Care Home: Lindisfarne Ouston

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What the care home does well What has improved since the last inspection? Since the last key inspection on 19 September 2007, there has been a review of the care plans to take account of the recommendations in that inspection report. The home has provided training to staff with specific emphasis on promoting residents` privacy, choice and dignity. Complaints are recorded, showing the nature of the complaint and how it was investigated and the outcome of that investigation. The manager has put in place various measures to address the problem of odour in some bedrooms. What the care home could do better: The system for recording medications received from the pharmacist needs to be reviewed. The current system does not provide accurate accountability for the number of tablets in stock. The temperature in the treatment room is extremely high. This has been commented on in previous inspection reports and requirements placed on the provider to take suitable steps to resolve this. Mobile air-conditions have been provided but this has little or no effect on resolving the problem. Care plans need to be more descriptive to guide staff on how specific care should be provided. Some of the care plans were less than specific on what needs to be done by staff to manage certain behaviours or provide specific care for the individual. The staff induction programme should be organised in a way that complies with the "Skills For Care" induction standards. The two files on induction that were examined did not provide a clear and systematic induction for the staff concerned. There were too many aspects of the induction covered on the first day of commencement of employment. This could be tiring and confusing for people who are new to the care profession. Staff supervision is not taking place as often as it should be so that it can be beneficial to staff development. The manager and her line manager commented that there are plans to develop a system in the home to help with orientation (themed corridors). This should be given due attention. CARE HOMES FOR OLDER PEOPLE Lindisfarne Ouston Institution Terrace Ouston Co Durham DH2 1QW Lead Inspector Sam Doku Unannounced Inspection 10:00 5th and 8 September 2008 th 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.V371662.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.V371662.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 4922892 ouston@gainfordcarehomes.co.uk CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd 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.V371662.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. 19th September 2007 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 peoples use. The home is part of the Gainford Care Home Group. The fee for the home is £455.00 per week. They do not include hairdressing, chiropody and some of the activities. Lindisfarne Ouston DS0000046626.V371662.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. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The inspection was unannounced and started on 5th and completed on the 8th September 2008. Before the visit the inspector looked at: • • • • Information we have received since the last key inspection visit on 19 September 2007; How the home dealt with any complaints & concerns since the last visit; Any changes to how the agency is run; The provider’s view of how well they care for people, as highlighted in the details provided in the Annual Quality Assurance Assessment (AQUAA); During the visits the inspector: • • • • • • • talked to the people who use the service, the manager and care staff; looked at information about the people who use the service and 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 person they care for; looked around the home to make sure it was safe & secure; checked what improvements had been made since the last visit; the inspector told the manager what he found. All of these activities contributed to the inspection findings. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 6 What the service does well: Relatives, residents and other professionals who were spoken with commented positively on the home and the care provided. Some of the comments include:• • • • • • “No problems with the place. They keep us informed about mum’s progress and how she is getting on”. “Our mum has been here for a long time and we have never had any need to complain. This place is excellent and I recommend it to anyone”. “I am very happy I chose this place. We get looked after very well”. “The carers are very caring and they help me with anything I need. I can talk to them if I am not happy”. “ I can’t fault this place. There is always plenty to eat and the place is always clean”. “The staff respect your wishes. I get up when I want and go to bed when I want. You have your freedom”. The environment is spacious and residents and staff are able to move about freely. The corridors are wide enough to allow residents with walking aids to move about without any restrictions. Residents are able to furnish their rooms to their own taste and with their personal belongings. Residents have been encouraged to bring personal belongings to the home, thus providing a familiar environment for them. The home provides staffing in sufficient numbers to help meet the needs of the residents. The home also undertakes good recruitment practices to protect people living in the home from unsuitable carers. All the appropriate checks are taken before appointments are confirmed. The management arrangements are good and staff confirmed that the manager is always available for advice and that she is very supportive of the staff and the residents. There are systems in place to review the quality of care within the home and checks are regularly carried out on the premises to ensure that they are safe. There are varied and useful social and recreational activities for residents to engage in. These include twice weekly bus trips to local places of interest, coffee mornings and arrangements for regular visits by the clergy to offer pastoral care for those who want it. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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 Ouston DS0000046626.V371662.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 Ouston DS0000046626.V371662.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): 1, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care needs assessments are carried out by the home and the social worker before admission is arranged, ensuring that the individual’s needs are clearly identified and care plans put in place to meet them. Furthermore, prospective residents and/or their relatives are provided with the good information about the home and are offered the opportunity for them to visit before making their decision about coming to live there. This assists in making the best decision. EVIDENCE: The provider has a policy relating to the admission of new residents. Full and detailed assessment of prospective residents are carried out by either a social worker or by the home. Where a social worker carries out the assessment, copies made available to the home as part of the admission process. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 10 The home also carries out their assessments of the individual in their own home to make sure Lindisfarne Care Home has the necessary skills and facilities to meet the needs of the prospective resident. Residents’ files show evidence of assessments being carried out before admissions were arranged. Some of these were in people’s own homes and others were in hospital settings. Residents and relatives commented positively on the admissions process. People described how they were offered the opportunity to visit the home and the chance for the prospective resident and or their families to ask questions about residential care in general. One family said they were offered the chance to have dinner with the residents and to talk with other residents about their experience in the home. They commented that the staff took time to explain things to them during that visit and felt reassured by the visit to the home. The manager and staff stated that it is the policy of the home to ask prospective residents and their relatives to visit the home and assess the place for themselves before making up their minds. The manager went on to explain that in some cases it is not possible for the prospective residents to visit the home and see it for themselves before admission is arranged. In these cases families or advocates are encouraged to do so on their behalf. All residents are provided with copies of the Service User Guide. However, the guide would need to be reviewed to include the address and contact details of the local office of the Commission. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 11 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. Residents’ personal and healthcare needs are fully met. The home has good procedures in place for the safe administration of medicines. These promote and health and welfare of the service users. Furthermore, the residents are treated with respect and dignity, thus enhancing their sense of wellbeing. EVIDENCE: Detailed care plans are available for each resident. The plans set out the residents’ health and personal care needs and action plans for meeting those needs. However, some of the actions plans are not specific enough to guide staff on the detailed ways of dealing with certain behaviours or the general care provided. The home has suitable arrangements in place for meeting the healthcare needs of the residents. Record of contacts with healthcare professionals, including GPs, psychiatrist, nurses, chiropody service, dentist, optician and other Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 12 healthcare services are maintained. The daily report sheets show that the healthcare needs of the residents are fully met. This contains details of contacts with medical practitioners and other professionals. The accident book was examined and contained details of all accidents in the home. The manager carries out a monthly review of accidents to help identify any recurring incidents in the home. The arrangements for the administration and storage of medicines are generally good. The drugs administration system was examined and it was noticed that the system of stock-control is not sufficiently robust enough to account for the running total of tablets contain in individual bottles. Records relating to the administration of medicines have been properly maintained. The temperature in the treatment room where the medicines are stored is very high and there is a risk to medicines being adversely affected by the high temperature in this room. However, the area manager assured the inspector that a new air condition system would be installed within the next few weeks as she realises that the current arrangement is not effective. Copies of prescriptions are kept in the home to ensure that medicines can easily be accounted for and traced back to the chemist if necessary. The manager confirmed that staff who are responsible for the administration of medicines have all received appropriate training. The residents confirmed the view that the staff treat them with respect and dignity. Staff were observed to treat service users with respect and dignity. Staff interactions with residents in the dining room and in the lounges were good examples of how they treat them with respect and dignity. Residents were politely spoken to and assistance with personal and intimate care was provided in a discreet and dignified manner. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The home supports and encourages residents to maintain close relations with their friends and families. Furthermore, opportunities are provided for residents to exercise control and choice and to engage in meaningful activities of their choice. This promotes their independence and well-being. The residents are offered good variety of wholesome and nutritious meals in comfortable and pleasant surroundings, which promote their health and wellbeing. EVIDENCE: The residents are engaged in a number of social and recreational activities. The manager and the residents confirmed that social and recreational activities are organised and residents are encouraged to join in. However the residents are free to join in social and recreational activities if they wish. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 14 Some residents commented on the weekly trips to local places of interest and how much they enjoy it and look forward to the twice weekly trips. There were positive comments also about other social activities such as bingo, gentle exercises, sing songs and visits by the clergy. Staff members commented that the relatives and visitors are welcome at any reasonable time, throughout the day and evening. A number of the residents have regular visits from their relatives as the visitors’ sign-in book shows. Relatives stated that they are able see their loved ones in the privacy of their own room or in the home’s lounges or dining room if they wish. Mealtimes are flexible and relaxed and residents are offered a choice of healthy and nutritious meals. The home has in place a 3 weekly menu. Discussions with the manager and the chef indicated that the home relies on fresh produce to provide residents with home made meals. Meals are generally served in the dining rooms, which are nicely decorated and benefit from plenty of space to enable staff and residents to freely move about without restrictions. A staff member commented that if any resident wishes to have their meals in their room, arrangements would be made to make it happen. She indicated that this is a common practice and that often some residents decide to have meals in their rooms. A choice of menu is always available for the residents to choose from. Cooked breakfast and continental-type breakfast is always available for residents to choose from. The residents confirmed this and stated that there is always plenty to eat and drink. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 15 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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have information about how to make a complaint This promotes their right to complain about the service if they feel they need to. Furthermore, all Staff are aware of the Protection of Vulnerable Adults procedure, and suitable training has been provided. This protects the residents from abuse. EVIDENCE: The Service User Guide contains a summary of the home’s complaints procedure. Copies of the guide are made available to all the residents. Relatives who were spoken with said they are aware of the procedure. Residents and relatives stated that they would feel confident complaining if they are not happy. Two relatives commented that if ever they were unhappy with anything, the staff dealt with it immediately. One said the manager “treats any concerns she raises very seriousl”. The majority of the staff members have received training in “safeguarding adults from abuse”. There is regular refresher training available to make sure all staff are up to date on safeguarding issues, which was confirmed in the staff training plan. In discussions with staff they demonstrated an understanding of the need to protect residents from all forms of abuse. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 16 There is a system for recording all complaints that have been received. The record shows the nature of the complaint and how it was dealt with. There is evidence that the home takes complaints seriously and a summary of all complaints are in the complaints register. In discussion with the staff it was evident that they did not have knowledge of the Mental Capacity Act. There has been no training regarding the Mental Capacity Act 2005. However, the manager spoke about the forthcoming training on the 24 September this year, which she would be attending, and cascading the knowledge she gained to the rest of the staff. All staff have had enhanced CRB checks done on them. Suitable references have been obtained as part of the recruitment process. The Admin Officer maintains very good record of residents’ personal allowances. There is regular auditing to make sure that all monies are accounted for. Records of purchases made on behalf of residents are maintained and receipts provided where necessary. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 17 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, 20, 22, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers an accommodation and an environment that is safe, clean and well maintained. However, there need to be some ways of altering the environment to help people with dementia to find their way around more easily. This would further promote and enhance the general welfare, dignity and comfort of the service users. EVIDENCE: There are suitable arrangement in the home for ensuring a good standard of cleanliness and hygiene. Consequently, the home is generally free of odours. Bedrooms were clean and personalised to reflect individual preferences. All the communal areas are appropriately furnished and decorated to a good standard. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 18 The home is large and has long corridors, which can be confusing for someone who may have dementia or poor eyesight. The registered manager and her line manager informed the inspector that the provider is looking to alter the environment in ways that would assist people to easily find their way round the home. This would take the form of “themed” corridors to help people find their way more easily. The bedrooms are spacious and allow residents to move about freely and to accommodate their personal belongings without the rooms looking congested. There are good arrangements in place for regular maintenance work in the building. The maintenance book shows that the handyman has kept on top of any safety work that is needed to maintain a safe environment. These include fire safety checks and drills. Sufficient and suitable equipment has been provided to enable residents to remain as independent as possible. These include handrails in corridors, toilets and bathrooms. The home has suitable infection control policies in place. Staff have had training in infection control and the staff training log confirms this. The home has adhered to effective infection control procedures. The kitchen was noted to be clean and maintained to good standard. There is a cleaning rota showing how the domestic staff keep up with the cleaning activities in the kitchen. Records relating to food temperatures and other food hygiene measures are maintained. The chef has implemented the “Safer Food Better Business” system into the home. This appears to be working very well and the chef is committed to the principles behind the system. The laundry was well ordered and appropriate COSSH notices are in place. The laundry machines are suitable for cleaning foul linen. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 19 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. The staffing numbers are satisfactory and promote the safety and welfare of the residents. Furthermore, the home adheres to good recruitment practices, which safeguards the welfare of the residents from unsuitable carers. EVIDENCE: There are sufficient number of staff employed in the home to meet the residents’ needs. Relatives and residents confirmed this. Care staff also stated that they feel that there are sufficient staff on duty at all times. The duty rota confirmed that the manager deploys sufficient number of staff on daily basis to meet the needs of the residents. The staff training log shows that the necessary training is provided to equip them for their roles. Some of the training includes moving and handling, first aid, protection of vulnerable adults, dementia awareness, challenging behaviour, fire safety, food hygiene and health and safety training. This was confirmed by the manager and a list of training shows the planned training that all staff are to receive by the end of this financial year. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 20 In discussions with the staff, it was evidence that there was very little awareness amongst them of the Mental Capacity Act. The manager confirmed the commitment by the provider to have Mental Capacity Act training. The training programme includes four planned training days on the Mental Capacity Act by the end of January 2009. The staff induction programme should be organised in a way that complies with the “Skills For Care” induction standards. The two files on induction that were examined did not provide a clear and systematic induction for the staff concerned. There were too many aspects of the induction that were covered on the first day of commencement of duty. This could be tiring and confusing for staff who are new to the care profession. The home has been following the company’s policy on recruitment. All the files contain completed job applications, copies of job description, appropriate references, evidence of CRB checks and records of training. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36, 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 managed by a qualified and experienced person and is run for the benefit of the residents. The safety and welfare of residents is protected through robust health and safety arrangements. EVIDENCE: The registered manager has long experience of managing a residential care home. Staff commented positively on her ability as a manager and feel that she is approachable and supportive of them. The staff indicated that she runs the home for the benefit of the residents. This view was supported by a number of residents and visitors during conversations with them. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 22 The home continues to maintain a quality assurance system, which includes surveys and questionnaires for people living at and visiting the home. They also include Regulation 26 visits from the provider. The service also has accreditation with Investors In people. The personal allowance records and receipts of transaction show that there is a good system in place and that the residents’ monies are safe and properly accounted for. The Admin Officer conducts regular audits to make sure that peoples’ monies are safe. There are suitable arrangements for staff to receive one-to-one supervision from the manager. However, this is not happening at the expected fequency. Some staff have not received supervision in nearly a year. Staff nonetheless confirmed that the manager is always available to talk to or provide advice when needed. They felt well supported by the manager and the provider company. The company’s Health and Safety policies remain in place. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The staff adhere to the policies as set by the company. Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, gas and electrical appliances have been carried out by the contracted companies. All the servicing records that were examined were up to date. These included servicing of passenger lift, hoists, water treatment, electrical installation and gas servicing. Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 23 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X 3 X 3 X 3 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 3 3 X 3 2 X 3 Lindisfarne Ouston DS0000046626.V371662.R01.S.doc Version 5.2 Page 24 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 Suitable arrangement must be made to ensure that all tablets are account for and the amount in the bottles tally with the records that are maintained. Care plans must contain detailed information, which demonstrates how the home will meet people’s needs. Timescale for action 30/11/08 5. OP7 15 30/11/08 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 OP2 OP36 Good Practice Recommendations The Service User Guide should reviewed to reflect the current address and contact details of the local office of the Commission. Supervision should take place for all staff at least six times each year. Lindisfarne Ouston DS0000046626.V371662.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 Ouston DS0000046626.V371662.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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