Care Home: Lindisfarne Seaham

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What the care home does well Each person who lives at the home has had their needs assessed to make sure the home can give them the care and support they need. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Information is available to help people make an informed choice about the service before they decide to use it. All of the people have care plans, which give information to staff about how to support them and meet their needs. The staff at the home treats the people as individuals and supports them to live the life they choose as much as possible, so they will have new experiences and know that their opinions are valued. People who live at the home experience a variety of activities. This gives them choice, as well as building their self-esteem and confidence. The home is clean, warm and pleasantly furnished so the people who use the service have a comfortable place to live. Staff supports the people to use local services so they are part of the community. The home has procedures for staff for the administration and recording of medication. This is to make sure the people who live at the home receive their medication when they need it and at the correct times. The home has procedures for dealing with complaints so any disputes are settled quickly so good relationships are maintained. The home has adult protection policies and procedures for the staff to follow. At the time of these visits to the service staff knew how to safeguard and protect the people who live at the home. What has improved since the last inspection? The activities co-ordinators hours have been increased form 30 to 35 hours per week. The garden area is now secure, and new garden furniture has been purchased. Specialised food moulds have been introduced to enhance the appearance of blended and soft foods. Areas around the home are now themed following the Stirling University model of dementia awareness. Mealtimes have changed to meet the needs of the service users. The home now provides a transport service for relatives. The first floor lounge has been extended. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 The service now has a male only unit, and specialises in challenging behaviours. Some service users now have access to local day centres and community facilities. Sky TV has been installed. A mobile sensory unit has been purchased. Life story books have been introduced. There is now a floating member of staff in addition to the standard required, this member of staff goes between each unit providing extra support and help, and ensuring that service users have adequate fluids. Care pans are now person centred. Key code locks have been fitted to different areas to enhance service user’s safety. What the care home could do better: Wherever practical, service users risk assessments should be agreed and signed by themselves or their next of kin. This will ensure that all parties are fully aware of the risks identified. Fixed orientation notice boards will help those service users with dementia to know the time, date, season and the names of the staff on duty. Fixed signs should also in place on toilet doors, bathrooms, dining and lounge areas. The medication fridge temperature and room temperatures should be recorded; this will ensure that medicines are being stored at the temperature recommended by the manufacturer. One of the handwritten medication entries was not completed properly; there must always be two staff signatures and the quantity received must always be recorded. Key inspection report CARE HOMES FOR OLDER PEOPLE Lindisfarne Seaham King Edward Road Dawdon Seaham County Durham SR7 0BG Lead Inspector Jim Lamb Key Unannounced Inspection 7th September 2009 09:00 DS0000068621.V377520.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Lindisfarne Seaham DS0000068621.V377520.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) seahamgch@btconnect.com CLS@gainfordcarehomes.co.uk Gainford Care Homes Ltd Vacant Care Home 61 Category(ies) of Dementia (51), Mental disorder, excluding registration, with number learning disability or dementia (10), Old age, of places not falling within any other category (51), Physical disability (10) Lindisfarne Seaham DS0000068621.V377520.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 place - 51 Mental Disorder - Code MD - maximum number of places - 10 Physical Disability - Code PD - 10 Old people not falling within any other category - Code OP - 51 The maximum number of service users who can be accommodated is: 61 2nd October 2008 2. Date of last inspection Brief Description of the Service: Lindisfarne Seaham is a large purpose-built home in a residential road in Seaham, which is a coastal town in County Durham. It is owned and operated by Gainford Care Homes Limited, which operates around 11 care services in the Tyne and Wear area. This home has been open for about 18 months. This home provides accommodation for a total of 61 people. The building is set on a slightly elevated site and has three main units. On the lower ground floor is a 10-place spacious, self-contained unit for people with a physical disability who may stay for short-breaks or on a longer term basis. On the ground floor is a 36 place unit that provides nursing care for older people with dementia care and mental health needs. On the first floor is a 15 place unit that provide personal care for up to older people with dementia care or mental heath needs. All the bedrooms are large, single occupancy rooms with private en-suite facilities. All three units have their own lounges and bathrooms. There is large, pleasant dining room on the lower ground floor for residents to join together, if they wish, at mealtimes. The weekly fee for the residential unit is £455.50. The weekly fee for staying in the unit for people with a physical disability is £486.50. The weekly fee for the nursing unit is £ 603.98 (this includes a continuing health care contribution.) Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 5 This information was given at the time of the inspection visit. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. 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 quality rating for this service is 2 stars. This means that the people who use the 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, how the service dealt with any complaints and concerns since the last visit, any changes to how the home is run, the providers view of how well they care for people, and the views of people who use the service and their relatives, staff and other professionals. During the visit we talked with people who use the service, relatives, staff, the manager, the area manager and visitors, 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 and 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 and comfortable, and checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: Each person who lives at the home has had their needs assessed to make sure the home can give them the care and support they need. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 7 Information is available to help people make an informed choice about the service before they decide to use it. All of the people have care plans, which give information to staff about how to support them and meet their needs. The staff at the home treats the people as individuals and supports them to live the life they choose as much as possible, so they will have new experiences and know that their opinions are valued. People who live at the home experience a variety of activities. This gives them choice, as well as building their self-esteem and confidence. The home is clean, warm and pleasantly furnished so the people who use the service have a comfortable place to live. Staff supports the people to use local services so they are part of the community. The home has procedures for staff for the administration and recording of medication. This is to make sure the people who live at the home receive their medication when they need it and at the correct times. The home has procedures for dealing with complaints so any disputes are settled quickly so good relationships are maintained. The home has adult protection policies and procedures for the staff to follow. At the time of these visits to the service staff knew how to safeguard and protect the people who live at the home. What has improved since the last inspection? The activities co-ordinators hours have been increased form 30 to 35 hours per week. The garden area is now secure, and new garden furniture has been purchased. Specialised food moulds have been introduced to enhance the appearance of blended and soft foods. Areas around the home are now themed following the Stirling University model of dementia awareness. Mealtimes have changed to meet the needs of the service users. The home now provides a transport service for relatives. The first floor lounge has been extended. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 8 The service now has a male only unit, and specialises in challenging behaviours. Some service users now have access to local day centres and community facilities. Sky TV has been installed. A mobile sensory unit has been purchased. Life story books have been introduced. There is now a floating member of staff in addition to the standard required, this member of staff goes between each unit providing extra support and help, and ensuring that service users have adequate fluids. Care pans are now person centred. Key code locks have been fitted to different areas to enhance service user’s safety. What they could do better: If you want to know what action the person responsible for this care home is Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.2 Page 9 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 10 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.V377520.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 5 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users are provided with enough information about the service to enable them to make an informed choice about whether this is where they want to live. EVIDENCE: People who come to stay here are given an information pack, called a Service Users’ Guide, which includes useful information about what they can expect from the service. Everyone is encouraged to come and have a look around the home before making a decision. In this way people have good information to make a decision about whether to move to this home. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 12 There are clear records to show that the needs of the service users were assessed before they moved in so that the home knows whether those needs can be met here. Care managers of the Social Services Department carry out most assessments and these are provided to the home. The manager also carries out assessments of prospective new service users, to make sure that the home can meet their individual needs. The assessments also include brief details of people’s spiritual and social care needs so that the home can plan to support them in these areas. Evidence was seen in service user’s files that service users or their representatives had signed a contract. The contracts were detailed and included a breakdown of the fees and who was responsible for paying them. The home provides short-term respite care, intermediate care is not provided. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system is clear enough to ensure that staff have the information they need to meet the assessed needs of the service users. EVIDENCE: A comprehensive range of assessments is completed to identify each service user’s current health, personal and social care needs. This information is used to devise and update individual care plans. Service users are involved in planning their care and have a key worker who monitors and helps to update care plans. Samples of four service user care plans were examined: These addressed physical health, personal hygiene, continence, memory and cognition, skin integrity, communication, social and spiritual needs. The recording was detailed, specific and personalised to the persons requirements. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 14 The plans demonstrated care and support to be provided by staff and what the person can do independently. There were also good examples of plans that showed how risks to the person are managed or minimised. These should be signed by the service user or their representative’s; this will ensure that everyone is aware of the risks identified. Service users said they always receive the care and support they need, and that the staff always treated them with respect and maintained their privacy and dignity. One service user said, This is a smashing place, the staff are very great. My family live close by and I am able to see them most days. Another said, My daughter and son visit quite often, I have no complaints and I like the staff very much. Service users have a choice of local GP practices, and the residential side of the home has an allocated District Nurse. There are arrangements for an optician, dentist and podiatrist to make home visits. Service users also receive input, if required from mental health care professionals, physiotherapist and occupational therapists. All contact with health care professionals is well recorded. Service users have their moving and handling, nutrition, continence, and pressure sore risk needs assessed. Falls assessments are also completed. Each service user has a life story completed, (this is good practice) and provides staff with a much greater awareness of each persons life experiences and background. There were some good examples of care plans linked to specific health care needs and medical conditions. Where identified these incorporated appropriate aids and equipment used. All staff who administers medication undertakes relevant training. A sample of medication charts was examined. These were appropriately recorded and have service user’s photographs for identification purposes. The staff team were reminded that all handwritten entries in the medication charts must have two staff signatures, and that they must record the quantity received. All personal care and medical examination/treatment is carried out in private. Service users confirmed that staff treated them with respect and personal care is always carried out in a dignified manner. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users are offered a very good quality lifestyle, which includes varied social contact and activities. EVIDENCE: Each person has an assessment of their social needs that gives details of his/her background, lifestyle, routines and interests. The information is used to implement individual social care plans. Wherever possible, staff supports individual needs and requests for one-to-one activities and outings. There are outing at least twice weekly to places of interest. The home has its own transport for outings. Photographs of outings are displayed in the home. A memory box is located outside of each service user’s bedroom door, and this promotes their identity. The home has a very enthusiastic activities co-ordinator and she keeps very detailed social care records for each service user. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 16 The home has a well thought out activities programme, and service users are supported and encouraged to participate. The home has an open visiting policy. Visitors are welcomed and can take refreshments and meals. Service users choose whom they wish to see and where to receive visitors. Contact with friends and family is supported through visits, telephone calls and letters/cards. If relatives have difficulty getting to and from the home, the home will arrange to transport them in the home’s minibus. Three visitors said they are always kept up to date with important issues affecting their relative, and were pleased with the care provided. One raised a concern, and this was discussed with the manager, she said that staff will now receive additional training in the area of concern raised. Some service users continue to manage their financial affairs. Where this is not possible they are assisted by relatives/representatives. The homes management does not take responsibility for finances, other than holding cash for personal spending in the safe. Service user’s nutritional needs are assessed and care planned where necessary, and weights are monitored. Special diets are catered for. These currently include low fat, diabetic and soft diets. Blended food is served separately in moulds that resemble the food that they are. Independent eating is encouraged, with use of aids if needed. The current menus showed that there is a choice of meals available. Menus are displayed. The inspector observed lunch. The tables were nicely set with cloths, placemats and full range of condiments. Hot and cold drinks were available. The meal was served at a leisurely pace, and staff were on hand to offer discreet help if needed. Service users told the inspector the food is good. They confirmed choice of meals is offered. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints management is effective, and this results in the service users being protected from harm and abuse. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. Copies are available in service user’s bedrooms. For those service users without capacity, advocacy arrangements are in place. One service users said she had been given copies of the procedure and that staff listened to her concerns and always dealt with them fairly. Since the last inspection visit, there has been one complaint received and this was appropriately resolved. The home has a Whistle Blowing policy, a copy of the Local Authorities Vulnerable Adults procedures, and a copy of the Department of Healths Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 18 document, NO SECRETS. Staff are aware of these procedures and have easy access to them. Safeguarding adults training is ongoing for all staff. Service users can deposit cash for safe keeping, and records are kept of accounts. A sample of personal finances records was examined all transactions were appropriately recorded. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a very comfortable and safe environment for those living there. EVIDENCE: The home was clean, well decorated and well maintained. The grounds were attractive, tidy, safe, and accessible. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 20 During the last six months, there has been some significant improvements made The manager agreed to display fixed orientation boards providing information depicting: date/day, weather, the names of the staff on duty, appropriate fixed signs on toilet doors, bathrooms, dining and lounge areas are also needed. This will enhance and promote the orientation for people with memory problems. The management team have been in contact with Stirling University who provided them with information about environmental design, and colour schemes that they have used throughout the home. This is good practice. Service users can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in very good condition. All bedrooms have got en-suite facilities. Lighting was bright and domestic in design. All doors have privacy locks and room sizes exceed the required standards. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. Service user’s bedrooms have opening windows and restrictors are in place that have been approved by the Fire Brigade. The rooms were centrally heated and the heating level could be controlled within each bedroom. The home has under floor heating. There was emergency lighting throughout the home. The kitchen was spotlessly clean and well organised. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was exceptionally clean and free from offensive odours. The laundry facilities are very well organised. The washing machines have the specified programme to meet disinfection standards. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good match of well-qualified staff, who are appropriately recruited and supervised. EVIDENCE: The personnel records of three staff were examined. All three had completed application forms, the dates of employment were clear, making it easy to follow a clear employment ‘audit trail’. The manager also completes an audit check list and this ensures that all the necessary checks have been completed prior to commencing employment. All had the required two work references, (crb) criminal record bureau check, documentary evidence of identity, induction and training and development information. All staff has an annual training matrix drawn up, this covers all mandatory training needs, and other core training needs, such as Dementia Awareness and Adult Protection. Individual staff members have his or her individual Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 22 training needs analysis on their personal file. These have recently been revised to cover developmental as well as mandatory and core training. Staff levels on the day of the inspection met the agreed level for the number of service users. There are enough domestic, maintenance, and catering hours. All staff were over 18 years of age and those left in charge were at least 21. The training needs of the staff are identified in supervision and appraisal sessions. The homes training programme meets the National Training Organisation requirements for the first six months. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The day to day management of the home is well managed by an appropriately trained manager; she has the relevant experience in care home management and the needs of the service users. The acting manager is supported by first level nursing staff, and the area manger. The home is temporarily without a registered manager. The Proprietor said that she has interviewed several people for the post, but none were suitable. The post will continue to be advertised. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 24 There is a range of quality systems in the home. There is an annual survey of the views of the service users and their families. The findings are collated and an action plan drawn up to address any areas of concern. There are also regular meetings held with both the service user groups and with the staff group. These are minuted and action points listed. Both individual and central supervision records were studied. These records show an appropriate bi-monthly pattern of supervision, with an annual work performance appraisal. All staff receives annual health and safety training. This is good practice. Checks of the fire log book showed that all the required checks and tests of equipment and systems take place at the proper intervals, as does fire safety training. The home’s accident book is kept up to date and information is fully recorded. Each accident is reviewed after 24 hours to check the outcomes of the accident and any treatment given. There is a monthly audit of accidents, and a detailed audit of all falls. Servicing and maintenance records are comprehensive and well maintained. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 25 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 4 4 4 4 4 4 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 3 X 3 X 3 X X 3 Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The temperature of the medication room and fridge should be regularly monitored. This will make sure that medicines are being stored at the temperature recommended by the manufacturer. One of the handwritten entries on the medication records did not have two staff signatures, or the quantity received. All medication records must be properly completed. This will make sure that the person receives the correct medication at the right times. All risk assessments should be agreed and signed by the service user concerned or their representative. This will ensure that everyone involved is aware of the risks identified. Fixed orientation boards, and fixed signs on toilet, bathroom doors, and lounge and dining rooms should be in place. This will help people with memory problems to DS0000068621.V377520.R01.S.doc Version 5.3 Page 27 2. OP9 3. OP8 4. OP19 Lindisfarne Seaham become more orientated in their environment. Lindisfarne Seaham DS0000068621.V377520.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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