Inspection on 12/09/07 for Pine Lodge

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pine Lodge 06/08/08

Pine Lodge 14/06/06

Pine Lodge 15/03/06

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Pine Lodge Blundell Avenue Freshfield Formby Merseyside L37 1PH Lead Inspector Ms Lorraine Farrar Key Unannounced Inspection 12th September 2007 01:30 Pine Lodge DS0000063016.V345660.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 Lodge DS0000063016.V345660.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 Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Lodge Address Blundell Avenue Freshfield Formby Merseyside L37 1PH 01704 872133 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) jennymcggotadsl.co.uk The Frances Taylor Foundation Mrs Jennifer McGibbon Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 Brief Description of the Service: Pine Lodge provides accommodation and support with nursing care for 12 adults who have a learning disability. Many of the people living there also have physical disabilities and the service provides aids and adaptations to meet their needs. There are care staff available 24 hours a day, during the day there is a registered nurse in Pine Lodge whilst at night a registered nurse is based in there but shared with two other registered care homes located nearby. Pine Lodge is owned and operated by the Francis Taylor Foundation, a national organisation who provide services for people with a variety of support needs. The registered Manager of the home is Mrs Jenny McGibbon and the registered Responsible Individual for the organisation is Mr Terry Maguire. Pine Lodge is located in the middle of Formby Pinewoods and shares the site with, two other registered homes, a day centre for 65 people and a convent. All the services support adults who have a learning disability. Services share transport, kitchen facilities, large grounds and some administrative support. Most of the bedrooms are single rooms, where two people share there are screens provided for privacy. All service users have their own toilet, which is either in or near to, their bedroom and is adapted to meet their needs. There is a dining room, several seating areas, adapted bathrooms, a small kitchen within the unit and a small, private, courtyard outside. It currently costs between £900 and £1,100 pounds each week to live at Pine Lodge. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this inspection was gathered in a number of different ways. Any information the CSCI has received regarding the service is taken into consideration. An unannounced site visit took place on the 12th September 2007 where time was spent reading records and looking at the building. A system called ‘Case tracking’ was used as part of the visit. This involves looking at the support a person gets including their care plans, medication, money and bedroom, time is also spent meeting with people who live there and with staff about how they meet the persons needs and choices. Case tracking was used to look at life in the home for three of the people living there. Discussions took place with three members of staff including the manager and the inspector met six of the people living there and observed daily life at Pine Lodge. The manager contributed to the inspection by filling in a pre-inspection assessment and relatives of the people living there had the opportunity to give their views by filling in comment cards before the inspection. Five relatives completed comment cards and their views are incorporated into this report. An expert by experience was also present during part of the site visit. An expert by experience is someone who has experience of using services for adults with a learning disability and has received training in taking part in and contributing to the CSCI inspection process. The expert spent time looking at the environment at Pine Lodge and meeting with the people who live there and staff, focusing in particular on choices offered to people and opportunities for taking part in activities. Following the site visit she prepared a report of her findings and her views are included within this inspection report. An easy to understand summary of this report is available. If you would like to see a copy please ask the staff working at Pine Lodge. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last key inspection of Pine Lodge in June 2007 clearer records are kept of the recruitment checks carried out for new staff. These checks help to ensure that staff are suitable and safe to work with the people who live there. The majority of care plans and risk assessments for the people living at Pine Lodge are up to date and contain clear guidance and information about how to support the person in a way that meet their needs and choices. Meal times have improved with people offered a choice of meals and places to sit. Staff take time to support people on a one to one basis where needed and the atmosphere is unrushed and peaceful. Work has commenced in refurbishing some communal areas with a large TV and comfortable sitting chairs provided in the large lounge and dining room. This helps to make the environment more comfortable and homely for the people living there. Staff have received training in fire procedures and in supporting people who have their meals via a peg tube. This helps to ensure that they are supporting people safely and in line with current good practice. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is obtained about and provided to new service users to enable people to decide if the service can meet their needs and choices. EVIDENCE: Care records were looked at for one person who has moved into Pine lodge within the past few months. These showed that before the person moved in staff met with them and their family and Social Worker to discuss the persons needs and choices. An assessment was carried out which covered their health and personal care needs, the way they communicate and their social interests. In addition staff obtained a copy of their assessment and care plan written by Social Services. This level of information helps everyone to decide if the care service will be suited to meet the persons needs and their choices. Relatives said that they usually get enough information to help them make decisions about the service. One relative commented that they would find a regular newsletter useful to keep them fully informed. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 10 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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples individual needs and choices are generally recognised and met within the service. EVIDENCE: Relatives of the people living at Pine Lodge said that they feel the service always or usually meets the needs of the people who live there. One commented that there had been a couple of occasions when this had not occurred however senior staff had dealt with this when it was raised. Another commented that, “staff are aware of the individual needs of the residents, their eating and sleeping habits, and are constantly making sure that they are stimulated and entertained wherever possible.” Individual care plans and records are compiled for everyone living at Pine Lodge. These state that they are written with input from their family and keyworkers along with observations of the person in daily life. The input from a variety of people involved in the persons life ensures that as full a picture of the person is obtained as possible. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 11 Three care plans were looked at during the site visit. One had information missing which the manager advised had been taken to be reviewed by a senior manager within the organisation. A lack of readily available and up to date information and guidelines regarding a persons care and recent life may lead to staff not having sufficient information available to support the person correctly. This could impact on the quality and consistency of care offered to the person and potentially place them at risk. The other plans contained information about the support the persons needs with their health and personal care along with their social interests and likes and dislikes. Clear information was recorded about the different ways people communicate and how to respond to this. For example one health plan gave clear guidance on how to recognise whether the person was in pain. This helps to ensure that staff are all aware of and know how to respond to and meet the persons needs and choices. These plans also contained copies of risk assessments for the person that cover activities they may be involved with along with risks to their health. These assessments identify any risks to the person and given guidance on how they can be minimised. Plans and risk assessments had been reviewed recently and updated where needed to ensure the information was still relevant. Records showed that people are able to make decisions within their capabilities. For example staff understand their non-verbal communications and support them to get up or go to bed when they choose and to take part in activities they enjoy. Where decisions are made by other people there are records of this. For example two plans recorded that the person has their medication within their food. Guidelines made it clear the person is to be informed of this and that it was to make it easier for them to take. Senior staff, their family and GP had signed the guidelines. The use of formal records and consulting with a variety of people helps to ensure that decisions taken on behalf of the person are in their best interests. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 12 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 14 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at Pine Lodge are supported to live the lifestyle of their choice. Further opportunities to spend time away from the site may benefit peoples overall lifestyle opportunities. EVIDENCE: Relatives of the people living at Pine Lodge sad that the service always or usually meets peoples different needs. Their comments included, “people are treated with respect. They are given the opportunity to go to church. Their families can also go if they want” and “(my relative) is offered a choice of activities and enjoys outings related to music. Staff know him well and tailor experiences to add to the quality of his life”. The expert by experience spent time meeting with service users and staff and commented that, “I feel the people who live at Pine Lodge are happy. They seemed to have lots of choices and staff seemed to help them chose what they would like to do on a daily basis.” Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 13 Staff were able to explain to the expert by experience and the inspector the different activities people enjoy and the way they like to spend their time at home. Bedrooms were personalised to suit the persons choices, for example one man who enjoys football had a colour themed room with football posters and a large TV to watch matches on. There is an on site day centre called Fernley on the site. This is operated by the same organisation and provides a service to adults who have a learning disability and live in the local community as well as people who live in the care homes on site. In addition to the day centre there is also a well equipped hydrotherapy pool, which staff from the day centre are qualified to use. The people living at Pine Lodge attend the resource centre four days a week, spending the fifth day at home or engaged in activities within the local community. Religious services are held on site every Sunday which people are supported to attend if they wish. Everyone is able to go on an annual holiday with some people having recently retuned from a holiday in Blackpool. Staff explained that they had discovered during this holiday that some people enjoyed watching Crown Green Bowling and they are now seeking a place nearby where people can go to watch this activity regularly. Records showed that people are getting out and about, for example they now use local services such as the hairdresser and dentist rather than having home visits. People are also supported to get to e some events in the community they enjoy. One plan showed that the person enjoys lively events and music and in the past couple of months she had been supported to go to pop concerts, the theatre, a disco and on holiday. Records are not always maintained of the things people enjoy at home. For example one plan said the person enjoyed playing the piano, although staff said they supported him with this, there were no records that this support had been provided recently. The lack of accurate records, particularly for people who cannot make verbal requests could lead to them not regularly being offered the opportunity to engage in activities at home that they enjoy. Relatives said that staff help the people living at Pine Lodge to keep in touch and one relative commented, “we are able to visit at any time and are made very welcome by staff”. Routines within Pine Lodge are sometimes flexible. For example everyone attends the on site resource centre and nobody living there currently attends local colleges or adult education facilities within the local community. This lessens the opportunity available to people to become members of their local community and get out and about more regularly. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 14 People are able to get up and go to bed when they choose and staff try to provide support based around peoples individual needs. One lady likes to eat her meal in peace and quiet as soon as she returns home and this support was seen to be provided during the site visit. There is a large kitchen on site, which provides meals for all the different services. Within Pine Lodge there is a smaller kitchen used to make breakfast, drinks and snacks. A choice of three meals is offered at lunch and teatime along with a choice of desserts. These choices include plenty of fruit and vegetables to offer people a healthy diet. Part of the evening meal was observed during the visit. People were supported to use adapted cutlery and crockery and to have one to one support from staff if needed. Meals are staggered so that only the people currently being supported are in the dining area. This helps to offer people a peaceful time in which to eat their meal, without distractions or having to wait too long. Staff were seen to sit with people and take their time, offering support and chatting with the person. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the people living at Pine Lodge are recognised and met within the service. EVIDENCE: Relatives of the people living at Pine Lodge said that the service always or usually gives the support to people that is agreed. Their comments included, “(my relative) is a much loved resident. Her needs are anticipated, reviewed and the appropriate measures are taken to ensure the wellbeing of a happy resident” and “the personal care given to (my relative) is superb. The standard of care is without equal in my experience”. Care plans contain health action plans, which give clear information about the persons health and the support they need. This includes information on the aids and adaptations the person uses, any specific health issues they may have and how to identity if they are in pain. Plans also contain information about the personal care needs people have and the way they need and prefer this support to be offered. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 16 Clear information is recorded about how to support the person to meet their care needs and good practice was noted in that the emotional support one person required with aspects of their health care was clearly recorded, along with how this support is provided. Assessments of people health and personal care needs are regularly carried out and records maintained of their weight and any seizures they have are also maintained. This helps to quickly identify and take action on any changes to the support the person may require. Staff were aware of and able to explain the support they provide to people with their health and personal care and how people demonstrate their choices in this area. Records showed that the people living at Pine Lodge receive regular support to see health professionals such as the dietician, GP and consultants. Service users medication is stored in a locked room with a secure trolley available for times it is taken into the communal areas. Records were clear with checks being carried out on medication received into and returned from the service and records of medication given clearly recorded. This helps to provide a clear audit trail and prevent mistakes occurring. Medication was stored correctly and in line with manufacturers instructions. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are listened to and acted upon at Pine Lodge. However a couple of incidents within the service may lead to the people living there not feeling safe within their home. EVIDENCE: Relatives of the people living at Pine Lodge said that they know how to raise any concerns they have and the service always or usually responds appropriately to this. Their comments included, “I would normally contact the manager on a personal basis. However there is a leaflet in the entrance explaining the official procedure” and “I feel free to make any comments to staff or ask questions. I know if I wanted to make a complaint staff would enable me to do it”. There are polices in place to guide staff in dealing with any complaints or adult protection issues and staff have received training in this area. There have been a couple if incidents within the service whereby people living there have been assaulted by other people living there. Although these incidents were dealt with and investigated and some steps taken to prevent them occurring again, this may lead to people not feeling safe within their own home. Records of money held in the home for three people were checked. Receipts are provided and the records tallied with the amount of money recorded. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 18 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, 26 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pine Lodge provides a safe, comfortable home for people to live in. Some areas do not appear homely and would benefit from re-decoration. EVIDENCE: A relative of one of the people living at Pine Lodge commented, “ the entrance hall and the communal rooms could do with smartening up, they are rather dismal. Having said this the private rooms of the residents were completely made over about 15 months ago”. The expert by experience noted during a tour of the building that, “all of the bedrooms are done in the colours that the residents want. They get to pick the colours they like and the furniture they want for their bedroom. The bedrooms are all done in lovely colours. Pine Lodge is very clean.” Pine Lodge is in the middle of Formby pinewoods and although in scenic surroundings it is quite isolated from the nearby community. As a purpose Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 19 built care home it does not fit in with other properties in the local area and is instantly recognisable as a care facility. Shared areas include, a large dining room and living room, a small lounge and a sensory room a seating area in the corridor, bathrooms a kitchen and small courtyard. Pine Lodge shares extensive grounds and parking with other services on the site. All areas of the building are accessible to people with mobility difficulties and there is a variety of equipment to meet peoples needs in this area. This includes, adapted toilets and baths, moving and handling equipment and an electric door to the main building. An accessible shower room has been created which offers people a choice of facilities for their personal care. Bedrooms are furnished and decorated to a high standard and personalised by the person or their representative. The communal areas are not as homely or well decorated and furnished. However the large dining room and lounge has been recently furnished with comfortable chairs and a large TV, which provides a more comfortable and inviting place for people to sit. Other lounges have mis-matched furniture and the decoration in corridors is ripped in places. However staff advised that there are plans in place to decorate corridors within the next few months. Everyone living at Pine lodge has a designated toilet, which is decorated and furnished with aids and adaptations to suit their needs. Most people have their own bedroom. In the shared room screens are provided to offer privacy when needed. One person has a buzzer fitted to their bedroom door. This helps to alert staff that the person is leaving their room so they can offer support. However this buzzer is very loud and may disturb the sleep of other people nearby. There is a separate laundry room with industrial washing and drying machines, clear systems are in place for minimising the risk of cross infection with laundry and the environment was observed to be clean and pleasantly smelling throughout. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 20 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, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at Pine Lodge are supported by a staff team who can meet their needs and choices. However a high turnover of staff may lead to service users feeling un-settled. EVIDENCE: Relatives of the people living at Pine Lodge said that they feel staff always or usually have the skills and experience to support people. However several relatives expressed concern regarding the turnover of staff within the service. Their comments included, “there has been a tremendous turnover of staff”, and “ an improvement in staff retention might benefit the residents further, as consistency in care is very important in order for residents to build a relationship with and have confidence in, their carer.” During the site visit, staff the inspector and expert by experience spoke with, were able to explain how they support the people living there, understand their non verbal communication methods, and the things people do and do not enjoy doing. The expert by experience commented, “the staff there are very nice and friendly. The staff I met are very helpful and love there jobs, they love the Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 21 residents they work with and seemed to do there best to make sure they where happy.” The manager explained that there has been a turnover of staff within the past year, however they are in the process of recruiting to vacant posts and she hopes to have a stable team in place soon. Three staff files were looked at as part of the site visit, they showed that checks are carried out on staff before they start working at Pine Lodge. These checks include obtaining two written references, a Criminal Records Bureau check (CRB) and check of the protection of vulnerable adults list. These recruitment checks help to ensure that staff are safe and suitable to work with the people who live at Pine Lodge. Records and discussions with staff showed that they are supported to access training in basic care practices. This includes, fire, moving and handling people and the protection of vulnerable adults. In addition staff undertake training in more specialist areas such as use of peg feeds, dealing with conflict and communicating with people. New staff undertake a nationally agreed induction course, which provides information about how to support people safely and in line with current good practice. The training provides helps to ensure staff have the knowledge and skills to support people safely and meet their needs and choices. Some staff have achieved a qualification in care (NVQ) and other staff stated that they would like to undertake this course but have not yet had the opportunity. This is a national qualification, which ensures staff are aware of and provide good care and support in their daily work. . Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 22 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. Pine Lodge is managed safely for the people who live there. Planned quality assurance checks will help to ensure the service is of a good quality and continually improving. EVIDENCE: Mrs Jenny McGibbon is the registered manager of Pine Lodge. She holds a registered nurse qualification for working with people with learning disabilities and has worked in a management capacity for some time. She does not currently hold a management qualification but explained she is working towards this and hopes to complete it in the near future. The manager has just introduced quality audit checks within the service. The first check was carried out in August 2007 and covered the support offered to Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 23 people with their care plans, medication activities and social needs. The deputy manager explained that they plan to put together a review sheet so that actions to be taken can be recorded and monitored. The organisation employ a member of staff who is due to visit Pine Lodge shortly to carry out an audit of the service based on national standards of care for adults. Once these checks and audits are established they will help to ensure the quality of the service offered and to plan future improvements. Certificates and records showed that regular checks are carried out on equipment and the building to ensure it is a safe place to live in. This includes checking fire equipment is working and that gas and electrical supplies are safe. Staff receive training in areas of health and safety such as food hygiene and fire, which helps them to support the people living at Pine Lodge safely. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 24 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 X 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 4 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA6 Regulation 17(1)(a) Requirement All current care records relating to people living at Pine Lodge must be maintained on site. This will ensure staff have access to all the information required to support people safely and in the way they prefer. Timescale for action 15/10/07 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. Refer to Standard YA14 Good Practice Recommendations Complete records should be maintained of the activities people are supported with at home. This will provide clear information regarding the support offered to people with the things they enjoy. Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 26 2. YA24 The quality of sleep of people whose bedrooms are near to a loud buzzer needs to be monitored. This will ensure that people are getting a restful sleep and their health and welfare is not affected. 3. YA16 Opportunities for further education in the local community should be explored, This will offer people the opportunity to participate in their local community more. Staff should be offered the opportunity to undertake an NVQ qualification in care. This will provide them with up to date knowledge and skills in care practices. 4. YA32 Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pine Lodge DS0000063016.V345660.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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