Care Home: Lindisfarne Nursing Home

What the care home does well The service encourages service users to bring items of personal belongings into the home. Some service users have used this opportunity to furnish their rooms with personal items, making it more personal to them. These include, small pieces of furniture, pictures and photographs of family and friends. The home has a good system in place for ensuring that the service users receive good medical care from their GPs and other medical personnel such as psychiatrist, dietician, chiropodist and optician. Comments from relatives and service users were very positive. One relative said, "the home contacts the GP when ever they are worried and they tell me what is happening". The religious and spiritual needs of the service users are fully met. This was identified in both the care plans and on discussion with the residents. For example, "the staff help me to take part in the religious service". Staff have a good rapport with the service users and were knowledgeable about their needs and preferences. Staff were seen speaking quietly and pleasantly and respectfully with service users. Residents and their relatives confirmed that the staff treat them with respect one said, "the staff are always lovely and they get me what ever I need". What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Lindisfarne Nursing Home Kepier Chare Crawcrook Ryton Tyne & Wear NE40 4TS Lead Inspector Suzanne McKean Key Unannounced Inspection 31st July and 8th August 2008 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 Nursing Home DS0000018174.V369282.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 Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lindisfarne Nursing Home Address Kepier Chare Crawcrook Ryton Tyne & Wear NE40 4TS 0191 413 7081 0191 413 7308 e.bellas@gainfordcarehomes.com CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd 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) Eileen Bellas Care Home 61 Category(ies) of Dementia - over 65 years of age (61), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (61) Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 61 rooms registered, one of two rooms without ensuite facilities (room 36) to be used as short stay/emergency respite only. Date of last inspection 20th June 2007 Brief Description of the Service: Lindisfarne Nursing Home is a two-storey purpose built home providing nursing care and personal care to people suffering from mental illness and dementia. The home is situated in the centre of Crawcrook and close to local shops, park and other facilities, and is on a main bus route. All bedrooms are single and the majority are en-suite, and all the necessary services and facilities are provided including an emergency call system and bathrooms and toilets that are suitable for physically frail or disabled people. There is a passenger lift to take residents and visitors between floors. A choice of lounges is also available. There is easy access into and around the home and corridors and doors widths are wide to allow access for wheelchair users. The home has extensive and pleasant gardens and a safe area for residents to sit outside. Fees in the home range from £400 to £549. For free nursing care and continuing care, the PCT makes up the difference. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. How the inspection was carried out:Before the visit: We looked at: • Information we have received since the last visit on 20th June 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 31st July 2008 and a further visit was made on 8th August 2008 and took a total of 9 hours to complete. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager and regional manager and registered person what we found. What the service does well: The service encourages service users to bring items of personal belongings into the home. Some service users have used this opportunity to furnish their rooms with personal items, making it more personal to them. These include, small pieces of furniture, pictures and photographs of family and friends. The home has a good system in place for ensuring that the service users receive good medical care from their GPs and other medical personnel such as Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 6 psychiatrist, dietician, chiropodist and optician. Comments from relatives and service users were very positive. One relative said, “the home contacts the GP when ever they are worried and they tell me what is happening”. The religious and spiritual needs of the service users are fully met. This was identified in both the care plans and on discussion with the residents. For example, “the staff help me to take part in the religious service”. Staff have a good rapport with the service users and were knowledgeable about their needs and preferences. Staff were seen speaking quietly and pleasantly and respectfully with service users. Residents and their relatives confirmed that the staff treat them with respect one said, “the staff are always lovely and they get me what ever I need”. What has improved since the last inspection? What they could do better: There was an odour in the entrance and on the first floor corridor, which needs to be investigated, and action taken to address it. Although the programme for formal supervision has been started it is not yet fully up to date and the manager is working to improve this to make sure that all staff are supervised at least six times each year. There were no risk assessments in place to make sure that residents are protected from harm in relation to the storage of toiletry items, which present a risk to residents who might pick them up and swallow them. Also a number Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 7 of window restrictors had been disabled increasing the risk of falls from a height to residents or, make access easier for intruders. The care plans are now completed to a satisfactory standard however they are to be improved further to more fully show the changing health care needs of the residents and the way they will be met. There are plans to enrich the environment of the home to give a more stimulating and appropriate living space for the residents taking into account their dementia care needs, this should be pursued. The meal times in particular are to be reviewed to make sure that they are conducive to residents having a pleasant and positive experience when having their meals. 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 Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 8 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 Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 9 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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessments of the residents carried out before offering a place allow the home to make sure they can care for them, and the residents can be sure that their needs can be met. EVIDENCE: The care plans contained the necessary information to show that assessments are carried out before any resident is admitted to the home. The documentation is detailed and contains the necessary information for the staff to make a judgement as to if a place should be offered to the residents. These assessments then form the basis of the care planning process for the resident. Residents said that they were given the opportunity to visit the home before they decided to move but the majority had relied upon their family to choose for them. Lindisfarne Nursing Home DS0000018174.V369282.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems and records make sure that health and social care needs are delivered in a respectful way and the care plan documentation shows how this is achieved. EVIDENCE: All residents have a care plan which includes an assessment and a plan of care. They show that the personal and health care needs of the residents are being met. Staff have had some recent training in the completion of the documentation and ongoing use of these should result in further improvements as they become more used to them. They have improved significantly since the last inspection was carried out and staff spoken to were knowledgeable about the care plan documentation. They were making entries throughout the day and referring to them when professional advisors visited to see specific residents. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 11 One of the care plans was particularly well developed and was person centred. Necessary risk assessments are completed for a selection of areas and they were detailed. Residents are supported to access NHS services and facilities as and when they need to. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the staffs company. Residents were dressed for the activities they were undertaking and looked smart and tidy. A number of residents were positive about the care being given. An example of this is “Its nice here” and “the staff are lovely”. Care is given in a discreet manner taking into account the individual residents previous lifestyles and the way they want to spend their time. Staff are knowledgeable about residents’ preferences and needs. They were seen being kind and polite with cheerful banter taking place throughout the day. Staff spoke to residents always explaining what was about to happen and what they were going to do so that residents knew what to expect when being helped to move around the home. This was particularly evident in the care staff who were flexible in how they gave the care according to how the resident was feeling. This was shown when a resident who had been quite agitated throughout the morning became more settled and the care staff then used this opportunity to offer the personal care he needed. All residents have individual rooms that they can use if they need to discuss issues with family, friends or staff so that their privacy is safeguarded. There are plans to make improvements to the environment taking into account the dementia care needs of the residents and make it more appropriate. This had been started and should be developed further to give a more stimulating environment. More are to be items provided that the residents can interact with in a positive way and the staff are to be trained in ways they can encourage residents to participate in purposeful activities. Lindisfarne Nursing Home DS0000018174.V369282.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are well supported to spend their leisure time and are supported to maintain contact with their families and the local community. EVIDENCE: The home employs an activities co-ordinator for forty hours a week. The staff were able to describe the social and recreational care needs of the service users. This was shown in the care plans and confirmed by visiting relatives. There are regular activities for the service users. One service user described some of the opportunities they had been offered and although they felt that this was enough they did not always want to take part. Service users’ religious and recreational needs are fully met. Service users confirmed that they enjoy the activities organised for them, including visits to the home by local religious ministers. These are well attended by people who genuinely wanted to be involved in the service. Service users confirmed that they are free to join in social activities if they wish and that they are not made to join in activities if they do not want to. A number of art and craft materials Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 13 and board games are available for service users to use, which has enhanced the recreational opportunities for them. Relatives commented that they are aware of the activities that the staff organise for the service users. These include individual trips to the local the shopping centre and the occasional social outings and in-house social activities. Relatives stated that they are able to visit at anytime convenient to them. They said the flexible visiting times make it easier for them to visit more often. Some relatives are actively involved in the care of their loved ones and make regular visits to the home. The home supports the relatives to make positive contribution to the care provided in the home. There is a four-week rotational menu in operation in the home. Past menus indicate that the home provides wholesome and nutritious meals for the service users thus promoting good health. Service users were very complimentary about the food. They confirmed that they are provided with good choice and that there is always plenty of food for them. There were some differences in the way the meals were organised between the breakfast and the lunch and between the days of the visits. The breakfast on the first visit was provided in the main dining room on the first floor and all residents were being offered it at the same time. This resulted in it being a very cluttered environment and it was noisy. The lunchtime was a more settled and quiet time and the residents were offered their meals in either of the two areas on the floor where there are dining tables. This may not have been the usual way that the meals are organised. The Manager agreed that it was an area, which could be reviewed to make sure that the residents are always offered a pleasant calm atmosphere for their meals. Lindisfarne Nursing Home DS0000018174.V369282.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good policies and procedures in place to that make sure those complaints are dealt with efficiently and that residents are safeguarded from abuse. EVIDENCE: There are good policies and procedures available setting out how to make a complaint. The procedure is displayed in the home and the staff knew how to deal with any complaints that are raised with them. The complaints processes were clear, and included the investigation and the outcome. The residents and relatives spoken to were aware of the complaints policy and said that they would know who to speak to if they had any concerns. There have been four complaints investigated in 2008 and the records show that they were dealt with appropriately taking into account the level of satisfaction of the complainant. There are policies and procedures in place for Adult Protection. The staff have received training that is ongoing about how to recognise abuse and what to do if they suspect that abuse is taking place. One alert was raised since the last inspection which was dealt with appropriately in conjunction with the local Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 15 authority safeguarding procedures, involving the family. This was concluded to the satisfaction of the family and the local authority. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers accommodation that is generally clean and well maintained, but lacks specific premises design features to help people who are deaf or have dementia. While this promotes the general welfare, dignity and comfort of service users, it can create environmental barriers for people with specific needs. EVIDENCE: Service users are encouraged to furnish their rooms with personal items, making it pleasant and familiar environment for them. The bedrooms are large and spacious and allow service users to accommodate their personal belongings without the rooms looking cluttered. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 17 Access into and within the home is good and meets the needs of those service users who have mobility difficulties or have use of walking aids such Zimmer frames or wheelchairs. There are specialist bathing facilities to promote independent use by those who are capable of doing so. All the bedrooms and toilets have suitable lock on the doors to ensure privacy. This provides the opportunity for service users to remain independent and to enjoy good levels of privacy. However, there is no loop system fitted in the lounge areas to help people with hearing difficulties hear the TV/radio or adequately hear visiting ministers/activities or residents meetings. In addition, the first floor caters specifically for people with a dementia but does not have specific design features that would give someone cues to find their way around or help them to maintain existing skills. This may create environmental barriers for people with these specific needs to make sense of their environment and could impact on their quality of life. There are sufficient numbers of communal areas for service users to choose from. These include a range of lounges, dining rooms, and communal spaces that service users can use. Window restrictors have been fixed to all windows and all radiators have suitable coverings, which ensure security and safety for the service users. However on the first visit a number of the window restrictors had been disabled and the windows opened to their full extent. This presents a possible risk to the residents as they could fall or climb out and the staff must be reminded of the potential hazard. Checks of hot water are carried out by the home and these show that hot water did not exceed 43°c. thus protecting the service from accidental injuries. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. Although the home was noted to be clean and free from offensive odour there were two areas in which there was a strong, unpleasant odour. It was not clear as to the source of the odour. However, it did remain even after the periods of high activity around changing beds and personal care. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are skilled, well trained, and competent staff employed in sufficient numbers to make sure that they can provide good care to the residents. EVIDENCE: The home maintains good staffing levels, which ensured that service care needs are met. Past rotas showed staffing levels being consistently maintained. The staffing level at the time of arrival for the inspection was; • 1 Deputy manager • 3 Registered Nurses • 10 Care staff Since the last a deputy manager has been appointed to support the manager and to relieve her of some of her duties so that she can undertake other duties such as supervision of staff and staff induction and training. Service users and relatives also indicated that there are always sufficient staff on duty to meet the needs of service users. The home has a long established staff team who have been provided with the necessary training to equip them for their job. The majority of the staff have Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 19 attained NVQ Level II or above. Of the 38 staff, 24 of them have achieved NVQ Level II or above and 9 of them are in the process of doing their NVQ training. Staff spoke of the good training they have received and the benefits to them and the service users. Examination of the staff training record showed there is up to date training all of the areas necessary for the staff to be safe in their roles. Although there are some gaps these are planned in or where there are extenuating circumstances for individual staff and this is being dealt with. There is also now a good induction procedure for new staff into the workplace. There is good documentary evidence of induction training provided for all new staff. This makes sure that the registered persons can satisfy themselves that staff have received proper induction and have been assessed as competent to undertake their duties unsupervised. The records of the most recently appointed staff were examined. These contained evidence of good recruitment procedures being followed. This ensures that the service users are protected from possible abuse from people who would be deemed as not suitable to work with vulnerable people. Suitable references have been obtained and checks such enhanced CRB and ID checks have been carried out and were all in order. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 20 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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management systems are working effectively to protect service users and staff and to meet their needs. EVIDENCE: The Registered Manager has the appropriate qualifications and experience to successfully manage the home. The manager contributes towards the general feeling of well being in the home. Staff said they felt well supported and were able to work toward qualifications. Supervision is offered to the staff so that they have an opportunity of one to one discussion with management. The way that supervision was being offered Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 21 was discussed. The programme is not up to date although there is now a programme. The manager is responsible for both implementation of safe working practices such as testing water temperatures and fire safety but also for auditing all systems and procedures through the home to ensure safety of residents, visitors and staff. The senior mangers visit the home on a more than monthly basis and records are now kept of this. This also includes the use of an observational tool, which is used to determine the quality of the life of the residents and is a researchbased model. The home is subject to regular internal audit and has in the past achieved the highest rate of compliance in local authority services. Residents and visitors are asked their views on the service provided and there are questionnaires available through the home. This has been recently undertaken and the results are being analysed. There are regular resident meetings where they can be consulted in the way the home is run and records of these are kept. The accident recording in the home is robust. Case tracking showed that entries in the accident book were reflected in the daily record within individual care files. Accidents are monitored and analysed so that risks can be identified. Safety is promoted for residents by using these systems effectively and by having a staff group that is trained in fire safety, moving and assisting, infection control and food hygiene. Staff meetings are held regularly and staff said that they found them useful, giving the chance to hear what is planned in the home. They also have the chance to raise any concerns they have. The home employs an administrator for thirty hours per week. Each resident has an individual balance showing a running total of monies kept in the home. They have individual wallets containing his or her money locked securely in the safe. Transactions are signed and dated by two members of staff and are audited weekly by the manager. Residents can access their money at any time. These were not examined on the visit but the processes have not changed. There is also an amount of money assessable by the nurse in charge, which can be used if residents need access to money out side of office hours. During the first visit there were a number of the bathroom areas that had toiletries (not identified as belonging to a specific resident). Residents in the home can access these areas. There are residents who are at risk of swallowing these materials; one particular resident has a history of this, which is identified in the care plan. No risk assessments were in place for this. This was pointed out to the deputy manager so that immediate action could be taken. Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 22 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 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 3 X 3 X 3 2 X 2 Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 23 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 OP26 Regulation 16 (2) (k) Requirement The odour in the entrance and on the first floor corridor should be investigated and action taken to address it. The Registered manager must ensure a system is in place for all staff to receive supervision at least six times each year. (Outstanding from 30/09/07) Risk assessments must be in place to make sure that residents are protected from harm regarding: • The storage of toiletry items. • The disengagement of window restrictors. Timescale for action 01/11/08 2. OP36 18 (2) 01/11/08 3. OP38 13 (4) 01/09/08 Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP7 Good Practice Recommendations The registered manager should ensure that the care plans accurately show the changing health care needs of the residents and the way they will be met. There are plans to enrich the environment of the home to give a more stimulating and appropriate living space for the residents taking into account their dementia care needs, this should be pursued. The meal times must be reviewed to make sure that they are conducive to residents having a pleasant and positive experience. 2. OP8 3. OP15 Lindisfarne Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Nursing Home DS0000018174.V369282.R01.S.doc Version 5.2 Page 26 - 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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