 31/01/07 Lindisfarne Ouston DS0000046626.V301108.R01.S.doc Version 5.2 Page 21 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. 5. Refer to Standard OP12 OP16 OP18 OP35 OP36 Good Practice Recommendations Service users should be consulted about their social interests and the home should consider doing life story work and including this within the care plan. The complaints policies within the home should all reflect the relevant contact information and details for The Commission. The policy on managing aggression should be updated to reflect current practices within the home. The company should arrange for a second person to audit pocket money of service users on a regular basis. Supervision should take place for all staff at least six times each year. Lindisfarne Ouston DS0000046626.V301108.R01.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: 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 DS0000046626.V301108.R01.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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