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Inspection on 09/01/07 for Pine Heath Nursing Home

Also see our care home review for Pine Heath Nursing Home for more information

This inspection was carried out on 9th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Resident`s enjoy very good relationships with the staff at this home and feel well cared for. The way staff speak to resident`s is appropriate and based onfriendship. There was plenty of laughter heard during the day. Residents were happy and relaxed. Residents say that their choices and preferences are understood and respected by staff. Many examples of this were given and it was evident that residents feel in control of their daily living. Some residents invited me to look in their rooms. All the rooms seen were clean and tidy. The rooms contained important personal items to make it feel like home.

What has improved since the last inspection?

The number of staff on duty has improved. As a result, resident`s said they received the care they needed when they wanted it. They also described how quickly staff answered call bells and were able to sit and chat to them. Some staff have received training about adult abuse. Not all staff are sure about some of the policies at the home that are about protecting people from abuse. As a result, more training in this subject is needed.

What the care home could do better:

The records kept about the care given to residents needs to improve. Some of the difficulties currently experienced is because of the changes made to the residents looked after at the home. Nurses left the home and the responsibility for completing these documents now falls to the senior care staff for the first time. For the same reasons, staff do not receive supervision at the moment. The home has an opportunity to improve the documents they use as part of a review of staff supervision. Some records required for inspection were not available and it was agreed they would be sent on to the Commission. They had not been received by 18th January 2007. There is no record held at the home that details monthly visits by the owners. These are a legal requirement and the owners have been advised of this before. The home has not complied in full with all the requirements made at the last inspection. The requirements are repeated as necessary and it is essential that the home meet all the requirements within the timescales.

CARE HOMES FOR OLDER PEOPLE Pine Heath Nursing Home Cromer Road High Kelling Holt Norfolk NR25 6QD Lead Inspector Mrs Geraldine Allen Unannounced Inspection 9th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pine Heath Nursing Home DS0000015672.V326752.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. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Heath Nursing Home Address Cromer Road High Kelling Holt Norfolk NR25 6QD 01263 711429 01263 711488 diane.varrall@virgin.net 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) Diamond Care (UK) Limited Diane Lynne Varrall Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42) of places Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Pine Heath is a care home providing personal care and accommodation for up to 42 older people, some of whom may have dementia. It is owned by Diamond Care (UK) Ltd. The home is located on the main road between Holt and Cromer. The home consists of a two-storey building. Most of the rooms are single and of a good size. There is a passenger lift to allow easy access to all communal areas and private space. Communal space is limited, with the lounge accommodation half of what it should be for the number of registered places. However a large room just off the registered accommodation has been made into an activities room and is bright and airy. Activities take place in there every day. The grounds are attractive and extensive though would benefit from some concrete walkways so service users could enjoy them more. The manager confirmed that the fee range at the time of inspection was between £338.50 and £500.00, dependent upon the size and standard of accommodation. The fee payable can be provided in writing on request before a resident enters the home. The amount payable is included in the terms and conditions of residence given to all residents or their representative. Any changes to the fee are advised in writing. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 9th January 2007. On the day of inspection, 30 older people were living at the home. Information was obtained from a variety of sources and was used to provide evidence of the standard of care given at this home. The manager, Ms Varrall, was not present for the inspection during the morning, but staff on duty were very helpful and provided the requested information where they could. Before the inspection took place, Ms Varrall, completed and returned a preinspection questionnaire. Questionnaires were sent to the home by the Commission for residents and relatives to complete. Only 2 residents completed and returned questionnaires. None were received from relatives or visitors to the home. As a result, it was difficult to understand what people thought about the care given at the home. On the day of inspection, various records were looked at including records kept about the care given to residents, files kept about staff, records kept about resident’s personal allowances and also records about health and safety arrangements. In addition, most residents were seen and spoken to during the day, with 3 residents being spoken to in depth. Staff on duty were also seen, with 3 staff being spoken to in private. A tour of the premises took place and lunch was eaten with residents in the dining room. Ms Varrall was not able to provide some information at the time of inspection and it was agreed that she would forward the required information for the beginning of week commencing 15th January 2007. This had not been received by the Commission by 18th January 2007 and it was necessary to finish the draft report at the time. Overall, it was found that care provided is adequate. The standard of some of the records seen was poor, however the experience for resident’s living at this home was good. Timescales for improvements have been agreed with Ms Varrall and the home will be assessed again when the dates have passed to ensure the home fully complies with the requirements. Some of the requirements made have been repeated from the last inspection, as they have not been met in full. It is essential that the home meet all the requirements within the timescales or enforcement action will be considered. What the service does well: Resident’s enjoy very good relationships with the staff at this home and feel well cared for. The way staff speak to resident’s is appropriate and based on Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 6 friendship. There was plenty of laughter heard during the day. Residents were happy and relaxed. Residents say that their choices and preferences are understood and respected by staff. Many examples of this were given and it was evident that residents feel in control of their daily living. Some residents invited me to look in their rooms. All the rooms seen were clean and tidy. The rooms contained important personal items to make it feel like home. 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. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents have a needs assessment completed before moving into the home. This needs to be developed to include more information about social, emotional and spiritual needs so that staff have a full understanding about the individual. Standardised assessment documents need to be used to ensure all aspects of care are considered as part of the assessment process. EVIDENCE: Three care plans were looked at in detail. These showed that the needs assessments were variable in detail and standard. None had been signed or dated. One had been completed on a piece of paper rather than the needs assessment format. All assessments were task orientated and social, emotional and spiritual needs were not clearly identified. Ms Varrall is aware that work is needed on the assessment and care planning process. One resident confirmed she had visited the home before she decided to live there. She had been shown around and had seen the room she subsequently Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 9 moved in to. Ms Varrall confirmed that residents or their representatives were invited to visit the home and to see the rooms available. Ms Varrall confirmed that current practice was to put the fee rate in writing prior to moving into the home only if this was requested. The fee rate is included in the terms of residence provided to each resident. These were seen on file. The service provider advises changes to fee rates in writing. The home does not provide intermediate care. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records that detail the care to be provided to each resident is not as good as it should be and staff are keen to improve the content and standard of the records. There was evidence that residents receive health care in a timely way. The home has good practices in place for the control and administration of medicines. Staff are employed in sufficient numbers to meet the needs of residents in the way and at the time that suits the resident. Improvements to the environment need to be made to ensure the privacy and dignity of residents is protected, especially when they are using the toilet and bathing facilities. EVIDENCE: Three records of care given to residents were looked at in detail. Some information is held in the treatment room and some in the resident’s own bedroom. The standard of the records seen was variable and the type of information to be kept did not comply with legal requirements. For example, none included marital status and none had a photograph of the resident. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 11 Information about which doctor provided medical care was not always accurate. These records were discussed with Ms Varrall and also separately with staff on duty. All acknowledged there needs to be improvement in content, layout and standard of recording. Until the homes recent change in resident category, nursing staff were responsible for completing and reviewing the care plans. Care staff now have this responsibility and are still learning. Ms Varrall is aware of the work needed and it was agreed that care records would be reviewed after 3-months to allow staff time to review current care plans and implement new formats. Staff handover at the start of the afternoon shift was attended. Issues concerning each resident were discussed openly and the process allowed good transfer of information to take place to encourage continuity. The need to ensure that confidentiality is maintained was discussed with 2 staff. The arrangements for looking after and dispensing medicines was looked at. A member of staff was discreetly observed administering medicines at lunchtime. The practice seen was safe and followed the home’s procedures. The arrangements for medicines were also discussed with 2 staff in detail. The senior carer confirmed she had received training in-house and felt confident about medicines, especially as the pharmacist has now changed the way medicines are packaged. The records were up to date and easy to read. Medicines were stored in locked trolleys. Evidence of the GP agreement for the use of homely remedies was seen. Controlled medicines were stored in a locked wall cabinet that also contained the register. Three residents were spoken to at length during lunch. They confirmed that staff were quick to respond to their call bells and respected their wishes if they wished to stay in bed for a while. They felt there were enough staff about to give them the care and time they wanted. One said that the staff were always popping in to speak to her. The interaction between staff and residents was observed throughout the day. Staff treated residents with respect and interactions were friendly and jovial. Residents said they felt well cared for and that staff were kind and thoughtful. One stated that “nothing is too much trouble” and another that “you can have a laugh with them, they are lovely”. The residents said staff were approachable and they felt they could speak with any of them if the had a worry. They described staff as reliable, always doing what they said they would do. Ms Varrall provided copies of letters recently received at the home from relatives. These used expressions such as comfortable, dignified, happy, content clean and well cared for to describe their relative’s experience of the care at this home. There were also references to the friendliness of the staff. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 12 Some of the communal toilet facilities do not protect the privacy and dignity of residents. Some of the toilets are not large enough. As a result, the lobby of the toilet rooms containing multiple toilet cubicles are used, with commodes placed in this area. There is no lock to these doors and the dignity and privacy of residents is therefore compromised. This was discussed with Ms Varrall and it was suggested that “engaged” signs, as a minimum should be fitted to the doors. This also applies to bathing facilities. Pine Heath Nursing Home DS0000015672.V326752.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. Residents described good experiences of living at the home. They felt they were in control of their daily living and were confident staff would respect their choices. Residents said their visitors were welcome at any time. Residents said they enjoy food that is well prepared and tasty. EVIDENCE: Three residents were spoken to in depth. They described the choices they are able to make around their daily living and confirmed that staff respected the decisions they made and complied with them. For example, one resident said he often likes to lay in bed in the morning. He said he just tells staff and they return later to see if he is ready to get up. The residents also described making choices about where they spend their day. They spoke about the activities organiser and how she arranges various activities and events they could go to if they wished “but we don’t have to”. A resident said she was impressed with the laundry service provided at the home and that her clothes were always laundered over night and returned to her for the morning in good condition. One resident said he liked to watch his television in his own room and was happy to be left to do this. Another resident said she liked to read but Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 14 she also has plenty of visitors who were always made welcome at any time. She said that staff will offer refreshment and have also invited her visitors to stay for a meal. One resident said she had enjoyed her Christmas, describing it as “the best I have ever had”. They all spoke about the “excellent” and “traditional” Christmas lunch. A meal was eaten with residents and observations of the care and support over this period were made. One resident required assistance to eat. A member of staff who sat beside him and gave discreet help throughout the meal provided this. Residents said choices for their main meal were established the day before. All 3 residents said the food was always good and that there was plenty of it. Most plates were cleared, with very little waste being observed. Most ingredients were fresh and the food was well presented. Residents served in their bedrooms had their meals presented on trays with covers over the plates. The dining room was appropriately laid out so that residents had space to get to the table. Tables were attractively laid with cloths, paper napkins, vases of artificial flowers and condiments. Pine Heath Nursing Home DS0000015672.V326752.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good complaints procedures in place that are well known. Residents feel able to discuss any concerns with staff. The home has adult abuse policies in place but not all staff know them. All staff need to receive adult abuse awareness training. EVIDENCE: Residents said they were aware of the complaints procedure and felt able to discuss any worries or concerns with any member of staff. Copies of the complaints procedure were seen in the care records kept in the resident’s rooms. The home has investigated 2 complaints since the last inspection. Both were dealt with within 28 days. One of the complaints was partly upheld. Three staff were spoken to in private during the course of the day. Not all staff were aware of the home’s abuse policy. A copy of the policy was seen in Ms Varrall’s office. Some training in abuse awareness had been done last year but not all staff have attended. The need to ensure all staff received this training was discussed with Ms Varrall. Staff were aware of the whistle blowing policy. Three staff files were looked at in detail. It was only possible to confirm on 1 file that Criminal Records Bureau checks had been obtained. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and is in a good state of decoration. Resident’s bedrooms were clean and tidy, with personal items seen that made the rooms more homely. The home needs to ensure residents’ privacy and dignity is maintained by fitting either locks and/or engaged signs to all toilet and bathroom doors. The drains and drain covers in the converted shower rooms are raised and may cause a resident to trip. They need to be removed and the surface made even. Rusty toilet frames need to be replaced as they are unhygienic. EVIDENCE: A tour of the premises was undertaken with a senior carer in charge during the morning. All rooms on the ground floor were seen, and some rooms on the first floor were looked at. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 17 All bedrooms seen were clean and tidy and were furnished and decorated in the way the resident wished. Some bedrooms had recently been decorated. Bedrooms were of varying sizes and some have very high windows that do not allow residents to see out if seated. The member of staff said residents who do not stay in their bedrooms during the day were be accommodated in these rooms. Two bedrooms have en-suite facilities. Toilets and bathrooms were situated close to bedrooms. As previously stated, where toilets are too small, residents use a commode in the toilet lobby. The doors to all toilets and bathrooms need to either have locks fitted or “engaged” signs attached to ensure privacy and dignity are maintained. Toilets have also been converted from shower rooms but still have the drain and drain cover in place, representing a trip hazard for the visually impaired and those with mobility problems. A rusty frame was also seen on the toilets. Various bathing aids are available, including assisted baths such as a Parker bath and chair hoist. Unassisted baths are also available. The bathrooms were clean but rather clinical and would benefit from domestic decoration such as plants and pictures. All areas of the home were clean and tidy and no unpleasant odours were detected. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27. 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence to show that the home does not follow a good recruitment procedure that protects residents. All staff files need to be reviewed and kept in the same way so that information is easy to find. Any gaps in staff files need to be filled with the appropriate information being obtained where necessary. Staff say they receive training relevant to their role and feel well supported. The home employs sufficient staff on each shift to meet the individual needs of residents. EVIDENCE: A copy of the rota for the month of inspection was obtained. Three staff files were looked at in detail, 1 was for an overseas staff, and 3 staff were spoken to in private. Staff files were variable in terms of information held. There were important gaps in the information held. The staff files need to be reviewed and missing checks and information needs to be obtained. It was agreed that the home would be given 2 months to complete this task. Ms Varrall confirmed that all staff receive induction training and a blank copy of the training was seen. Staff keep their induction training record once complete. The induction training covers all aspects of care. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 19 It was agreed that Ms Varrall would send a copy of the training plan for 2007 as she was not able to access the document at the time of inspection. The training plan had not been received by 18th January 2007 and it was not possible to obtain evidence of the staff training that has taken place since the last inspection. Staff said they felt they received training in subjects that were relevant to their role. They felt well supported and were able to get advice and guidance from Ms Varrall and senior staff if needed. The staff rota showed that the home employs staff in sufficient numbers to ensure resident’s needs are well met. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ms Varrall is well qualified, experienced and competent. A copy of the quality assurance assessment needs to be forwarded to the Commission, together with an improvement plan. This is to demonstrate that the views of residents, relatives and other people involved with the home are sought and acted upon. The home operates good procedures for looking after resident’s personal allowances so that the risk of financial abuse is reduced. Staff were not receiving supervision at the time of inspection. Some of the records seen need to be improved and staff trained to ensure good standards are developed and maintained. The service provider makes monthly visits to the home but does not provide a written report of his visit to either the home or the Commission. The home is maintained to a good and safe standard although some areas for improvement have been identified elsewhere in this report. EVIDENCE: Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 21 Information was obtained by looking at records, speaking with residents and staff and also Ms Varrall. Ms Varrall said she has been registered as manager at this home for 3 ½ years. She is also a registered nurse. A copy of the quality assurance summary and improvement plan was not available at the time of inspection. It was agreed that a copy would be forwarded to the Commission early in the week commencing 15th January 2007. This had not been received by 18th January 2007. Ms Varrall said she keeps all letters and cards received from relatives and produced a selection for viewing. The arrangements for looking after resident’s personal allowances were looked at with one of the administrators. The home currently looks after the personal allowances for 21 residents. Monies were kept in a locked cash tin within a locked filing cabinet. Each resident had a clear, zipped, plastic wallet and a cashbook. The cashbooks detail income, expenditure and a running total. The administrator initials for each transaction but was advised that best practice requires 2 signatures for each transaction. Two staff described the interim period whilst the home was changing from nursing to residential care. Both agreed it had been a difficult period. The senior carer referred to the significant changes to her role and the knowledge she needed to have. Both felt they had been well supported. Ms Varrall said supervision is not currently taking place. Senior staff will be responsible for staff supervision and are yet to receive training to do this. It was suggested that supervision documentation should be developed so that a copy is accessible to Ms Varrall for monitoring the standard and content of the supervision being provided by the senior staff. The records seen included records of care needed and provided, resident’s personal allowances, medication records and staff files and staff rotas. Some records were not available or are to be updated for inspection purposes and forwarded by the beginning of w/c 15/1/07. Those to be forwarded are the staff training record & staff training plan for 2007 and the Quality Assurance summary. These had not been received as at 18th January 2007. Ms Varrall said that, the owner visits the home regularly but he does not provide a visit report. Staff have received health & safety training that includes fire safety, risk assessment and moving and handling. That the last recorded training events seen were August 2005. Accident records were looked at. These showed that accident records are completed correctly and in a timely way. During the course of this inspection, a contractor was conducting fire safety maintenance. Risk assessments were seen. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 1 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 X 18 2 2 x 2 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 2 2 Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered persons must ensure that a service user’s plan is in place for all service users. Care plans must be developed in compliance with Schedule 3 of the Care Homes Regulations 2001. The registered persons must ensure that resident’s privacy & dignity is respected at all times and particularly when personal care is provided. The registered persons must ensure all staff receive training about abuse awareness and are fully conversant with the home’s policies and procedures in this regard. The registered persons must ensure all toilet and bathing facilities have privacy locks or engaged signs fitted. The registered persons must ensure that the hazards presented by the drain covers in the converted shower rooms are effectively dealt with to prevent accidents. The registered persons must DS0000015672.V326752.R01.S.doc Timescale for action 10/04/07 2 OP10 12(4)(a) 23/01/07 3 OP18 13(6) 13/03/07 4 OP21 12(4)(a) 23/01/07 5 OP19 13(4)(a) 13/03/07 6 OP29 18(1)(a) 23/01/07 Page 24 Pine Heath Nursing Home Version 5.2 7 OP29 18 & 19 8 OP30 18(1) 9 OP33 24(1) 10 OP36 18(2)(a) 11 OP37 26 ensure that robust recruitment procedures are used at all times and that documentary evidence of this process is kept available for inspection purposes. The registered persons must ensure that a staff file is kept for all staff in accordance with Schedule 2 of the Care Homes Regulations 2001. The registered persons must ensure a record of all staff training is maintained. This requirement is repeated. The registered persons must ensure a copy of the quality assurance summary is forwarded, together with any improvement plan made as a result. The registered persons must ensure that all staff receive recorded supervision at least 6 times per year. This requirement is repeated. The registered provider must ensure that visits to the home are made monthly and that a copy of the visit report is sent to the Commission. This requirement is repeated. 13/03/07 23/01/07 13/03/07 13/03/07 13/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 OP3 Good Practice Recommendations It is recommended that pre-admission assessments include elements about social, emotional and physical care as well as the physical needs of the resident. It is recommended that a standard document is used for all pre-admission assessments to ensure all aspects of DS0000015672.V326752.R01.S.doc Version 5.2 Page 25 Pine Heath Nursing Home 3 4 OP26 OP35 care are considered. The rusty toilet frames need to be replaced as they are unhygienic. Two signatures should be obtained for all financial transactions undertaken on behalf of residents. Pine Heath Nursing Home DS0000015672.V326752.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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