Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 09/06/08 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 9th June 2008.

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

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 manager and newly appointed deputy manager work well as a team and demonstrated a strong commitment to improve the standards at the home. The manager provides clear leadership and direction to her staff. There is an open door policy. The Pines wing of the home provides a very comfortable and well-appointed environment for the residents with a good range of bright and comfortable spaces. Many improvements have been made to the Firs wing including updating and renewal of bathrooms and toilets and a new garden. Through staff training, the manager ensures that Equality and Diversity are promoted such as the introduction of Life History books. There is a positive and wide range of activities in the home. These have been enhanced both in respect of an additional activities organiser as well as the activities provided. Residents and their relatives are encouraged to raise any concerns they may have. Visitors are welcomed into the home and are consulted about the way the home is run. Staff are well trained and supervised. As evidenced in care plans seen, the manager makes good use of the internet to gain information for staff regarding medical conditions and medication.

What has improved since the last inspection?

The environment has improved considerably to the benefit of the residents as detailed in the report. Care planning has been further upgraded with an initial care profile and person centred care plan. Risk assessments have been developed and enhanced to include preventative measures. A number of health professionals such as occupational therapists, physiotherapists and district nurses have assisted and supported the home in providing a hazard free environment. Activities have been enhanced and extended. The use of shared rooms has been reviewed and currently one is used for single occupancy. Staff training has improved through accredited competence based training in topics such as medication, dementia, infection control, health and nutrition and equality and diversity. Good quality assurance systems have been introduced ensuring that residents` views are sought and an action plan devised to address any issues. Regular staff meetings are held.

CARE HOMES FOR OLDER PEOPLE Pine Lodge Retirement Home 32 Key Street Sittingbourne Kent ME10 1YU Lead Inspector Lisbeth Scoones Unannounced Inspection 9th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pine Lodge Retirement Home DS0000023989.V365315.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.V365315.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 pine.lodge@btconnect.com Mr Stephen Paul George Thompson Vacant Care Home 57 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Pine Lodge Retirement Home DS0000023989.V365315.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: Old age, not falling within any other category - (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 57. Date of last inspection 22nd June 2007 Brief Description of the Service: Pine Lodge Residential Home occupies two connecting wings of detached premises, with accommodation for 57 residents on two floors. The premises have been substantially extended and refurbished. It is registered for older people and for people with dementia. 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 nearby. The CSCI’s recent inspection report is on display. Weekly fees range from £328/£419 to £656. Pine Lodge Retirement Home DS0000023989.V365315.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 2 star. This means the people who use this service experience good quality outcomes. Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable The Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. This unannounced inspection was carried out over one day. It comprised discussions with the manager, deputy manager, members of staff and 8 residents. A tour of the premises was made and records pertaining to care planning, risk assessments, audit, medication records, menus, staff files, policies and procedures and staff training were examined. At all times the staff were helpful and co-operative. As part of the process for a Key inspection, services are requested to complete and return an Annual Quality Assurance Assessment (AQAA). This is a legal requirement, and provides information about how the service is performing; the AQAA was completed prior to the site visit. Other information about the service was obtained by sending out surveys to people who are using the service and staff working at the home. 8 Residents and 5 members of staff responded. Comments received are incorporated in the report. Since the previous inspection the CSCI has been aware of one complaint. This was investigated and has now been concluded. Two referrals to the safeguarding vulnerable adults team were made. One investigation has been concluded. The other has not and relates to the number of falls in the home. Appropriate action to rectify the situation has been taken and is on-going. Since the registered manager left in April 2008 there is no registered manager. Under the Care Standards Act 2000 it is an offence for a home to be run by any person who is not registered. The title ‘manager’ is used throughout the report as the person appointed by the Provider to be in charge of the day to day management of the home. Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The environment has improved considerably to the benefit of the residents as detailed in the report. Care planning has been further upgraded with an initial care profile and person centred care plan. Risk assessments have been developed and enhanced to include preventative measures. A number of health professionals such as occupational therapists, physiotherapists and district nurses have assisted and supported the home in providing a hazard free environment. Activities have been enhanced and extended. The use of shared rooms has been reviewed and currently one is used for single occupancy. Staff training has improved through accredited competence based training in topics such as medication, dementia, infection control, health and nutrition and equality and diversity. Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 7 Good quality assurance systems have been introduced ensuring that residents’ views are sought and an action plan devised to address any issues. Regular staff meetings are held. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pine Lodge Retirement Home DS0000023989.V365315.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.V365315.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): 1, 3 Quality in this outcome area is good Residents are provided with information that should be further improved. Residents only move into the home following an assessment of their needs thus ensuring that the home can meet these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection, the home has become registered to admit residents with a diagnosis of dementia. The Statement of Purpose has recently been updated reflecting this change as well as the change of manager and deputy manager. There is no Service User Guide but prospective residents are provided with a brochure and welcome booklet. Both documents are in need of additional information to meet the standard. Combining the two documents could be considered. Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 10 A number of care plans were perused and evidenced that a pre-admission assessment had been carried out to ensure that the home could meet assessed needs. This information is then used to devise a care plan. Pine Lodge Retirement Home DS0000023989.V365315.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, 10 Quality in this outcome area is good Residents’ needs are risk assessed and reflected in an individual plan of care. Regular risk assessment and care plan reviews are carried out. Residents’ health care needs are met. Residents are protected by the homes’ medication policy and procedures but a storage issue must be addressed. Residents are treated with respect and sensitivity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and her deputy manager have continued to work hard to improve the system for care planning. Further planned improvements were discussed to make care plans more person centred. Following a recent concern about the number of falls in the home, detailed comprehensive risk assessments have Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 12 been introduced in an effort to minimise the risk. District nursing staff, physiotherapists and occupational therapists have been involved in ensuring appropriate safeguards and suitable equipment. A Falls Prevention report has been compiled. Equipment identified as needed was ordered and arrived on the day of the inspection. Risk assessments are also in place to reduce the risk of pressure ulcer development and weight loss. Pressure-relieving equipment would be provided by the district nursing staff. Residents are regularly weighed. Where necessary, food and fluid charts are maintained. The manager has a weekly meeting with the district nursing staff. In relation to falls, these are audited, analysed and acted upon. Staffing levels have been reviewed and an additional member of staff employed for the 5-10 morning shift. This is the time that the staff are particularly busy. Medication reviews have been carried out. Residents spoken with were aware of and had been involved in the writing of their care plan. A signed agreement to that effect was seen in residents’ care plans. All care plans and risk assessments are reviewed monthly or when needs change. There was evidence that residents’ healthcare needs are met. Records are maintained of visits from district nurses, GPs, chiropodist and referrals to psychiatrist, optician and dentist. Whilst the care plan has a ‘doctor’s page’, not all visits or contacts made had been recorded. These were however recorded in the daily records. It was recommend that these are crossreferenced into the care plan to promote consistency. Medications were stored in a well-organised and secure manner and the home has the use of a drugs trolley. A monthly medication audit is carried out. Medication administration and recording procedures were examined and discussed with one of the team leaders. It was evident that she takes pride in ensuring that procedures are followed and medication ordered in a timely manner. MAR sheets were well maintained with the exception of the lack of a countersignature for handwritten entries. It was recommended that an initials list be available and kept with the MAR charts. A recent copy of the BNF (British National Formulary) is available but should ideally be kept with the medication for easy reference. Since the previous inspection, the ambient temperature in the medication rooms has been controlled ensuring it does not exceed 25 degrees Celsius. A change in legislation requires the home to have an approved CD cupboard for the safe storage of controlled drugs. A requirement was made for this to be in place within three months. Staff undergo competency assessments and supervised practice. Responsible staff are also completing accredited ASET medication training. Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 13 All residents spoken with confirmed that staff treat them with respect and that their privacy is maintained. A resident said, ‘The girls are good’. A relative said, ‘They care for my father very well’. Another resident said, ‘I have nothing but praise for the manager and all the staff. They listen and come and sit with you.’ The home has a hairdresser room and a hairdresser visits at least weekly Pine Lodge Retirement Home DS0000023989.V365315.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): Quality in this outcome area is good Residents can expect a lifestyle that meets their needs enabling contact with friends and family and exercising control. The manager endeavours to ensure that residents receive a healthy varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a wide range of activities for the residents. Since the previous inspection, in addition to older people, the home is registered to care for people with dementia. In order to ensure that all social needs are met and suitable activities provided, the home now employs two activities organisers. One activities person works every afternoon for 1.5 hours specifically with the dementia clients. An activities programme is on display. Activities in the home include quizzes, bingo, armchair exercises and arts and crafts. Outside entertainers visit the home on a regular basis providing music and entertainment. Mystery tours with cream teas have been secured with a local company. A resident said how much she had enjoyed a recent talk about Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 15 English Heritage. It is the manager’s intention to increase the leisure and social activities and provide better resources and outings. ‘Rummage’ boxes were seen in the lounges; a recent much enjoyed initiative. The manager discussed further improvements such as sensory features in a quiet room, the introduction of a library of listening classics for people with sensory impairment and reminiscence therapy. The gardens provide a safe and pleasant environment for the residents. One has a water feature and seating arrangements. A resident enjoyed sitting out in the sun with a relative. Residents’ families and friends are welcomed into the home at all reasonable times. 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 has information available regarding advocacy services should someone wish to access them. The manager and staff are trying hard to ensure that residents are provided with good and varied meals. The manager acknowledged that complaints have been made about the food. A comment card received made it clear that the resident was not happy. With residents’ involvement, through surveys, residents meetings and daily audits, the manager hopes to satisfy residents’ wishes and preferences. Recent initiatives have been additional side dishes for salads and individual gravy boats for those who wish it. Honey and marmite have recently been introduced. A resident said, ‘the breakfasts are very good’. Another said, ‘I have no complaints about the food’. 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. The kitchen was not visited at this inspection. Menus were seen on display. All staff receive Food Hygiene training and the chef has a level 3 in ‘hospitality’. Pine Lodge Retirement Home DS0000023989.V365315.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): Quality in this outcome area is good Residents’ 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. From discussion with the manager and the complaint file examined, it is evident that all complaints are taken seriously and responded to in a timely manner. The records include the action taken to prevent this from happening again. Residents spoken with said that their views are encouraged and they feel able to approach staff or the manager with any concerns they may have. There have been a number of complaints made since the previous inspection. Many of these are food related. See also standard 15. Both the manager and her deputy are adult protection trainers. The manager is also a trainer in challenging behaviour. Staff training is provided at induction and is ongoing as evidenced on the training programme. Staff spoken with demonstrated a good awareness of all issues that constitute abuse and knew the steps to take to report these. A whistle blowing policy is in place. At the time of the visit, one adult protection alert was open on the home. The manager is working hard to resolve the issues. Pine Lodge Retirement Home DS0000023989.V365315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good Residents live in a pleasant, safe, clean and improved environment. 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 two-storey extension providing a bright, comfortable, wellmaintained and safe environment for 42 residents. Apart from two shared rooms all rooms are single with en-suite facilities and meet the required standards in respect of size. The original part of the home is named ‘The Firs’ and provides accommodation for 15 residents. It is of a very different character and has since the previous inspection been updated and renovated. Following an occupational therapy assessment, bathrooms and toilets have been upgraded or renewed. With Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 18 residents’ input a new garden has been installed. The manager said that this area would be further improved with a wooden gazebo for residents to enjoy. As recorded at the previous inspection, there are five shared rooms at the Firs. These do not meet the minimum 16 sq metres space requirement. The use of these shared rooms has been reconsidered and one of these is now used as a single. As stated at the previous inspection, the manager must ensure that residents make an expressed choice to share a room where it meets the necessary requirements. An incident was discussed regarding two sharing residents and the manager is trying to address this issue. Current screening is not suitable to ensure the privacy of each resident. The manager said that suitable curtain screening would be provided. Residents also share one sink with a screening curtain. It was noted that this limited space was obstructed with one or two commodes. The manager said she would review the situation. Further improvements include the replacement of the kitchen floor. The home was clean and hygienic throughout with hazardous substances kept in locked cupboards and appropriate infection control procedures. Since the previous inspection, the home has a new laundry. A resident said that the laundry service was excellent. Pine Lodge Retirement Home DS0000023989.V365315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good There are adequate numbers of well-trained staff on duty at all times. Staff are employed in accordance with good recruitment procedures but staff files must be better maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs care staff, catering, domestic staff and laundry staff, a fulltime maintenance man and two activities co-ordinators. A flexi-bank has been established so that when the home needs additional carers there is a group of experienced, trained staff who can cover required shifts. Many staff have worked at the home for a long time. It is the manager’s intention to retain recently employed staff. New staff are provided with Skills for Care compliant induction programme incorporating the Common Induction Standards and competency assessments. They have a period of work shadowing with a senior staff member. On comment cards staff reported that their induction had been very good. The home operates with 6 care staff throughout the day and 4 waking night staff. As already referred to, an additional 5 to 10 morning shift has recently Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 20 been introduced. 4 care staff are allocated to work in The Pines and 2 staff work in The Firs. The manager said that staffing levels are kept under constant review as the dependency and number of residents change. Currently there are four team leaders and a senior carer. The manager said she hopes to appoint a permanent team leader for night duty. The manager and her deputy work office hours but also work hands on at weekends and at night. There is an on-call system out of hours. The manager and her deputy have invested much time and effort in updating and improving the staff development programme from induction through to National Vocational Qualifications (NVQ). 37 of staff members have achieved an NVQ level 2 or above with 33 staff working towards the award. Team leaders have an NVQ 3 and 12 are working towards this. All staff are required to attend mandatory training. A clear commitment to training is evident and staff spoken with said they were happy with the training opportunities. Additional training is provided in a range of other topics including dementia care, the Mental Capacity Act, care planning, wound care, adult protection and Equality and Diversity. Further training is provided by district nurses in topics such as continence and catheter care and Diabetes management. Since the previous inspection, a comprehensive employee handbook has been devised for all staff members. Job descriptions clearly identify roles and responsibilities. A number of staff personnel files were viewed. These are in urgent need of review as some pertinent information such as references and CRB’s was missing. The missing information was later found. It was agreed that all staff files would be audited as part of the home’s quality assurance. Pine Lodge Retirement Home DS0000023989.V365315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good The provider must appoint a registered manager to ensure the home is run in the best interests of the residents. Residents’ financial interests are safeguarded and their health, safety and welfare promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager recently left and the home is currently run by the previous deputy manager assisted by a recently appointed deputy. At the time of the inspection no application for registration of a manager had been submitted to the Commission. A requirement has therefore been made that an Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 22 application for registration be submitted in respect of the current manager Ms Eve Fielding within three months. It is the responsibility of the provider to ensure that services in his ownership comply with all the requirements of the relevant legislation. The new manager has many years of experience in care home settings. She has an NVQ 4 in care and is working towards the Registered Manager’s Award (RMA). The deputy manager has the RMA and has signed up for the NVQ 4 in care. In a relatively short time, the manager has made significant improvements to the overall running of the home and provides clear leadership encouraging input from staff, residents and relatives. Through discussion it was evident that she has a good knowledge base and understanding of the varied needs of the residents. She has a clear vision on how the service could be improved further. The home has developed improved quality assurance processes including an annual survey with residents, relatives and friends. Results are fed back to all parties and an action plan devised to address any issues. Residents/relatives meetings take place every two months. Suggestion boxes in reception areas give another opportunity to give feedback. Whilst the registered provider visits the home regularly, no formal records are maintained which is a requirement of this report. The manager carries out regular audits such as medication and care planning. As identified in standard 29, staff files need to be included. Policies and procedures are regularly reviewed. The environment is upgraded and maintained as part of the home’s ongoing development programme. A quality matrix is in place. Good arrangements are in place to safeguard residents’ finances. Records of monies paid in and receipts of monies spent were examined and in good order. From information provided in the AQAA, it is ascertained that all maintenance and safety checks and services are carried out when due. Accident and incident records are maintained and the CSCI informed of any reportable events as per Regulation 37. Pine Lodge Retirement Home DS0000023989.V365315.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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 3 2 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 3 x 3 Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement That a CD cupboard be purchased that meets the Misuse of Drugs (Safe Custody) Regulations 1973 That monthly visits are carried out, recorded and filed at the home to be available for inspection That an application for registration be submitted within three months in respect of the current manager Ms Eve Fielding Timescale for action 30/09/08 2 OP33 26 (1) (4) (a) (b) (c) 8 (1 (b) (i) 31/07/08 3 OP31 09/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pine Lodge Retirement Home DS0000023989.V365315.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone 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.V365315.R01.S.doc Version 5.2 Page 26 - 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!