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Inspection on 12/09/06 for Pine Lodge Retirement Home

Also see our care home review for Pine Lodge Retirement Home for more information

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

What has improved since the last inspection?

The home has employed a new chef. Some carpeting has been laid in Firs. A record of falls is now being kept as requested at the last inspection.

What the care home could do better:

The home needs to substantially increase the number of staff on duty so that the needs of the Service Users can be fully met and to provide training that is competency based. The number of staff with an NVQ needs to be increased to meet with the 50% requirement. The Firs is in need of redecoration and the furniture needs to be repaired or renewed. Service Users in Fir were not happy with the staff working there as they were `bossy` and `they were told what to do` That all sections of the care plan and risk assessments are completed and that staff are fully aware of the content and where they are stored. That the odours in the hallway and Room 6 in Firs are removed and a radiator cover fitted in the communal bathroom. All fire doors must be closed and not propped open unless in a legal manner with fire alarm release door stop.

CARE HOMES FOR OLDER PEOPLE Pine Lodge Retirement Home 32 Key Street Sittingbourne Kent ME10 1YU Lead Inspector Graham Cummings Unannounced Inspection 12th September 2006 09:45 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 Lodge Retirement Home DS0000023989.V309009.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 Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Lodge Retirement Home Address 32 Key Street Sittingbourne Kent ME10 1YU 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) 01795 423052 01795 423052 Mr Stephen Paul George Thompson Mrs Gillian Lesley Thompson Post Vacant Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57) of places Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Pine Lodge Residential Home occupies detached premises, with accommodation for residents on two floors. The premises have been substantially extended and refurbished and is now registered for 57 service users. The Home has two shaft lifts and other mobility aids that enable it to accommodate wheelchair users. There is allocated car parking to the front and rear of the building and two enclosed garden areas. The Home is situated close to Sittingbourne town centre, with local shops, public transport and other community facilities within the vicinity. The cost of the service ranges from £330:00 to £395:00 per week The overall quality of the service provided is poor Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit was carried out by Graham Cummings and Sarah Montgomery and completed the Key Inspection. The visit took place on the 9th September 2006. The visit consisted of talking to the Manager, Deputy Manager, 2 staff and 5 Service Users. The Inspectors looked at 6 care plans and 3 staff files and toured the premises. The home does not have a Registered Manager at present and the Acting Manager is applying to CSCI for registration. The home is split into two groups named Fir and Pine. Occupancy in Fir is 21 and in Pine 31. The Inspectors found that the provision of care being delivered differed between the two groups. The Inspectors were concerned at the lack of number of staff on duty that were expected to meet the needs of 51 Service Users. The Inspector put the information into the DOH staff hours calculation with an outcome that Pine group needs should have a total of 506 hours per week, equivalent to 72 hours per day. The current staff hours for Pine group is 39 hours per day. Using the DOH calculator for Firs group the outcome to meet the needs was 342 hours per week equivalent to 49 hours per day. The current staffing is 26 hours per day. The Service Users spoken to in Fir group were not happy with the way staff spoke to them in a bossy manner. Service users informed the inspectors that night staff told them off for using the call buzzer and some personal care had not been carried out. The furniture and décor was poor and there was a musty smell in the entrance corridor, Room 6 had an offensive odour and the carpet needed replacing. The Service Users in Pine group told Inspectors that the staff were helpful and polite, the food was good and there were no complaints. The furniture and décor was all of a good standard. An immediate requirement was made regarding the carpet on the upstairs landing between rooms 32 and 35 that was uneven and a major trip hazard. The Inspectors were assured it would be dealt with the following day. Since the inspection, a letter confirming it had been dealt with has been received. Care plans were in place but did not contain all of the relevant information and needed completing, it was also noted that staff did not appear to know where the care plans were kept. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 6 Staff training was mainly done through watching videos and answering questions that were checked by the Acting Manager, who, if appropriate gave out certificates. Of the 27 staff employed 7 have an NVQ. Individual supervisions were not being carried out and the acting Manager said that they would be starting very soon. Of the 10 Requirements made at the last inspection 6 have not been completed and an extra period of time has been given for them to be completed. The Inspectors have made a total of 10 Requirements. Following the writing of the report, the Inspector was informed that the occupancy in Firs was 18 and not 21 as originally stated by the Manager. What the service does well: 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. Pine Lodge Retirement Home DS0000023989.V309009.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 Lodge Retirement Home DS0000023989.V309009.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 The quality of the service provided is adequate. Service Users have the information required to make an informed choice about where to live and have their needs assessed prior to placement. Prospective Service Users and relatives can visit the home to assess suitability. The home does not cater for intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The Manager informed the Inspectors that new referrals are assessed prior to any placement taking place to ensure their needs could be met. When looking at the files the admission assessment was in place but not on all of them. Some information was missing, for example, there was blank area in the ‘reason for referral’ on 1 file. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 9 Prospective Service Users could visit the home prior to agreeing to any placement. Pine Lodge Retirement Home DS0000023989.V309009.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10,11 The quality of the service provided is poor Service Users cannot be confident that all of their care needs will identified within their individual plans and this may compromise the quality of care offered to them. Service Users cannot be confident that their health care needs will be fully met. EVIDENCE: The Manager informed the Inspector that new and improved care plans were in place. The Inspectors looked at six care plans and found that there was information missing in all of them. In one Service User’s Personal Details forms there were no dates of birth, place of birth, previous address and blank spaces for names of the optician, dentist, key-worker and care manager. There was a mixture of the same information missing on the other five Personal Details forms seen. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 11 In the Life Story section one was blank with a note to ask family members and the other five contained only minimal information of no more than two or three lines of narrative. Weight records were blank or not been taken for months, one Service User’s weight had not been recorded since the 1/6/06 following a recorded loss of 5lbs. The majority of care plans contained the statement to ‘monitor, report and document any change’, the Inspectors were concerned that due to the low number of staff on duty to meet the needs of the Service Users that staff were not able to record information fully. Pine group has 3 staff to meet the needs of 31Service Users, 2 are double handed. Firs group has 2 staff to meet the needs of 21 Service Users, 1 is double handed. Dates and signatures were in place for the evaluation of care plans. One Service User in Firs group stayed in bed most of the time but got out for their meals. The care plan stated they required assistance with eating and drinking, it also stated that they needed their incontinence pad changed every 2 hours, 2 staff were required for moving and handling. An Inspector spoke to the Service User and was informed that their ‘pads are changed sometimes once a shift sometimes more often’. As a shift is 6 or 7 hours according to the staff rota this is not acceptable and needs to be addressed. The Service User also informed the Inspector that they had about 10 to 15 minutes help with eating their meals and drinking was ‘informal and whoever was coming upstairs’. The Service User had not been weighed as the home does not have sit on scales so no record is available to monitor any weight loss. This issue also needs to be addressed. A Service Users spoken to in Firs informed Inspectors that they found ‘staff bossy, they tell you what to do’. They talked about night staff and said ‘some are nice some aren’t, if you ring your bell they tell you off and they don’t always answer’. They said that they had complained to the Manager but that the home does nothing about their concerns. The Provider informed the Inspector that the only way to cancel the call was by going to the room. Another Service User in Firs expressed unhappiness but would not say more, when asked further they replied ‘what’s the point’. The Inspector spoke to a Service user who had not had a bath for 2 weeks because the staff member who usually did it was off sick. A staff member was asked why other staff did not carry out this task they replied ‘they are too busy and she is done in the afternoon’. The Service User had an en-suite room but the bath has never been used as the taps do not work and there is no hoist. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 12 The wishes of Service Users regarding illness and death were not recorded on 4 of the 6 care plans seen. Pine Lodge Retirement Home DS0000023989.V309009.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality of the service provided is adequate. Service Users lifestyle is limited due to lack of transport but indoor activities are good. Service Users maintain contact with family and friends. Service Users do not have choice and control of their lives. Service Users receive a wholesome and nutritious diet. EVIDENCE: The home has a good activities programme that includes floor Ludo, Snakes and Ladders, Reminiscence sessions, Flower Arrangement, knitting to raise money for Age Concern. The Manager transfers crosswords from books onto a large piece of paper and pins it to the wall, Service Users are then able to see or read the clues. Service Users are able to choose if they want to participate. It was unclear if this happened in Firs as well. The dining are in Pine group was in good decorative order. The dining area in Fir group was in need of decoration as the walls were stained and skirting boards stained and dirty, a cupboard in the corner of the room looked broken. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 14 The home does not have transport so do not go on external trips or outings, Service Users rely on staff using their own cars for Doctors and Hospital appointments. Some Service Users are taken out by family members when they visit. Family and friends are able to visit the home at any time and are able to participate in any of the activities taking place. The home has recently appointed a new Chef and there are 3 kitchen assistants. The Manager said that the menu is drawn up 4 weekly and include meals suggested by Service Users at their meeting. The menu consists of 1 hot meal or a salad. Pine Lodge Retirement Home DS0000023989.V309009.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality of the service provided is poor. Service Users complaints are not listened to and acted upon. Service Users are not fully protected from abuse. EVIDENCE: Since the last inspection the home received a complaint dated the 1/2/06 from a family member who didn’t think it right to pay whilst their family member was in hospital. The Acting Manager responded on the 20/02/06. There was no further contact from the complainant and the issue was dealt with within the 28 days stated in the home’s policy and procedures. The Commission has not received any complaints since the last inspection. The Inspector when talking to a Service User in Fir group was told that they had ‘complained to the Manager 2 or 3 times that staff tell her off, what do they do - nothing’. Another Service User expressed unhappiness but wouldn’t say anymore, when questioned further said there’s no point’. Staff have had some Adult Protection training, this consists of watching a video and answering questions. This is acceptable as part of the Induction programme but staff should have Adult Protection training that is competency based. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 16 The Inspectors were very concerned that the number of staff on duty was inadequate to fully meet Service Users needs and therefore protect them from neglect. The Inspector using the information gathered from the Acting Manager, staff and Service Users, documentation and tour of the home put the details into the DOH staff hours calculation. The outcome for Pine group with 2 High dependency, 1 medium and 28 low dependency needs should have a total of 506 hours per week, equivalent to 72 hours per day. The current staff hours for Pine group is 39 hours per day. Using the DOH calculator for Firs group, 1 high dependency, 1 medium and 19 low dependency needs, the outcome 342 hours per week equivalent to 49 hours per day. The current staffing is 26 hours per day. The number of staff on duty to fully meet the needs of the Service Users must be seen as a priority to prevent Service Users from being protected from abuse. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,25,26 The quality of the service provided is poor. Not all Service Users live in a safe well maintained environment. Not all Service Users have safe and comfortable indoor and outdoor communal facilities. Not all Service Users’ own rooms suit their needs. Not all Service Users live in safe comfortable surroundings. Not all of the home is clean, pleasant and hygienic. EVIDENCE: The Inspector toured the buildings and found that there was a vast contrast in condition and decoration between Pine and Fir groups. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 18 Pine group was clean, tidy and free from any offensive odours and well decorated. The carpet in the hallway between rooms 32 and 35 was uneven and a dangerous trip hazard, an Immediate Requirement was made and the Acting Manager told Inspectors it would be dealt with urgently, an action plan was requested. (A letter confirming the work had been completed has been received.) Service Users were positive in their comments about Pine group saying, ‘no complaints, the staff are helpful and friendly’; ‘I’m happy with my room’ and ‘I’m happy, staff are good, foods good I’ve no complaints. On entering Fir group there was an unpleasant musty odour in the corridor. The dining area was in need of redecoration as the walls and skirting boards were stained. The last inspection made a Requirement that the lounge needed to be redecorated and chairs should be replaced, this has not been done. The chairs are worn and the arms have ingrained dirt. The television picture was all green and either needs adjusting or a new television purchased. The corridor walls are marked and need redecorating. The conservatory lounge had 3 chairs that had stuffing coming out of the arms and others were worn and stained. The Inspector went into room 6 and there was a strong odour of urine with the carpet stained and in need of being replaced. The communal bathroom had no radiator cover and the flooring had been ripped by the hoist. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality of the service provided is poor. Service Users needs cannot be met fully because of the inadequate numbers of staff that are on duty at any given time. Their safety and welfare are also compromised by the poor staffing levels. Service Users are protected by the home’s recruitment policy. The care of service users may be compromised because staff receive inadequate training in key areas of their work. EVIDENCE: The Inspectors were informed and the rota shows that 3 staff are on duty in Pine group with 31 Service Users and 2 staff work in Firs with 21 Service Users. The rota showed that there should be 4 waking night staff on duty each night, 2 in each group. The Inspector put the information into the DOH staff hours calculation with an outcome that Pine group with 2 high needs and 1 medium needs and 28 low needs should have a total of 506 hours per week equivalent to 72 hours per day. The current staff hours for Pine group is 39 hours per day. Using the DOH calculator for Firs group the outcome to meet the needs of 1 high needs, 1 medium needs and 19 low needs was 342 hours per week equivalent to 49 hours per day. The current staffing is 26 hours per day. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 20 It was apparent from the information seen and the comments from Service Users that staffing levels need to be increased substantially to fully meet the needs and safety of the Service Users. It was mentioned that sometimes there was only 1 member of staff on duty in Firs and that at weekends there was only 3 waking night staff to cover both groups. The Manager said that staff recruitment was difficult in the location and although adverts had been placed the quality of the responses was of a low standard. The home currently employs 27 staff full and part time of these 7 have an NVQ. A lot of the training is done through watching videos and completing a questionnaire that the Manager marks and gives out a certificate, this is acceptable as part of the induction but staff need to attend training that has a certificate of competency. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37,38 The quality of the service provided is poor. The quality of care offered to Service Users is affected by the home not having a Registered Manager. Service users cannot be confident that the home is run in their best interests. The care of Service Users may be compromised because staff do not receive any supervision. The Health, Safety and Welfare of Service Users and staff are not promoted or protected. EVIDENCE: The home does not currently have a Registered Manager though the home’s Acting Manager is looking to apply for the position. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 22 The Inspectors found that the standard of care Service Users received was different depending on whether they were in Pine or Fir group. Service Users comments in Pine indicated they were happy and content and that the staff are helpful and supportive, yet in Fir Service Users said ‘staff didn’t listen’, ‘staff were bossy’, ‘there’s no point in saying anything’. The Inspector saw no evidence of any formal staff supervision taking place and was informed that it was recommencing soon. The care plans were lacking in information regarding personal details and life history and it was unclear that staff had read the care plans or understood where they were filed. The health safety and welfare of Service Users differed depending on the group they were living in. The Inspector was unable to get clarification or any reason as to why this was. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 1 2 X X 2 X 2 2 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 1 2 1 Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 24 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(1) Requirement Timescale for action 2. OP8 13(1)(b)1 3(4)(c) Unless it is impracticable to carry out such consultation, the registered person shall, after 30/11/06 consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. All sections of the care plan must be completed. (Refer to Schedule 3 and 4). Not completed from last report now to be completed by: The registered person shall make arrangements for service users (b) to receive where necessary, 30/11/06 treatment, advice and other services from any health care professional. The registered person shall ensure that (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. That Service Users weight is monitored regularly and if necessary equipment purchased to enable this. Not completed from last report now to be completed by: DS0000023989.V309009.R01.S.doc Version 5.2 Page 25 Pine Lodge Retirement Home 3. OP10 12(4)(a) 4. OP14 12(5)(a)1 2(5)(b) 5. OP18 13(6) 6. OP19 16(2)(k) 23(2) (b)(c)(d) The registered person shall make suitable arrangements to ensure that the care home is conducted - (a) in a manner which respects the privacy and dignity of service users in that bathing is given when requested and Service Users are listened to. Not completed from last report now to be completed by: The registered provider and registered manager shall, in relation to the conduct of the care home maintain good personal and professional relationships with each other and with service users and staff; and (b) encourage and assist staff to maintain good personal and professional relationships with service users. Not completed from last report now to be completed by: The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Not completed from last report now to be completed by: The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users –16(2)(k) keep the care home free from offensive odours – in that the carpet in Firs bedroom 6 is replaced; 23(2)(b) the home is kept in a good state of repair externally and internally; (c) equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order; (d) all parts of DS0000023989.V309009.R01.S.doc 30/11/06 30/11/06 30/11/06 31/12/06 Pine Lodge Retirement Home Version 5.2 Page 26 7. OP21 23(2)(d) 8. OP25 13(4)(a) (c) the care home are kept clean and reasonably decorated; in that the dining room, lounge and corridor in Firs is redecorated; Firs conservatory lounge chairs are replaced; carpet in bedroom 6 replaced; a radiator cover is fitted in Firs communal bathroom. An Immediate Requirement was left relating to upstairs landing carpet in Pine between rooms 32 and 35 needed to be stretched. The registered person shall, having regard to the size of the care home and the number and needs of service users ensure that – the flooring in the communal bathroom in Firs is replaced and a radiator cover fitted. The Registered person shall ensure that – all parts of the home to which service users have access are so far as reasonably practicable free from hazards for their safety and (c) unnecessary risks to health and safety of service users are identified and so far as possible eliminated in that fire doors are kept closed unless kept open with recognised fire alarm sensitive door closures. 31/12/06 31/12/06 9. OP27 18(1)(a) The registered person shall, 30/11/06 having regard to the size of the care home, the statement of purpose and the number and needs of service users (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 27 10. OP28 18(1)(a) 11. OP30 18(1)(c) (i) The registered person shall, having regard to the size of the care home, the statement of 30/11/06 purpose and the number and needs of service users (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Not completed from last report now to be completed by: The registered person shall, 31/12/06 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that persons employed by the registered person to work at the care home receive (i) training appropriate to the work they are to perform. The Registered person shall ensure that persons working at the care home are appropriately supervised – that is a minimum of 6 times per year. 31/12/06 12. OP36 18(2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pine Lodge Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 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 Retirement Home DS0000023989.V309009.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!