Inspection on 21/09/07 for Lindisfarne Seaham

This inspection was carried out on 21st September 2007.

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 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 Seaham 02/10/08

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 Seaham King Edward Road Dawdon Seaham County Durham SR7 0BG Lead Inspector Tanya Newton Unannounced Inspection 09:30 21 September 2007 st 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 Seaham DS0000068621.V346785.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 Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindisfarne Seaham Address King Edward Road Dawdon Seaham County Durham SR7 0BG 0191 5812891 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) CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd Position Vacant Care Home 61 Category(ies) of Dementia (51), Mental Disorder (10) registration, with number of places Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE, maximum number of places 51 Mental Disorder – Code MD, maximum number of places 10 2. The maximum number of service users who can be accommodated is: 61 Date of last inspection Brief Description of the Service: Lindisfarne Seaham is a large purpose built home which is built on a slightly elevated site on St Edwards’s road Dawdon a residential area in Sunderland. The home provides accommodation for a total of 61 people. The home is built on three levels the ground floor unit providing accommodation to 10 people in the category of mental disorder (MD). The other two floors will provide accommodation for older people with dementia who require residential or nursing care. Fees are £431 per week. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out on the 21st September 2007. During the inspection time was spent talking to people using the service, staff, relatives and management. A number of records were looked at and the grounds and building itself were inspected. The home was also asked to complete a self-assessment, which provided the inspector with information prior to the site visit. Information gathered throughout the inspection maybe included within the inspection report. A short observational framework for inspection (SOFI) was carried out which provided the inspector with information regarding the interactions between staff and people living at the home. What the service does well: What has improved since the last inspection? What they could do better: All staff must give medication safely. The home needs to employ a registered manager. A policy on people’s money should be developed and relatives would like seating to be made available outside. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 6 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 Seaham DS0000068621.V346785.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 Seaham DS0000068621.V346785.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. 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. Admissions are well managed and people are provided with information about the home before moving in. EVIDENCE: The home provides a statement of purpose and service user guide, setting out its aims and objectives, the range of facilities and services it offers to people. This enables people to make fully informed choices about whether the home can meet their indivdual needs. People are encouraged to visit the home unannounced and spend time there, share a meal etc, to aid their decision making process. People are only admitted after a full assessment of need is carried out by an appropriately trained person and the home is certain their care needs can be met. Where only short term intermediate care is required the same process will follow, plans of care will centre around promoting independence to return Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 9 home. Any services utilised whilst in the community ie physio etc will continue to be identified in the care plan. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. People’s health care needs are well managed by the home. Systems to administer medication are in the main safe and people living at the home say that they are treated well and that the standard of care is high. EVIDENCE: The health and personal care which a person receives is based on their individual needs. What is identified during the assessment process is put into the plan of care and agreed by the person being admitted or their advocate. Care is delivered in accordance with the care plan, with privacy, dignity and personal choice being maintained and promoted at all times. The care plans include risk assessments so that people can continue to take reasonable risks in a safe manner. The staff maintain high standards of personal care whilst promoting people’s capacity for self care. Equipment necessary for promotion of tissue viability is provided as required for prevention of pressure sores. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 11 Nutritional screening, falls risk assessment and moving and handling needs are all assessed on an ongoing basis. Care plans are evaluated and reviewed monthly. Appropriately trained staff are always on duty to assess people’s health and liase with GPs if necessary. Medication is administered only by appropriately trained staff and the home has a comprehensive medication policy. In the main, accurate records of all medicines received, administered and those leaving the home are maintained. One person had made a number of medication errors, this matter was being dealt with by the manager. A short observational framework for inspection (SOFI) was carried out which provided the inspector with information regarding the interactions between staff and people living at the home. The data provided clear evidence that there were good interactions for all people living at the home and that people were treated with dignity and respect. One of the relatives said “Sionce my relative arrived at Lindisfarne, he has been extremely well cared for. He is kept immacuately clean, well fed, stimulated and entertained, but above all he is happy – very happy!” another commented “I have never seen mam look so happy and content”. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities with input from the people that live there. Relatives are made welcome and encouraged to visit the home. People living at the home said that they were able to make choices within all aspects of daily living. There is a varied menu and people likes and dislikes are well catered for. EVIDENCE: Routines of daily living and activities are flexible and varied to suit individual expectations, preferences and capabilities. Personal choice is promoted at all times. People’s interests are recorded, there is a daily activity programme which is flexible. The home has in-house entertainers monthly and trips out weekly. Relatives are invited to all events. People are encouraged to forge and maintain links within the local community. Activities are advertised in written and pictorial formats and photos of outings are displayed for memory prompts and reminiscence. Memory books for individuals reminiscence are being formulated. A newsletter is available monthly with details of achievements and forthcoming activities. People can have visitors at any time Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 13 and private visiting areas are available. People’s spiratual needs are respected. People are encouraged to make choices and decisions wherever possible and this was observed throughout the day. A staff member said “We encourage independence, let people do what they can for themselves and then support where necessary. Meals are varied, appealing, nutritious and based on individuals choice. There are fridges in lounges so that people can access drinks or ice-cream as they wish. The choice of menu is recorded daily but remains flexible. Special dietry needs are catered for and people are assisted to eat if necessary. A pictorial menu system is available to enhance choice and picture cards for all drinks etc are available to promote communication. Comments from people living at the home included “I had a nice lunch, it was fish and chips” and “It’s canny here and the food is good”. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and adult protection matters are supported by clear guidance and training. EVIDENCE: The home has a complaints procedure in place, which is displayed throughout the home. The complaints procedure is also available in a pictorial format to aid peoples understanding. The home has not received any complaints since it opened and any concerns are dealt with immediately. Staff are trained to recognise and prevent abuse. The home has a clear adult protection procedure which links with the local authority procedure for safeguarding adults. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in whistle blowing (telling someone) if there was a problem. Information on how to report abuse is publically displayed for relatives, people living in the service and staff to follow. Staff are also trained to manage challenging behaviours and deescalate situations. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 15 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 excellent. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and furnished and decorated to a high standard. EVIDENCE: The home is new and is purpose built and it exceeds the national minimum standards. All rooms have en-suite facilities. Many of the rooms have been personalised to individual choice and taste. There are bathrooms throughout the home which have adaptations to assist those who are less mobile and there are a variety of lounge/dining areas for people to enjoy. The grounds are safe, accessible and well kept. One relative said that they would like to see some seating available outside. The building complies with local fire and environmental health regulations. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 16 The home has picture signage throughout to promote the orientation of people who have dementia. There is also a multi sensory room where people can go to relax. The unit currently designated for people with a mental disorder has a separate entrance and car parking further along the main road. A key- pad access in the internal corridor will provide access to the main building. There are 10 single en-suite bedrooms including two rooms with a tracking system in place for people with nursing needs if this is required. The hoist arrangements can be removed leaving the tracking system in place. The unit has two lounge/dining rooms and a small kitchen with washing machine. The Regional Manager said that it was the intention of the home to enable people to develop and retain domestic skills. The unit has a dedicated office and additional lounge area. The unit has 1 separate toilet and two assisted bathrooms in addition to en-suite facilities in each bedroom. The premises were clean, hygenic and free from any odours. Policies for the control of infection are in place and adequate handwashing facilities are available. The home has two full time domestic staff who are maintaining the home to excellent standards. There were no odours in any part of the building. One of the relatives said “The home is beautiful”. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 17 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. Staffing numbers support people’s needs. The home has an excellent commitment to staff training and recruitment practices protect people living in the home. EVIDENCE: Staffing numbers and the skill mix of qualified/unqualified staff are appropriate to the assessed needs of the people living at the home. These remain under constant review as the occupancy of the home increases. The home has thirteen care staff and three full time nurses. There were five staff on duty throughout the day. The home also has bank staff to support any shortfalls in staffing numbers. Induction records were viewed, all staff have completed an induction and the majority of staff had completed all of the mandatory training which includes first aid, food hygiene, manual handling, protection of vulnerable adults (POVA) and health and safety. Dementia training will also be provided for all staff, any gaps in training are being addressed and there was evidence to support this. All staff have either completed an NVQ or are working towards the qualification. The manager also said that a consultant psychiatrist was willing Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 18 to provide staff with training on specific functional illnesses so that people admitted under the category of MD would have their needs fully supported by the staff team. Recruitment procedures are thorough and protect people living and working in the home. All staff undergo enhanced criminal record bureau (CRB) checks before the post is confirmed. Two written references are received for all staff one of which is from their previous employer and a full 10 year employment history is recorded, with any gaps explored. Staff are trained and competent to do their jobs. The home has clear policies on equal opportunities. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and relatives and people using the service are regularly consulted about the service they receive. Financial arrangements are sound and health and safety systems and practices protect people. EVIDENCE: The home does not have a registered manager as the person who was applying for the post has since left. The day to day operations of the home are well managed by an appropriately trained manager. There are clear lines of accountability within the home. Staff, relatives and those living at Lindisfarne are actively involved in the decision making process of the home. The home has an annual plan for quality assurance which includes, meetings with people using the service, relatives and staff. These are held monthly and information Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 20 from these are included in quality monitoring. The proprietor completes a regulation 26 visit monthly. The home has also sent out satisfaction surveys and are collating the responses from these. People’s financial interests are well managed and accurate records are maintained. A check was made on three people’s money, all were correct and had receipts in place for any expenditure. It is recommended that the home introduce a policy on peoples personal monies. Health and safety systems were looked at. Safe working practises are maintained in line with current regulations and appropriate risk assessments are available. All safety checks for maintenance are carried out by external contractors as designated by law. All accidents are recorded and reported appropriately. Safety procedures are posted and explained during the staff induction process. Accident statistics are audited monthly and care plans amended where required. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 21 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP31 Regulation 13(2) 8 Requirement All staff must adhere to the policy on the safe administration of medication. The home must ensure that there is a registered manager in post. Timescale for action 31/10/07 31/12/07 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 Refer to Standard OP19 OP35 Good Practice Recommendations Garden furniture should be provided outside. The home should develop a policy on the holding of people’s monies. Lindisfarne Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 23 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 Seaham DS0000068621.V346785.R01.S.doc Version 5.2 Page 24 - 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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