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Inspection on 22/06/07 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 22nd June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The registered manager and deputy manager have been employed in the home for around 6 months and have made significant improvements and developments to the home in that time; providing clear leadership and direction and developing care planning processes and training amongst other things. The Pines wing of the home provides a very comfortable and well appointed environment for service users with a good range of bright and comfortable space. There is a positive and wide range of activities in the home. A responsive and open approach to concerns and complaints has been introduced. Visitors are welcomed into the home and included in the running of the service appropriately. Residents stated that the meals in the home are of good quality.

What has improved since the last inspection?

A number of significant improvements have been made since the last inspection improving the quality of lives for service users. The process of assessment prior to entering the home has been reviewed and updated.The care planning process has been further developed ensuring that the needs of all service users are addressed, although further work in this area would be beneficial. Healthcare records have been improved ensuring that information is appropriately recorded and healthcare issues monitored. A range of measures to improve the general environment of the home have been made, including renewal of some carpets and redecoration of bedrooms and communal areas. A new laundry facility is almost complete. There are further plans to develop the home, in particular the Firs wing of the service. Substantial improvements have occurred in the area of staff development including new induction processes incorporating the Common Induction Standards, the provision of effective training and competency based assessments and supporting staff to achieve NVQs. This work is on going. Staffing levels have been increased and remain under review. Quality assurance processes have been developed. A new management team have been employed.

What the care home could do better:

2 requirements and 4 recommendations have been made as a result of this inspection, which represents a significant improvement from the last key inspection. Both requirements are in respect of the environment. There is reportedly work planned to improve the Firs wing of the home. This needs to be detailed in action plan giving realistic timescales and a copy provided to the Commission for Social Care Inspection. There are 5 double rooms currently in use in the Firs part of the home which, according to the schedule of accommodation, fall below the minimum space requirement of 16 sq m. Additionally one service user reported that they did not have a choice with regard to the sharing of the room and the rooms viewed did not have adequate screening to ensure privacy. The registered manager has stated that records confirm a positive choice was made to share a room on admission. 3 of the double rooms are currently occupied by only 1 person. Amongst the recommendations made were to continue to develop care plans and risk assessments. To commission an occupational therapy assessment of the premises to ensure all adaptations and equipment is provided. To continue to update mandatory training.

CARE HOMES FOR OLDER PEOPLE Pine Lodge Retirement Home 32 Key Street Sittingbourne Kent ME10 1YU Lead Inspector Joseph Harris Key Unannounced Inspection 22nd June 2007 10:00 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.V343227.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.V343227.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 Mrs Lorraine Edith Cousins Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Pine Lodge Retirement Home DS0000023989.V343227.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 only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - (OP) The maximum number of service users to be accommodated is 57. Date of last inspection 9th January 2007 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 £345:00 to £450:00 per week. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection culminated in a site visit to the home on the 22nd June 2007. The visit started at 10am and finished at 5.30pm lasting for approximately 7.5 hours. During the course of the visit discussions were held with the registered manager, the deputy manager, staff, service users and relatives. A tour of the premises was completed and a range of documentation was viewed including records relating to service users, staff, medication, training, health and safety and the running of the home. What the service does well: What has improved since the last inspection? A number of significant improvements have been made since the last inspection improving the quality of lives for service users. The process of assessment prior to entering the home has been reviewed and updated. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 6 The care planning process has been further developed ensuring that the needs of all service users are addressed, although further work in this area would be beneficial. Healthcare records have been improved ensuring that information is appropriately recorded and healthcare issues monitored. A range of measures to improve the general environment of the home have been made, including renewal of some carpets and redecoration of bedrooms and communal areas. A new laundry facility is almost complete. There are further plans to develop the home, in particular the Firs wing of the service. Substantial improvements have occurred in the area of staff development including new induction processes incorporating the Common Induction Standards, the provision of effective training and competency based assessments and supporting staff to achieve NVQs. This work is on going. Staffing levels have been increased and remain under review. Quality assurance processes have been developed. A new management team have been employed. What they could do better: 2 requirements and 4 recommendations have been made as a result of this inspection, which represents a significant improvement from the last key inspection. Both requirements are in respect of the environment. There is reportedly work planned to improve the Firs wing of the home. This needs to be detailed in action plan giving realistic timescales and a copy provided to the Commission for Social Care Inspection. There are 5 double rooms currently in use in the Firs part of the home which, according to the schedule of accommodation, fall below the minimum space requirement of 16 sq m. Additionally one service user reported that they did not have a choice with regard to the sharing of the room and the rooms viewed did not have adequate screening to ensure privacy. The registered manager has stated that records confirm a positive choice was made to share a room on admission. 3 of the double rooms are currently occupied by only 1 person. Amongst the recommendations made were to continue to develop care plans and risk assessments. To commission an occupational therapy assessment of the premises to ensure all adaptations and equipment is provided. To continue to update mandatory training. Pine Lodge Retirement Home DS0000023989.V343227.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 Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 8 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.V343227.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. Service users only move into the home following an assessment of their needs and they are provided with information about the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of service user files were examined, all of which contained satisfactory information gleaned prior to the individual moving into the home. Where a resident has a care manager the home had care management assessments in place and the registered manager has developed an assessment form, which is being used for all new admissions to the home. This covers all key areas of need. The information received is then applied to the care planning process. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 10 The home does offer short-term respite care and, although there are no dedicated facilities, the service follows their pre-admission assessment processes providing an environment to enable service users to return home following their stay. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. The service users’ needs are set out within individual plans of care, which can still be further developed. Healthcare needs and medication issues are suitably managed and service users are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager and deputy manager have completed a lot of work to update and improve systems for care planning introducing new formats and providing staff with training in this regard. Whilst the work completed represents a significant improvement there remains scope for development in this area. 4 service user files were examined and all had been completed consistently and adequately addressed individual needs and potential risks. However, it was Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 12 noted that the new care plan format does not fully lend itself to providing detailed actions and guidelines to address the assessed needs. Specific care issues should be separated out and guidelines put in place for each area including how each need should be met by the staff team. The plans should also emphasis individual abilities to a greater degree therefore encouraging independence. Plans were seen to be reviewed on a monthly basis in most cases, although the home could tighten up in this regard. The home has improved the process of risk assessment and incidents and accidents are responded to with an assessment of risk put in place. It was advised that the home also develops longer-term risk assessments where a consistent issue has been identified. These issues were discussed with the management team, who took on board the points raised. Refer to recommendation 1. Staff and service users are now included fully in the care planning process encouraging a more inclusive approach to the planning of needs. There was clear evidence available to demonstrate that the healthcare needs of service users are met. Records are maintained of all healthcare professional input including district nurses, GPs and complimentary healthcare professionals such as Chiropodists, Opticians and Dentists. The records include outcomes of any consultations, which are then included within plans of care and appropriately communicated to staff. There is adequate space for service users to meet health professionals in private; this includes a dedicated room for consultations/treatment. Weight charts are completed routinely and other healthcare needs such as pressure area care, incontinence issues and oral health are documented within care plans. Medication processes were examined for the Pines wing of the service. MAR sheets were kept up to date and were clear. It was noted, however, that systems for monitoring controlled drugs could be improved, which is an area that the registered manager has identified for improvement. At the time of the visit the temperature in the medication room was 29c. The majority of medication is required to be stored at a temperature of 25c, therefore additional temperature controls should be considered. Refer to recommendation 2. Medications were stored in a well-organised and secure manner and the home has the use of a drugs trolley. It is suggested that an up to date copy of the British National Formulary is purchased for the service. The registered manager completes a monthly medication audit with any actions required communicated to the staff responsible for managing and administering medications. Additionally the home has improved the level of training for staff with respect to medication issues. Staff undergo competency assessments and supervised practice as well as Boots MDS training. Responsible staff are also completing accredited ASET medication training. All service users and relatives spoken to confirmed that they are treated respectfully by staff in the home and that their privacy is maintained. One relative stated, “I can’t fault the staff, they care for my father very well. He has improved since coming to Pine Lodge”. One resident said, “The staff are lovely, they have time to stop and chat and I feel well cared for.” Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 13 Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users can expect a lifestyle that meets their needs enabling contact with friends and family, exercising control and with a healthy balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a wide range of activities available in the home and a number of trips out are arranged both on an organised and impromptu level. The home has an activities co-ordinator who attends the home for two afternoons per week and she is supported by a volunteer. The activities in the home include quizzes, bingo, armchair exercises and arts and crafts. Outside entertainers also visit the home on a regular basis providing music and entertainment. A hairdresser visits at least weekly. The home has arranged a number of trips out over recent months including mystery tours and visits to local places of interest. Staff are also on hand to take residents out on a one to one basis. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 15 The families and friends of residents are welcomed into the home at all reasonable times. Relatives spoken with stated that they are made to feel welcome in the home and kept up to date with issues in the service. Additionally they reported that the home has started to have relative meetings and one issue raised has been to increase the level of inclusion of families and visitors in the running of the home. Residents are encouraged to retain control over their lives in respect of being able to bring possessions in from their homes and choosing how they wish to spend their days within an appropriately structured routine. The home does not take an appointee role on for any residents and their finances are either managed by themselves or someone independent of the service. The home has information available regarding advocacy services should someone wish to access them. All residents spoken with confirmed that the quality of food in the home is good and well presented. Both wings of the home have suitable dining areas and meal times are taken in a relaxed and unhurried atmosphere. Staff are available to assist residents in a discrete manner should they require such help. A conversation took place with the main full-time chef who has worked in the home for just over 6 months. He demonstrated a good understanding of the needs and requirements of service users. Residents are involved in the planning of menus to some degree and a range of choices are available at each mealtime. The kitchens were well stocked with a variety of good quality foods, fresh fruit and vegetables. Snacks are available throughout the day and the home caters for any special or religious diets. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users’ and their relative’s views are listened to and acted upon. Residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints process in place and the registered manager underlined her intention to take all complaints seriously and respond to them in a timely manner. The aim is to deal with all issues on an informal level in the first instance, but a formal process is in place should this be requires. The registered manager documents all concerns and complaints providing evidence of any action taken. One relative spoken with stated that he was impressed with the speed and manner that the home has dealt with any issues he has raised. “I have raised a number of issues and I can say that they have always been dealt with proficiently and in a short timescale. I feel able to take any issues to the manager knowing that they will be appropriately dealt with.” Residents also said that their views are encouraged and that they feel able to approach staff or the manager with any concerns that they may have. There have been no formal complaints raised since the last inspection. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 17 The registered manager has introduced updated policies and procedures in respect of abuse awareness and adult protection. Both the manager and deputy manager are trained trainers in this topic and have provided staff with training in this area, which is also covered through the induction process. It was reported that there are no adult protection alerts open on the home at the time of the visit. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 and 26. Quality in this outcome area is adequate. Service users live in a safe and improving environment. The Firs wing of the building requires further improvements and The Pines wing is well-maintained and suitable for residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pine Lodge is separated into two distinct parts of the building. The Pines is a purpose built extension to the home compromising all the required facilities of a care home with the exception of the kitchens. This part of the building, following a tour, was seen to be bright, comfortable, well-maintained, safe and meeting all requirements. The Firs side of the service, which is the original part Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 19 of the home, is connected by a first floor corridor. It is of a very different character and has strengths in its own right, however it is in need of some updating and review. Since the last inspection the owners of the service have invested in the upgrading of the environment and it is acknowledged that this is an on-going process. A number of issues were noted during the tour of the premises. There are 5 double rooms in The Firs none of which meet the minimum 16 sq metres space requirement. The use of these rooms as doubles need to be reconsidered. They do not possess suitable screening to ensure the privacy of each resident and there is only the use of a single sink in each room. One resident who shares a room stated, “I don’t mind sharing, but this lady just moved in. What’s her name? I don’t spend much time in my room anyway.” Residents should make an expressed choice to share a room where the room meets the necessary requirements. Refer to requirement 1. The kitchen, which serves the whole building, would benefit from refurbishment, although it was reported that the flooring has been replaced in the food storage area. A recent environmental health report made a number of recommendations, which need to be complied with, including the replacing of the kitchen flooring. The equipment in the kitchen should be reviewed and any necessary steps taken. The bathrooms and toilets in the Firs should also be reviewed ensuring that they are suitable for the needs of the service users. It is advised that an Occupational Therapy assessment of the Firs side of the building is commissioned to provide clear advice and recommendations on the work required. Refer to requirement 2 and recommendation 3. In general the environment is fit for purpose however and the more homely feel to the Firs should be emphasised as a strength of its character. The registered manager outlined some of the work that has already been done to improve the environment and plans for the further development of the home such as an enclosed garden. The home was clean and hygienic throughout with hazardous substances kept in locked cupboards and appropriate infection control procedures. The laundry is currently in the cellar, but a new laundry room has almost been completed, which will house 2 industrial washing machines and tumble driers with sluicing facilities. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. There are adequate numbers of staff on duty at all times and training has been improved and continues to be developed. Recruitment processes ensure the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates with 6 care staff throughout the day and 4 waking night staff. 4 care staff are allocated to work in The Pines and 2 staff work in The Firs, although 1 member of staff on each shift is designated to work between both units as required. In addition to the care staff the home has 2 cooks sharing the work throughout the week, domestic staff, a laundry assistant and a part-time maintenance man and an activities co-ordinator. The registered manager and deputy manager work through office hours, although they reported that their hours are very flexible and both work additional hours as required. There is an on-call system out of hours. At the time of the visit the home had 43 residents of which 3 are considered as having high level needs. The registered manager stated that as the needs and number of service users change the staffing levels remain under constant review. A flexi-bank has been Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 21 established so that when the home needs additional carers there is a group of experienced, trained staff who can cover required shifts. The registered manager and deputy manager have invested much time and effort in updating and improving the staff development programme from induction through to National Vocational Qualifications (NVQ). An excellent induction programme has been developed by the deputy manager incorporating the Common Induction Standards and competency assessments. This is worked through by all staff with plans for existing staff to work through this in the future. 14 staff members have achieved an NVQ level 2 or above with 7 staff working towards the award. 3 new staff are being employed who have already achieved an NVQ in care. A great deal of work is being undertaken to update mandatory training for all staff and the home is progressing towards this goal. A clear commitment to training is evident and staff commented that since the new management team have taken over the home there has been a marked improvement in staff training. Additional training is also being provided in a range of other topics including dementia care, care planning, wound care, adult protection and stroke awareness amongst others. Refer to recommendation 3. A number of staff personnel files were viewed, which contained all required information including evidence of CRB and POVA checks, proof of identity and two written references amongst other documents. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The home is well managed and run in the best interests of service users. Resident financial interests are safeguarded and health, safety and welfare issues are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for around 6 months alongside the deputy manager. She has many years of experience in care home settings and has previously managed services. She has attained the required qualifications. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 23 In a relatively short time span, with the support of the deputy manager and staff team, she has made significant improvements to the overall running of the home and provides clear leadership encouraging input from staff, residents and relatives alike. Through discussion it was evident that she has a good knowledge base and has developed a good understanding of the needs of the residents. The home has developed improved quality assurance processes including a range of questionnaires, which have been collated from service users and relatives. The responses have been examined and action points taken forward and addressed. The owners of the home complete monthly monitoring visits and record the outcome of the inspections. The registered manager also completes regular audits covering topics such as medication and care planning. The homeowners have begun to invest in the updating of the environment demonstrating a positive development programme. The home provides safekeeping for resident finances and a number of ledgers were examined, which demonstrated that they are kept up to date and the figures tallied with the amount of money held. Receipts are kept for all incoming and outgoing transactions. A range of documents were viewed in relation to health and safety all of which were up to date. Fire safety and accident records are maintained appropriately. Environmental health assessments are completed and reviewed. Service and utility checks are completed with maintenance certificates held on file including electrical wiring, legionella tests, waste contract, gas safety and equipment servicing. The Corgi gas safety certificate had not been received, but there was evidence to demonstrate that this had taken place in February 2007. A copy of this certificate will be forwarded to the Commission for Social Care Inspection on receipt. Pine Lodge Retirement Home DS0000023989.V343227.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 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 2 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Pine Lodge Retirement Home DS0000023989.V343227.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 OP23 Regulation 12(1), 23(1)(2) Requirement Timescale for action 01/08/07 2. OP19 23(2), 16(2) To ensure that all double room are suitable for purpose and that residents sharing rooms have made an expressed choice to do so. To submit a detailed action plan 01/08/07 scheduling all environmental work to be undertaken within the home providing realistic timescales. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 Good Practice Recommendations To continue to develop care planning processes with an emphasis on the guidelines to enable staff to meet individual needs. Systems for monitoring and recording controlled drugs should be reviewed and updated. The medication room should be maintained at a suitable temperature at all times. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 26 OP9 3. 4. OP22 OP30 To commission an Occupational Therapy assessment of the service. To continue to develop the staff training programme. Pine Lodge Retirement Home DS0000023989.V343227.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Retirement Home DS0000023989.V343227.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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