Inspection on 25/06/07 for Heatherside House

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heatherside House 19/11/08

Heatherside House 23/05/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Pine Tree Lodge Dousland Yelverton Devon PL20 6NN Lead Inspector Helen Tworkowski Unannounced Inspection 25th June 2007 10:15 Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 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 Pine Tree Lodge DS0000069209.V341354.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 Adults 18-65. 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. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Tree Lodge Address Dousland Yelverton Devon PL20 6NN 01822 854771 01822 854771 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) Sheval Limited Miss Samantha Ann Louise Gomm Care Home 25 Category(ies) of Learning disability (25) registration, with number of places Pine Tree Lodge DS0000069209.V341354.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 only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning Disability (Code LD) The maximum number of service users who can be accommodated is 25. New Registered Provider Date of last inspection Brief Description of the Service: Pine Tree Lodge is a care home providing personal care and accommodation for twenty-five people with learning disabilities aged 18 and over. This home is located at the end of a private driveway in the village of Dousland on the edge of Dartmoor. There are local amenities such as shops, pubs and post offices in the local village of Dousland and in the nearby towns of Yelverton and Tavistock. The home is a detached, two storey property, with a single storey extension, and has been open since 1984. Historically the home consisted of three self-contained units with communal facilities. Each unit had its own communal space consisting of lounge and dining rooms, a kitchen and laundry room. The home had nineteen single bedrooms, four of which have en-suite toilet facilities, and three shared rooms, one of which had an en-suite shower and toilet. The home is going through a major phased refurbishment and has been moved out of one area of the home. At present Service Users therefore have the use of one dining room and two lounges. One Service User is now occupying a room that was the dining room. Only one of the kitchens is used to cook meals. The home is surrounded by large gardens that are well maintained and accessible to service users. The Statement of Purpose and Service User Guide are available in the office of the home. The fees charged at the time of writing are £320 to £670, addition items charged for include: clothing and toiletries. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is the first one following the change of ownership to Sheval Ltd. Sheval Ltd has recently started an extensive programme of refurbishment, and this inspection report should be read in this context. This inspection included site visits to Pine Tree Lodge on 25th June 07 (10.15am- 4pm) and 26th June 07 (9.30am- 4pm). During this visit the inspector spoke with staff on duty and with the manager. The Inspector also spoke with two service users, and spent time sitting with Service Users observing what was happening. During the visit we looked around the home, looked at records relating to the care of four people, looked at staff records, safety records and medication. In addition, we also spoke with seven relatives of Service Users, health care professionals, social services care managers and other professionals who have had contact with the service. Surveys were sent to twelve of the seventeen service users, ten of these surveys were returned. Surveys were sent to all care staff, eight were returned. What the service does well: What has improved since the last inspection? What they could do better: It is recognised that there are plans to refurbish Pine Tree Lodge, however in the mean time some areas of the home are unkempt and smell of urine. The Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 6 smell of urine indicates that the continence of some individuals is not well managed. Also some of the bedding is worn and in need of replacement as it would be uncomfortable to sleep on. The food provided by the home is well liked by service users, but does not always reflect nutritional needs. There is a lack of fruit and vegetables. Pine Tree Lodge employs a party time activity worker but there are still limited opportunities for the people who live at Pine Tree Lodge to go out or to follow interests or develop skills at home. Opportunities to go out such, as going to the hairdresser, are not always taken; rather the hairdresser comes to the home. Pre employment checks on staff are not being properly made, this means that there is a risk of people who are not suited to the work being employed. Assessments that should be made to ensure that people are safe at Pine Tree Lodge are in need of some up dating and improvement, so that it is clear what needs to be done. 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. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are provided with information about the home, though this is not up to date. EVIDENCE: The home has a Statement of Purpose and Service User Guide. These documents provide information for a prospective Service User and their representatives about the home and what they can expect. Sheval Ltd (the Registered Provider) had provided a copy of these documents to the Commission, though since then the Company has amended them. The Statement of Purpose provided to the Commission is not complete. Sheval Ltd needs to provide updated and comprehensive copies of these documents to Commission. No new people have been moved to the Care Home since Sheval Ltd has taken over. The Manager, Sam Gomm, discussed with the Inspector the need for any new person to be able to fit in with the people who currently live at Pine Tree Lodge. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users needs are generally well recorded and there are risk assessments to help keep people safe. However some of the risk assessments are not up-to-date. The way service user money is managed is not appropriate. EVIDENCE: Nine out of the ten Service Users who responded to the surveys said that they feel they were treated well and that staff listened and acted upon what was said. Service Users and their relatives commented that the staff were caring. Each person who lives at Pine Tree Lodge has a Service User Plan (or Care Plan) that specifies the help that is needed. These documents are for the most part clear and well written; though in a few areas they lack detail. The Plans of four people were looked at in detail during this visit. There are also risk assessments, these documents help to identify any risks and how they can be eliminated or managed. Again for the most part these documents were clear and well written, however one or two of the risk assessments made little Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 10 sense. The falls risk assessment included an assessment and a score, however it was not clear what the score meant or what actions needed to be taken. It was also noted that one person had a moving and handling plan that specified the use of a hoist. However from discussions with the staff it was apparent that the hoist did not work and was not suited to the task. The Manager, Ms Gomm, was aware of this and was dealing with the issue. However the assessments and plans needed to reflect the current situation. It was also noted that the risk assessments in relation to bedrails were in need of review, so that they reflect good practice in this area. The Manager, Sam Gomm, said that she was aware of the new Mental Capacity Act, and that she needed to ensure that this would be implemented. This would include that there is a record of what decisions service users are or are not able to make for themselves. Service Users money is currently managed on their behalf by Sheval Ltd. Each person has an account, into which some of his or her income is being paid. Money is also being directly paid to Sheval Ltd, and a payment made by the company to each individual (personal allowance). The manager was not clear exactly what income each person might expect or if they had received the money. The payment of money belonging to a Service User into an account related to the management of running of the home, is not permitted by regulation. There is no concern that money has been misappropriated, those records that were seem were in good order and items purchased were receipted. Ms Gomm said that on completion of the refurbishment each Service User would have a locked draw in their room where they will be able to keep any money or valuables. Service Users files are kept in an office, and no information about service users was left lying around. Feedback from a professional who has contact with the service was “we sometimes hear inappropriate comments from staff, sometimes relating to toileting and personal care, which do not seem to value people”. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users have limited opportunity to take an active part in community life or to develop skills and interests. Meals, whilst the taste of Service Users, do not reflect their nutritional needs. EVIDENCE: Feedback from Service Users in surveys was that they generally were able to make their own decisions about how they spent their time. A few of the Service Users go out a couple of days a week to a day service; this is run by social services. The majority of people at Pine Tree Lodge spend their days at home. We looked at the daily records of how Service Users spend their time. Records show that some individuals spent their time doing very little for many weeks: watching TV or sitting in their rooms. An activity worker is employed and cooking sessions are organised, some trips out and group activities. However given that there are seventeen people in the home, these activities occupy very limited amounts of time. The feedback from professionals included: “All the people we support have communication diaries, it is unusual Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 12 to find that people have been taken out when they are not supported by out service. One individual wants to attend church events where he used to live but this does not happen”. Another professional commented that she had watched staff preparing for a bingo session, all the Service Users were excited, however she found it sad to see that the staff were joking about the fact that they had no prizes. She had found it sad that the staff placed so little value on this activity when it was clearly of importance to the Service Users. It was also noted that Service Users do not go out to the hairdressers, a hairdresser visits the home. There is a “tuck shop”, which means that Service Users do not have to go out to the shops for sweets and magazines. These are opportunities for Service Users to be present and participate in the local community. Removing these opportunities from people further isolates them. The Manager did confirm that Service Users do go out with staff to purchase their clothes, and in recent months people had been encouraged to buy new clothes for their wardrobes. As part of the inspection the Inspector ate a meal with Service Users. Service Users spoken with said that they enjoy the food. It has already been noted that meals used to be cooked and eaten in each of the three separate units. Because of the refurbishments meals are now being prepared in one kitchen and eaten in one dining room. This means space in the dining room is very limited for the seventeen people. The Manager said that the menu had recently been revised to include more of the foods that service users enjoy. The meal on the first day of the inspection was chips, ham and eggs, followed by rice pudding. Most of the meals on the menu were of a similar nature. There was very little evidence of fruit and vegetables. On the second day of inspection there was no fresh fruit or salad in the home. Some of the Service Users take medication for problems with constipation or to reduce their cholesterol. There was no evidence that the meals offered reflected these needs. The Manager said that she had used to purchase fruit however it rotted and was thrown away. Whilst it is recognised that not every one may enjoy fruit and vegetables however menus can be developed that do provide interesting and enjoyable food that meets nutritional needs. Service Users do not participate in cooking meals unless it is an “activity” organised by the activity person. It was noticeable during this inspection that there were generally more staff in the kitchen than with Service Users. During the meal staff were available to support Service Users for example to put tomato ketchup on the food. However it was not clear why Service Users were not given the opportunity to do this for themselves. The Manager said that it was hoped that when Service Users are able to return to the individual units they would be able to participate in the preparation of meals and in household tasks as part of daily life. The Inspector noted that Service Users had not previously been involved in such tasks before the refurbishment started, at the last inspection albeit under the previous ownership. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 13 We spoke with some of the relatives of Service Users who confirmed that support was provided for visits, and that they were kept up to date if there were any problems. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are treated with kindness, however their care needs are not always met. EVIDENCE: The people who live at Pine Tree Lodge spoken with or who completed surveys said that they felt that they were well treated. We also spoke with care professionals who visit the home. Their views were mixed. One person commented that information that had been requested had not been provided, and that she had at times found that Service Users were not receiving the support they needed. Staff had not been pro-active in seeking advice, although this was now improving. A medical professional did not have any major concerns, and felt that there had been improvements of late, however communication between staff still seemed to be an issue. The Commission looked at one of the programmes that had been set up for staff to follow when assisting a service user, and then observed what staff did. Staff only followed the programme in part. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 15 In talking to Service Users and looking around the home it was clear that some of the service users had issues with continence. The Inspector spoke with a senior member of staff about the smell and she said that they no longer noticed it. No service user or room should smell of incontinence. Proper management plans must be put in place to deal with these issues. We spoke with the Manager about the health care needs of a number of individuals, and it was clear that work had started to try and ensure that these needs were met. Contact had been made with a range of professionals, although some difficulties had been experience in actually getting services. We were shown the medication system. A monitored dose system is used; this is pre-prepared by the pharmacist in bubble packs. This system was well managed and records were up to date. There was a large stock of medication to be given when a person has a seizure; some of this medication was already out of date. There was no proper record of the amount in stock, and there was no record of this medication being signed in and out. There was guidance for staff on the circumstances when to administer “as required” medication for epilepsy, however there was no such guidance for medication administered in other situations. Of concern was a half a jam jar of various tablets, the Inspector was told that these tablets were ones that had been refused or dropped. Such medication should be returned on a more frequent basis to the pharmacist for destruction, so that there is a proper audit trail. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a complaints system. EVIDENCE: The Service Users who responded to the surveys said that they knew who speak to if they were not happy, though not all know how to make a complaint. The Inspector also spoke with relatives about whether they felt confident about raising concerns, and they said that this was the case. The home has a complaints procedure, though the manager was unclear about how complaints would be recorded. The home has policies in relation to Safeguarding Adults, and staff confirmed to the Inspector that they had recently received training in this area. Staff responding to the survey said that they were familiar with procedures in relation to the Protection of Vulnerable Adults. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The major re-furbishment that is underway will markedly improve the facilities at Pine Tree Lodge. In the mean time the accommodation is generally worn and in some areas smelly. EVIDENCE: This Inspection included a tour of the building. Pine Tree Lodge is undergoing a major phased re-furbishment, this has meant that one area of the home has been closed, and all of the Service Users moved to the other areas. This has resulted in all of the Service Users sharing the one dining room, as the second dining room is used as a bedroom. The area of the home that has been refurbished is almost complete. Service Users told the Inspector said that they were looking forward to moving to the refurbished rooms. The areas that have been re-furbished have been refurbished to a high standard; this includes each room having an en-suite shower room. The Inspector looked at some of the bedding provided for Service Users. One of the mattresses was very worn, and springs could be felt through the Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 18 material. None of the mattresses looked at had under blankets, in spite of these being in the linen cupboard. The Manager said that mattresses would be re-placed as part of the re-furbishment, although clearly this needs to happen sooner in some instances. There are radiator covers in some areas, though not all, where these are not covered there must be comprehensive risk assessments in relation to the risk of burns. The remaining areas of the home are due for re-furbishment. Some of the rooms are dilapidated, and carpets are worn. It is recognised that it may take time to work through the building and to make the necessary changes. However there were issues of immediate concern. Some of the bedrooms and one of the lounges smelt of urine. One of the visiting professionals commented on this. No home should smell of urine. It was also noted that some of the toilets were in need of cleaning. Mops and buckets for cleaning different areas were kept together, rather than separate, and dry. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are not robust and as stringent as they should be. Staff feel well supported in their work, which for the most part is focused on meeting physical needs. EVIDENCE: Many of the staff currently employed at Pine Tree Lodge have worked at the home for some time. Only one person has been employed since Sheval Ltd purchased the home. Staff responding to the surveys said that they were not asked to care for people outside their expertise, and that they felt that they had enough support. On the first day of the inspection there were three care staff on duty, plus the home manager. In addition there was a driver, a domestic and a gardener/ maintenance person. As the home has no cook one of the care staff cooked the meals. The Manager said that this not the usual level of staffing as one of the care staff had called in sick. Given the level of needs of Service Users, the Inspector considered that the staff should have been under some pressure to provide care and support. However this did not appear to be the case. It was Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 20 noted that Care Staff seemed to interact with service users in relation to care tasks rather than meeting wider social needs. The information sent to the Commission before the Inspection by Sheval Ltd says that all staff recruited in the last 12 months have had satisfactory employment checks. We looked at the actual recruitment records for staff recruited by Sheval Ltd. On file there was an application form, and a curriculum vitae. Two references had been taken in relation to the individual however these had not been received until the individual had started work. There was also a criminal records bureau check on file, however there was no check of the list of people unsuited to work with people who are vulnerable. No person may work in a care home unless this check, known as a “Protection of Vulnerable Adults” List check has been made. Also no person may work unsupervised until their Criminal Records Bureau check has been completed. The Information sent to the Commission before the Inspection by Sheval Ltd states that the staff development programme and induction meets the National Minimum Standards for the Service. We asked to see the induction for an individual but this was not available. From discussions with staff they felt they had sufficient training, although some individuals had not had training in relation to moving and handling. Each person had a record of their individual training on their file, however it was not possible to look at the training needs of the staff team as a whole. The Manager was aware of the need to be able to identify who had received training and where training needed to be updated. Form the information provided by Sheval Ltd, it was noted that only 15.4 of the staff had any training in relation to safe food handling. Many of the staff are involved in the preparation of food as there are no separate catering staff. Sheval Ltd have been registered to run Pine Tree Lodge for four months, and it is recognised that updating staff training is a long term project. Staff said in staff surveys that they received regular one to one supervision, and that there were group meetings. There were minutes of staff meetings, and the Manager said that these will be held regularly. Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect. Systems that need to be in place to ensure the quality and safety of the service are still in development. EVIDENCE: Ms Samantha Gomm has been recently registered as the Manager of Pine Tree Lodge, and consequently has the necessary skills and competencies. She is currently undertaking a qualification in relation to running a care home. Ms Gomm has instigated systems for seeking the views of people who have contact with the service; there was a record of this feedback. The Inspector discussed with Ms Gomm the need to show how issues raised have been dealt with. As a company runs Pine Tree Lodge, monthly unannounced visits are required to be made by a representative of the company. Reports must be Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 22 made of these visits and copies of these reports sent to the Commission. No such reports have been received, although a letter has been received confirming that visits have been made. These visits are one of the ways that Sheval Ltd can monitor the quality of care provided. The Inspector looked at the Fire Risk Assessment, it was not clear from this document how frequently staff should be trained in relation to fire. The record of checks made on the fire system appeared only to relate to the fire extinguishers, there were no other checks on other aspects of the fire system (emergency lighting or call points). No Legionella risk assessment was available, and whilst the Inspector was told that checks had been made on portable electrical appliances, no record of these checks had been made. There were risk assessments in relation to other aspects of health and safety, and it was clear that work had started to not only improve the physical environment but to make it safe. Pine Tree Lodge DS0000069209.V341354.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 Adults 18-65 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 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 2 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x x 2 x Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The “Statement of Purpose” must be up to date and contain all the information specified in the regulations. A copy of this document must be sent to the Commission. This document tells people about the service Pine Tree Lodge is to provide. Money belonging to Service Users must not paid into any account relating to the running of the business. People must not be exposed to unnecessary risks. There must be a written record of how risks are managed. This should include the risk of falls, the risk posed by the use of bedrails and those caused by unprotected hot surfaces (radiators). Each Service Users must be offered the opportunity to participate in activities and to develop their interests. Each Service Users must be given the opportunity to use community facilities such as shops and the hairdresser. Service Users must be offered a diet that is not only to their taste DS0000069209.V341354.R01.S.doc Timescale for action 01/09/07 2. YA7 20 (1) 01/11/07 3. YA9 13 (4) (c) 01/09/07 4. YA12 16 (2) (n) 01/10/07 5. YA13 16 (2) (n) 01/10/07 6. YA17 16 (2) (i) 01/10/07 Pine Tree Lodge Version 5.2 Page 25 7. 8. YA19 YA20 16 (2) (k) 13 (2) 9. 10. 11. YA26 YA30 YA34 16(2)(c) 16 (2) (k) 19 12. YA39 26 13. YA42 13 (4) (c) but also meets their nutritional needs. Service Users continence must be managed so that neither they nor their home smells. The medication system needs to be improved so that there are good stock records for all drugs but particularly those used to control epilepsy. There should be clear guidance the circumstances when “as required medication” should be given. Bedding and mattresses must be comfortable for the people who use them. Pine Tree Lodge must be kept free from unpleasant odours. Pre employment recruitment checks must be made to ensure that only staff suitable to work with vulnerable people are recruited. This must include two written references, and checks on criminal records and “POVA” List. The Registered Provider must ensure monthly-unannounced visits are made to report on the conduct of the home. Copies of these reports should be sent to the Commission. The people at Pine Tree Lodge must be protected from unnecessary risks. Environmental Risk Assessments, including those in relation to fire and Legionella infection, must be reviewed so that it is clear what the risks are and how they will be managed. 01/08/07 01/09/07 01/09/07 01/09/07 01/09/07 01/09/07 01/10/07 Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pine Tree Lodge DS0000069209.V341354.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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