CARE HOMES FOR OLDER PEOPLE
Lindisfarne Residential Home Whitehill Park Chester Le Street Co Durham DH2 2EP Lead Inspector
Tanya Newton Announced 12 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 Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Lindisfarne Residential Home Address Whitehill Park, Chester Le Street, Durham, DH2 2EP 0191 3883717 0191 3882808 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 Elsie May Hanson Care Home 28 Category(ies) of Dementia - over 65 years of age (28) registration, with number of places Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The home may accommodate a named individual as set out in a letter to the registered person dated 5th August 2004 which establishes the basis on which the individual`s needs will be met by the home. Where necessary the homes Statement of Purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individual, who falls outside the registered category. Date of last inspection 8 March 2005 Brief Description of the Service: Lindisfarne residential home provides care for up to 28 service users with dementia. The home is built over two floors with lift access, the home is situated within a housing estate in Chester-le-street which is a town close to Durham. The home is part of the Gainford Care Home Group. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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 was carried out on the 12/05/05 between the hours of 9.30 and 4.15. Service users and staff were spoken to as part of the inspection, feedback from which will be included throughout the report. 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?
Menus have been updated following comments in the previous inspection report. There has been an extensive programme of redecoration throughout the home and the environment now appears clean and bright. Rooms have been individually personalised to reflect service users individual choice and taste and the conservatory roof has been replaced (this room was previously
Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 6 very hot during summer months due to the glass ceiling, this has been changed to a covered ceiling). Activities provided by the home have increased, there is a better variety available and feedback from service users, relatives and staff regarding the activities was in the main positive. The manager has taken an active leadership role and comments from relatives, staff and service users regarding the management and staff were positive. 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 Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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 Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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) EVIDENCE: None of these outcomes/standards were assessed on this occasion. They will be examined during the next inspection of the home. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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) 7,8,9,10. The systems for the administration of medication are poor and potentially place service users at risk. EVIDENCE: An audit of some of the medication was undertaken, there is no audit trail and tablets are being administered from random areas of the blister pack. The manager was advised that this situation required urgent address. Some prescribed items were written on the medication sheet yet none were supplied, one service user was written up for a controlled drug, which was not recorded, on the MAR sheet. Two care plans were read as part of the inspection. The information provided within these has improved and service users/relatives are being encouraged to have input within these care plans, this should continue. Service users and relatives consulted with during the inspection confirmed that “the standard of care was good” and that “the staff are very kind and look after you very well”. Staff confirmed that training was linked to meeting the needs of the service users living within Lindisfarne.
Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 10 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) 12,13,15. Activities arranged by the home provide service users with stimulation and a range of activities. EVIDENCE: A visitor from the church spoke to the inspectors and commented that “ service users were very stimulated and that the activity co-ordinator had a good rapport with service users”, she also confirmed that she was made welcome to the home. Another visitor confirmed that they would like more stimulation for their relative and would like to see people go out more. Service users confirmed that there was a choice of social activities available, which they could attend at their leisure. Two service users confirmed that they were able to go out and one relative confirmed, “If I had to live here it would be ok”. Comments about the meals were positive; meals were attractively presented with a choice available. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 11 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) 16,18. The home has a satisfactory complaints procedure in place, with some evidence that relatives are aware of the process. EVIDENCE: There is a complaints procedure in place; service users and relatives confirmed that they would feel confident raising concerns. One service user stated, “I would be able to tell someone if I had any problem”. A relative spoken with stated that she had no complaints and that she visited the home twice weekly. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 12 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) 19,20,21,22,23,24,25,26. The standard of the environment within this home has improved and it now provides service users with an attractive and homely place to live. EVIDENCE: Decoration has taken place throughout the building, the conservatory roof has been replaced and service users bedrooms have been decorated. Bedrooms are being furnished individually. The environment was clean and odourless with high standards of cleanliness being maintained. 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. The fence, which had been a previous requirement to be fitted, had unfortunately blown down in the winds; the manager confirmed that this would be repaired. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 13 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) 27,28,29,30 Recruitment practices are not always robust and therefore potentially place service users at risk. EVIDENCE: Out of the six staff files reviewed two staff required a CRB this must be carried out with immediate effect. All staff files must be reviewed to ensure that they contain all of the required information. The manager was unsure whether the current induction programme meets TOPSS guidance; she is going to find out before the next inspection. There are six staff doing foundation training at present. Staffing numbers in the main meet the needs of the service users living at the home; there are a couple of vacancies at present, which have been advertised. Comments regarding the staff were positive and included “staff and management great” “staff are very kind, they look after you well” and “all staff are very good and patient”. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 14 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) 31,32,33,34,35,36,37,38. The manager and staff have formed positive relationships with service users living within Lindisfarne, EVIDENCE: Positive comments regarding the manager’s open door policy, and friendly approach, were received from service users, staff and relatives during the inspection. Comments from service users included “the manager is very good” and “its much better here, the staff and management are great”. A comment made by a staff member stated, “The manager has changed things for the better, it’s more homely now” Staff supervision has commenced this should now be provided at least six times a year for all staff. There are clear financial records in place for service users personal monies. The home is still awaiting a business plan from the financial director who has been in post since October 2004.
Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 15 Health and Safety records were looked at during the inspection, the manager must ensure that water temperature checks are carried out and recorded in the absence of the maintenance man, maintenance records were in the main up to date. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 2 3 2 3 2 Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.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. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that medicines are recorded, handled and safely administered in line with prescribers instructions at all times. All staff must have a Criminal Record Bureau check(CRB) and staff files must contain all information detailed within schedule 2. The home needs 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 water temperature checks are carried out in the absence of the maintenance man and that a record of these temperatures is maintained. Timescale for action 31/05/05 2. OP29 19 31/05/05 3. OP34 25 30/07/05 4. OP38 23 31/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 18 Lindisfarne Residential Home 1. 2. Standard OP19 OP36 The fence should be repaired where it has blown down. Staff supervision should be provided for all staff at least six times each year. Lindisfarne Residential Home B54 S7487 Lindisfarne Residential V217384 120505 Stage 4.doc Version 1.20 Page 19 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
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