Inspection on 06/08/08 for Pine Lodge

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pine Lodge 12/09/07

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 08/11/2008.

CARE HOME ADULTS 18-65 Pine Lodge Blundell Avenue Freshfield Formby Merseyside L37 1PH Lead Inspector Ms Lorraine Farrar Key Unannounced Inspection 6 August 2008 2.00pm Pine Lodge DS0000063016.V364234.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.V364234.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.V364234.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) jennymcg@gotadsl.co.uk www.ftf.org.uk Frances Taylor Foundation Mrs Jennifer McGibbon Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered person may provide the following category/ies of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 12 Date of last inspection 12 September 2007 Brief Description of the Service: Pine Lodge is owned and operated by the Francis Taylor Foundation, a national organisation that provides services for people with a variety of support needs. Located in the middle of Formby Pinewoods, Pine Lodge shares a site with two other registered care homes, a day centre for 65 people and a convent. All the services are for adults who have a learning disability. The services share main kitchen facilities, extensive grounds and a hydrotherapy pool. 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, to support people in all areas of their daily lives. 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. The weekly fee for living at Pine Lodge is based on people’s individual support needs, with a basic cost of £950 per week. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We gathered information for this inspection in a number of different ways. We carried out an unannounced visit to the home on 6 August 2008. This took place over 6.40 hours and included reading records and looking at the building. We spent time looking at the support the people living at Pine Lodge receive. This included looking at the support they get with their daily lives, care plans, medication, money, activities and environment. We met with some of the people living at Pine Lodge and some of the staff working there. We also spent time observing daily life and the support people receive in their everyday lives. Any information the Commission for Social Care Inspection (CSCI) has received since the last big inspection of Pine Lodge in September 2007 is also taken into account in writing this report. This includes information from a visit we carried out in April 2008 as well as any concerns that have been raised with us about the service. The manager completed a questionnaire we sent her before our visit, to provide up to date information about the home. Information from this was again used by us to plan this inspection and in writing this report. An easy to understand summary of this report is available. If you would like to see a copy please ask staff working at Pine Lodge. What the service does well: The staff working at Pine Lodge have a good understanding of the different ways that the people living there use to communicate and of their individual needs and choices so they are able to support them with their needs and choices. Good support is provided to people in meeting their health and personal care needs. This includes supporting them to seek professional health advice and monitoring and acting on any potential health issues. This helps to ensure that people get the support that they need and choose. People are supported to get out and about and engage in holidays and leisure activities that they enjoy. Their families are welcomed to visit and staff help Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 6 people living in the home so they can stay in touch with their families and friends. Any concerns or complaints that are raised about the service are taken seriously and acted upon, with appropriate advice sought. This helps to ensure the people living there and their relatives can feel confident that Pine Lodge provides a safe place to live. Pine Lodge provides the people who live there with a well adapted home where their mobility needs and support needs around personal care can be met. Aids and adaptations are provided on an individual basis to ensure people are safe and their needs met. What has improved since the last inspection? What they could do better: Care plans for the people living at Pine Lodge should be expanded to include planning and reviewing all of the support they are offered with their daily lives and chosen lifestyles. This will help to ensure that people get support to do the things they enjoy as well as support to remain healthy and well. The mealtimes experience for the people living at Pine Lodge should be formally reviewed to ensure that they are supported in as relaxed and sociable a manner as possible. Quality assurance checks and plans should be introduced to Pine Lodge. This will provide a way for the home to formally collect information about the service they are currently providing and help them plan future improvements where needed. Clear systems should be put into place for monitoring when safety checks are due to be carried out, and ensuring these occur in a timely manner. This will help to ensure all checks are carried out at the correct time and that the building is as safe as possible for people to live and work in. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 7 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.V364234.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.V364234.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 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. Sufficient information is obtained about and provided to people considering moving into Pine Lodge. This helps everyone to decide if it is the right place for the person to live. EVIDENCE: Pine Lodge has a policy in place that states before anyone is offered a place to live, a full assessment of their needs will be carried out. This will include obtaining information from the person, family and any professionals involved in supporting them. The person and their relatives are encouraged to visit the service and the person is offered the opportunity to stay overnight before they make a decision to move into the home. They and their family are also given information about both Pine Lodge and the Francis Taylor Foundation. This information is made available in an easy read picture format, which helps people to understand as much as possible about the information they are given. Although nobody new has moved into Pine Lodge since out last big inspection, previous inspections have showed that this process is followed. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 10 This planned approach helps to ensure that everyone has sufficient information and time to decide of Pine Lodge is the right place for the person to live. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 11 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 People who use this service experience adequate outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people living at Pine Lodge receive support from staff who are aware of their individual needs and choices. A lack of complete care planning may lead to all of their choices not being consistently met. EVIDENCE: Individual care plans and records are in place for everyone living at Pine Lodge. These record that they are written with input from their family and staff along with observations of the person in daily life. The input from a variety of people involved in the person’s life ensures that as full a picture of the person is obtained as possible. Plans contain information about the support people need and prefer with their personal and health care as well as with their leisure interests. Information about people’s health and personal care needs was clearly recorded and provided a good basis for staff to support the person safely and Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 12 well. Clear information is also recorded about how the person communicates. As the people living at Pine Lodge do not use recognised forms of communication, this individual information helps to ensure that staff who may not know the person very well can communicate effectively with them. We looked at care records and plans for three of the people living at Pine Lodge. One plan had not been formally reviewed since August 2007 in respect of the support the person requires with their health and personal care. This could lead to changes to the person’s needs not being noted as quickly as possible and therefore not being acted upon. Plans also contain information about how the person likes to spend their leisure time. However these are not as detailed as other plans and not reviewed in a way that clearly shows whether staff are providing sufficient support in this area. For example one plan recorded that the person likes horse riding but there was no indication that plans had or were being made to support her with this. A lack of planning in this area could lead to people not getting the support they would like. As attending the on site day centre is included in fees for living at Pine Lodge then the activities people are supported with there should be recorded within their plan. This will help staff to gain an overall picture of the person’s day and plan with them how they may wish to spend the rest of their time. Individual risk assessments are in place for people for 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. Discussions with staff showed that they have an understanding of the day to day decisions that people who live in the home can make and how to respond to these. This was backed up by records that showed people are supported with different leisure activities according to their choices and also that they are supported to go to bed at times of their choosing. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 13 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 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The individual lifestyle choices of the people living at Pine Lodge are recognised and opportunities to meet these are increasing so they can take part in activities that they prefer. EVIDENCE: There are a number of facilities on the overall site that the people living at Pine Lodge use. These include a modern day service that provides seven different groups people can join depending on their needs and choices. Whilst at the day centre people are also supported to go out and about. The day centre is also attended by people who have a learning disability and live in the wider community, providing an opportunity to meet new people. There is a hydrotherapy pool and ‘beauty rooms’ on site that are used for aromatherapy and reflexology. These facilities are decorated and equipped to Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 14 a very high standard and provide a relaxing environment for people. The organisation has qualified therapists and some staff from Pine Lodge have training in the use of the pool so people can access this facility outside as well as within the hours the day service operates. In addition a café partly run by volunteers opens on the site 3 days a week. This provides people with the opportunity to socialise in smaller groups and if possible help out with the café. There is a chapel on site, which has Catholic services every Sunday, and Church of England services every two months. In addition services are held at the day centre at Christmas and Harvest Festival and are led by ministers from the United Reform, Methodist, Roman Catholic and Church of England faiths. Relatives and members of the public are also able to attend the Sunday service, which again provides people with the opportunity to meet others. One of the people living at Pine Lodge told us that they get to go out and about when they want and staff we spoke with had a good understanding of the different things that people enjoy doing. Records showed that people are supported with a variety of activities. For example, one plan stated that the person enjoys holidays, shows, eating out and going to the zoo. Records showed that she had been supported with all of these things during a recent holiday. During our visit several people were seen enjoying the snoezelen (sensory room) or sitting in different lounges watching TV or listening to music. One person was receiving support to use the hydrotherapy pool. However the large dining / living room had a music channel playing fairly loudly for four hours. This could not only provide a distraction for people over their meal times but could also become repetitive for the people sitting in there for some time. We visited Pine Lodge in April 2008 during the evening. During our visit we talked with staff and observed the general routines within the home. We found that routines are flexible with people supported to get up and go to bed when they wanted to. We also found that people were offered drinks throughout the day and at night if they woke. These flexible routines help to ensure that staff are responding positively to peoples individual needs and choices. Relatives of the people living at Pine Lodge have previously told us that they are able to visit when they wish and that they are kept informed about important events in their relatives’ lives. This was confirmed by records in the home that showed staff communicate with relatives on the person’s behalf. A central kitchen provides the main meals for all of the services on site. There is also a small kitchen at Pine Lodge, which can be used to prepare breakfast, drinks and snacks. A choice of meals is provided each mealtime and the cook was able to explain the different diets that people require. The evening meal Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 15 was served on a hot trolley and we observed that special diet requirements had been catered for. Many of the people living at Pine Lodge require 1-1 support with their meals and therefore each meal can take some time. The people living there are supported to eat in the dining room at a time when there are staff available to give them 1-1 support. This means that people are able to spend their time elsewhere and do not have to sit in the dining room for a long time. We observed that for people who do not require 1-1 support with their meals, little direct support was provided. Two people were sitting alone eating their meal, which did not provide them with the opportunity to view the mealtime as a sociable occasion. In addition to the television playing fairly loudly, medication is also given out from the dining room. Although some people need their medication with their meal times this added to the overall distractions. Plans are currently being made to adapt the kitchen and cook all meals within Pine Lodge. This will provide the people living there with the opportunity to live a more domestic lifestyle and to become involved and aware of the purchasing and preparation of their meals. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 16 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 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The health and personal care needs and choices of the people living at Pine Lodge are recognised so their needs are met in the way they prefer EVIDENCE: Discussions with staff working at Pine Lodge showed that they have a good understanding of people’s health and personal care needs and how to meet these. In meeting the people living there it was evident that they are supported with their appearance and personal care in a way that meets their needs and choices and is appropriate for their age. Routines in the home are flexible based upon the person’s health and personal care needs and their plans for the day. There are a number of aids and adaptations at Pine Lodge that support people with their personal care. This includes adapted baths, an accessible shower and overhead tracking. These helps to ensure people can be supported safely. Everyone living at Pine Lodge has a health action plan in place. These contain information about the person’s health history, how they communicate, their Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 17 current health care needs and how these are to be met. They also contain a series of health records and assessments around areas such as their weight, pressure areas and moving and handling needs. These records are updated regularly and provide a good way to measure any changes to the person’s health and support needs. Care plans around health and personal care contain detailed information about the support the person requires. As the people who live at Pine Lodge do not use recognised forms of communication, this level of detail helps to ensure that staff can provide a good level of support. The majority of these plans had been regularly reviewed to ensure that they were up to date. Records showed that people receive support to access a range of health professionals. This includes regular appointments such as the optician as well as more specialist appointments such as the dietician and appliance clinic. In working with other health professionals and seeking advice the home staff are supporting the people living there to remain as healthy as possible. There is a separate room to store medication at Pine Lodge and this was seen to be clean and tidy. Care plans contain information about the support people require with their medication. Where it is given with their food this is clearly documented, agreed by relevant people and the reasons why are clearly recorded. This helps to ensure the process is clear and people are given their medication in a way that meets their health needs and also respects their rights. Records of medication given to people and received into the home are clearly recorded, an audit system is in place and staff receive training in dealing with medication. This all helps to minimise the risk of errors occurring and ensures that any issues can be quickly noted so that they can be dealt with. We checked samples of medication and records. These had been fully completed, were stored correctly and stocks of medication tallied with the home’s internal recording systems. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 18 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 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. Concerns and complaints are taken seriously and acted upon by Pine Lodge. This helps everyone to ensure Pine Lodge is a safe place for people to live. EVIDENCE: Information about how to raise concerns is made freely available to the people living at Pine Lodge and their relatives and friends via the service user guide. One of the people living at Pine Lodge told us that if they were not happy about something they would tell the staff and were confident that staff would listen and act on the concerns raised. Relatives of the people living at Pine Lodge have previously told us that they know how to raise any concerns that they have and feel they would be responded to appropriately. There are clear polices and procedures in place at Pine Lodge for dealing with any concerns, complaints or adult protection issues that arise. Staff receive training in recognising and dealing with adult protection issues and in discussion with staff it was clear that they are aware of how to implement these procedures. Where concerns have been raised in the past year the organisation has responded to these by co-operating fully with any investigations and following procedures. This open approach to concerns helps to ensure that people can feel confident they will be listened to and any concerns they have will be acted upon. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 19 Systems are in place for supporting people to manage their money. Records and receipts are kept of purchases made, a sample of which were checked and they tallied. This helps to ensure that any discrepancies that occurred could be quickly noted and could be acted upon. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 20 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, 27, 29 & 30 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. Pine Lodge is well adapted so it provides a comfortable home for people to live in that meets their specialist needs. EVIDENCE: Pine Lodge is based in the middle of Formby Pinewoods, near to the National Trust Park. Its location means that it is not directly part of the wider community; however there is a local train station, shops and facilities approximately 20 minutes walk away. The location of Pine Lodge means that it has scenic views and there are nearby walks within local areas of interest. It also has several gardens within the larger grounds that people can access, as well as an enclosed courtyard with seating, that is directly accessed via the home. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 21 Due to the layout of both Pine Lodge and the site, all areas are accessible for people with physical disabilities, with wide corridors and doorways and all areas at ground level. Shared areas of Pine Lodge include a large dining and living room, a small lounge and a seating area overlooking the courtyard. In addition a snoezelen room has been created in a second small lounge. This room is designed to provide a relaxing space for people with a calm, sensory feeling. The room has large beanbags for people to lie on and different light effects such as bubble tubes, as well as calming music. During our site visit we observed some of the people living in the home enjoying the environment created in there. The small kitchen at Pine Lodge is not accessible for people with mobility difficulties. However the organisation has plans to replace this kitchen and the manager advised that some adaptations will be incorporated into the new design. There is currently one shared room within Pine Lodge; this is shared by two people and has screens provided for privacy. Other bedrooms are single rooms. Bedrooms are decorated and furnished to a good standard and are personalised in accordance with the person’s tastes. One of the people living there confirmed to us that they had been involved in choosing the décor and furnishings for their room. There are adapted bathrooms and an accessible shower room available within Pine Lodge. In addition everyone has a designated toilet that has been decorated and adapted to meet their needs and choices. There are a number of aids and adaptations within Pine Lodge to support people with their mobility. These include overhead tracking, hoists, grab rails and electric beds. These aids mean that it is as easy as possible for people to get around and to receive support with their personal care. There is a separate laundry room with industrial washing and drying machines. 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.V364234.R01.S.doc Version 5.2 Page 22 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 People who use this service experience good outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people living at Pine Lodge receive support from staff who can recognised their individual needs and choices so they can meet them in the way they prefer. EVIDENCE: One of the people living at Pine Lodge told us that they like the staff team and that they get help and support when they need it. The people who live at Pine Lodge have specialist needs in regard to all areas of their daily lives. This includes the support they need with their personal care, how they communicate and the things they enjoy doing. In discussions with some of the staff it was evident that they have a good understanding of the individual likes and dislikes of the people living there, as well as their support needs and how they communicate. Staff were seen to spend time chatting with people and taking plenty of time to support them on a 1-1 basis with their personal care and with their meals. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 23 Records showed that before anyone starts work at Pine Lodge a series of checks are carried out. These include a set interview process, obtaining written references and checking with the Criminal Records Bureau (CRB) and register of people unsuited to work with vulnerable adults. These checks help to ensure staff are suitable to work with people who may be vulnerable. A member of staff explained that when they started working at the home, they had a full induction week, during which time they shadowed more experienced staff. This helps to ensure that new staff can begin to develop the specialist skills needed to support the people living 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 wound care. The manager explained that they have recently begun work with an outside company who are carrying out a training needs analysis for Pine Lodge. This will help the manager to plan future training based upon both the shared and individual support needs of the people living there. Over 50 of the care staff hold a nationally recognised qualification in care (NVQ). This training helps to ensure that staff are aware of current good practice and can support people safely and well. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 24 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 People who use this service experience adequate outcomes in this area. We have made this judgment using available evidence including a visit to this service. Pine Lodge is managed for the benefit of the people living there. Thorough planning and internal checking of the service would benefit the quality of the service provided. EVIDENCE: Mrs Jenny McGibbon is the manager of Pine Lodge. She holds a management qualification and registered nurse qualification for working with people with learning disabilities. She has worked in a management capacity for some time. Records showed that she takes part in regular training courses to ensure her knowledge is up to date. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 25 There are some systems in place for looking at the quality of the service Pine Lodge provides. A senior manager from the organisation visits regularly and provides a report of their visits along with any areas that need action taking. A survey of the views of relatives was carried out and five people replied; all replies were positive about the service provided. As many of the people living at Pine Lodge cannot fully express their views this provides an opportunity for their relatives to become involved in future planning for the home by raising any concerns they may have or making suggestions for future improvements However there is no formal system within the home for checking the quality of the service provided. A formal system that involves looking at the needs and choices of the people living there, as well as checking how the home operates against good practice standards in the field of care would enable them to make and carry out plans to further improve the service they offer. Records and certificates showed that regular checks are generally carried out on the environment and equipment to ensure they are safe to use. This includes checks on the fire system, moving and handling equipment and the mains electrics. However the gas certificate for the home was due to be renewed in March 2008 and had not been. Following the inspection we were given evidence that a gas safety inspection was booked to take place within two weeks but leaving it overdue for several months could put people in the home at risk. Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 26 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 X X Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 27 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 15(2)(b) Requirement A system must be set up for ensuring all care plans are reviewed regularly. This will help to ensure that any changes to peoples support needs and choices are quickly identified and can be acted upon. A system must be set up for monitoring safety checks on equipment throughout the building to make sure they are renewed when they are due and the home continues to be a safe place to for people to live. Timescale for action 30/09/08 2 YA42 13(4)(a) 15/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Care plans should include clear planning around people’s social choices. They should also record the activities people are supported with at the day centre. This will DS0000063016.V364234.R01.S.doc Version 5.2 Page 28 Pine Lodge ensure that staff can and are supporting people with their preferred lifestyles. 2 YA17 The noise levels and amount of distractions at meal times should be formally assessed and monitored. This will help to ensure that mealtimes are a relaxed and sociable occasion for people A formal system for checking the quality of the service provided and planning future improvements should be implemented. This will provide a formal way to plan and assess improvements to the service provided for the people living at Pine Lodge. 3 YA39 Pine Lodge DS0000063016.V364234.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North West Region Unit 1, Level 3 Tustin Court Port Way Preston PR2 2YQ 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.V364234.R01.S.doc Version 5.2 Page 30 - 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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