Inspection on 01/11/06 for Pine Meadows Care Centre

This inspection was carried out on 1st November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pine Meadows Care Centre 09/10/07

Pine Meadows Care Centre 01/02/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Pine Meadows Care Centre Park Road Leek Staffordshire ST13 8XP Lead Inspector Pam Grace Key Unannounced Inspection 1 November 2006 15:00 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 Meadows Care Centre DS0000066464.V316648.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 Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Meadows Care Centre Address Park Road Leek Staffordshire ST13 8XP 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) 01538 392520 01538 392530 pine.meadows @fshc.co.uk Four Seasons 2000 Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Barbara Jackson Care Home 70 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Mental disorder, excluding learning of places disability or dementia (2), Old age, not falling within any other category (70), Physical disability (50), Physical disability over 65 years of age (25) Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 20 Dementia (DE) - Minimum age 60 years on admission. 2 Mental Disorder (MD) - Minimum age 50 years on admission. Nursing day care services for 5 persons who are either elderly persons over 60 yrs, or suffering from PD aged 30 - 50 years - 5 beds. 50 Physical Disability (PD) - Minimum age 60 years on admission. 10 Physical Disabilities (PD) - Aged 30-60 years. LD(E) - two named service uses for the duration of their contract. Date of last inspection 1st February 2006 Brief Description of the Service: Pine Meadows Care Centre is a purpose built establishment consisting of two floors. The establishment is set in landscaped gardens and is close to Leek town centre and local amenities. The establishment is divided into three units; Acorn, Fir Cones and Chestnuts. Fir Cones Unit is a separate 20 bedded Dementia Care Unit, and is located on the first floor of the establishment. The Acorns unit provides personal care to elderly and younger service users with physical disabilities, and the Chestnut unit provides personal care and nursing care to elderly service users and younger service users with physical disabilities. There is ample dining and sitting accommodation provided on all three units. Fees at the time of this report range from £263.00 up to £550.00. Additional charges are made for newspapers, toiletries, hairdressing and chiropody. Pine Meadows Care Centre DS0000066464.V316648.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 was carried out over two days, by one inspector. The inspection had been planned with information gathered from the CSCI database, the Pre-Inspection Questionnaire that had been completed by the provider, and comment cards received from residents and relatives. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, residents and visiting relatives. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the care manager, and deputy manager, outlining the overall findings of the inspection, and the requirements and recommendations made. Residents spoken with were very positive about the care they were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. There had been five complaints made to the home, since the last inspection, these had been dealt with in a timely way under the home’s complaints procedure, by the care manager. Two of these complaints were upheld, and appropriate action taken. All of the complaints were dealt with by the care manager, and documented appropriately. There was a poor response from health professionals, residents and relatives in regard to requests for feedback about the home. Feedback and comment cards returned to the inspector totalled 1 `Have Your Say’ document, and 4 comment cards from relatives. However, feedback and comments received were generally positive, for example `I think the carers do their very best’. There are three part time activities co-ordinators employed at the home, totalling 38 hours weekly. All but one of the previous requirements were met. There were 2 requirements – and two recommendations, made as a result of this unannounced inspection. What the service does well: Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 6 The management and staff make the residents’ visitors and relatives welcome, and there are frequent visitors to the home. Health care awareness was evident, with the importance of any changes in health status and mental health, being continually monitored by appropriately trained, caring and diligent staff. Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Residents spoken with were very positive about the care that they were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. The home provides a co-ordinated programme of activities totalling 38 hours weekly, undertaken by three part time activities co-ordinators. Residents are individually assessed, and a personal/social history is recorded, in order to provide suitable activities for residents. The home was clean, warm and comfortable. Care plans seen were clearly written, and reviews were up to date. They evidenced that service user’s health and social care needs were being met. What has improved since the last inspection? What they could do better: Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 7 Care staff had not received supervision as per the National Minimum Standards (NMS). Housekeeping and kitchen staffing levels need to be reviewed, and sufficient levels of staff must be maintained. Rotas evidenced that there were shortages of housekeeping staff to cover weekend duties, and that kitchen staffing levels were inconsistently maintained. 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 Meadows Care Centre DS0000066464.V316648.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 Meadows Care Centre DS0000066464.V316648.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,and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are given sufficient information about the home and are able to make an informed decision on whether the home can meet their assessed needs. Each resident had a signed contract; following a full pre admission assessment to ensure their needs could be met in the home. The resident or relative receive a letter to confirm this. Prospective residents and their relatives are invited to look around the home prior to making a decision. Intermediate care is not provided by the home. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 10 EVIDENCE: A random sample of twelve individual pre-admission assessments and 12 care plans was examined. These evidenced that pre admission assessments are carried out on all individual residents before they are offered a placement at the home. Discussions with the care manager confirmed that she or the deputy manager usually carry out these assessments prior to admission. In their absence a senior member of staff will do this. The Statement of Purpose and Service User Guide provide information about the home. These are available to social workers, prospective residents and their families/representatives. The previous inspection report is also available to read at the home. The care manager stated that prospective residents and their families are welcome to come and visit the home and have a look around before admission. Pine Meadows Care Centre DS0000066464.V316648.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. This judgement has been made using available evidence including a visit to this service. Residents felt safe and well cared for and personal and nursing care was delivered with dignity and respect. EVIDENCE: A random sampling of 12 care plans was undertaken. In line with case tracking, residents and staff were spoken with. Appropriate risk assessments were evident in care plans seen. Wound treatment records were clear and up to date, and visits by health professionals were well documented. Care plans have vastly improved, in that they are signed, are clearer and easier to read, and have been placed into files that are appropriately and uniformly set out. The home is working with residents, their families/representatives, and local GP’s to determine a written plan of action/procedure to be taken in regard to `resuscitation’, this will be documented and included in the residents’ care plan Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 12 when appropriate. The inspector recommended that specific arrangements should be recorded in care plans, in regard to terminal illness. The GP visits the home at least once weekly to see residents who require a medical review. Additional visits can also be requested if required. Service users are protected by the home’s policies and procedures for dealing with medicines. Medication is appropriately stored, administered and recorded. Staff demonstrated a personal empathy with residents through a respectful, yet friendly discourse. Care plans seen evidenced that residents’ personal and nursing care needs were being planned and subsequently met on a continuous basis. Discussions with residents and staff confirmed the above. All of the residents spoken with felt very happy with the care they were receiving in the home. Residents who were unable to communicate looked comfortable, and well cared for. There was also positive feedback received on comment cards and the `Have Your Say’ questionnaires, for example `I think the carers do their very best’. Visiting relatives discussed the need for their relative to have chiropody with the inspector. Those relatives confirmed that they were otherwise satisfied with the care that their relative received. When asked whether dignity and privacy were upheld at the home all of the residents spoken to confirmed this and commented that the staff treated them with `respect’. Pine Meadows Care Centre DS0000066464.V316648.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social, spiritual and recreational needs of residents were generally being met at the home. The quality and choice of meals for residents are satisfactory. Residents exercise choice and control, and maintain contact with family, friends, their representatives and the local community as they wish. EVIDENCE: There is an ongoing programme of activities within the home, which is provided by 3 part time activities organisers, totalling 38 hours weekly. The inspector noted that an activities schedule was displayed in the main entrance of the home. The activities organisers undertake an assessment of individual residents needs, including a personal history. This is then recorded and documented, and enables a more tailored approach by staff, towards activities for residents. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 14 Individual spiritual needs were met by regular visits from both the Roman Catholic priest, and the Church of England Vicar. Residents and visitors spoken with were aware of these visits, and confirmed that residents could attend if they wished to. At the time of this inspection visitors were seen freely entering and leaving the home. Visitors spoken with were not aware of any restrictions placed upon them, apart from the avoidance of visiting during mealtimes. Visitors were able to see a relative in private. Residents were able to bring in small items of furniture and bedrooms were personalised with residents’ possessions. There is a hairdressing salon at the home, residents said they had the opportunity and choice to have their hair done, the care manager confirmed that most residents at the home were using this service. Staff and residents spoken with said that the routines within the home were quite flexible although meals needed to be taken within a time framework. Residents were able to get up when they wanted. Residents were able to spend time in their rooms or in the communal areas. The inspector spoke with many residents in regard to the quality and the quantity of meals offered at the home. Comments received were very positive. Staff were observed taking meals to residents who were on bed rest, and discreetly assisting those residents with eating and drinking. Some residents spoken with said that they were able to eat in their own room. 4 weekly rotational menus were seen during the inspection of the kitchen. The menus offered a balanced dietary content. The kitchen was clean and tidy, and a real improvement upon the previous inspection. The daily cleaning rota for the kitchen was clearly set out, it documented which areas of the kitchen had been cleaned, and what equipment had been cleaned in the kitchen, by which member of staff. There was also a daily record of what food had been given to residents. Fridge and freezer temperatures had been appropriately documented and recorded. Pine Meadows Care Centre DS0000066464.V316648.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place help to protect residents from harm and enable them to raise concerns should they have any. EVIDENCE: There was a clear and accessible complaints and protection of vulnerable adults procedure in place at the home. The care manager stated that she takes all concerns and complaints seriously and addresses them according to the procedure. She maintains a complaint audit log, which was seen by the inspector. There had been 5 complaints received by the home since the previous inspection. These had all been well documented, and dealt with by the care manager in a timely way. Two of those complaints had been upheld, and appropriate action taken. Residents and relatives spoken with confirmed that they would know who to approach should they have any concerns or complaints. Staff spoken with confirmed that they were aware of the need to monitor the safety of residents and to protect them from any form of abuse. POVA training for all staff is planned in the next few months. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for its stated purpose. Service users live in a safe, clean and comfortable environment, which has been adapted to suit their lifestyle, and individual needs. There has been a real improvement in the general cleanliness of the home, and the kitchen. EVIDENCE: The inspector toured the building, spoke with residents, and with visiting relatives. The home was found to be clean and well presented, and there had been a real improvement in the general cleanliness of the home and the kitchen. However, there were inconsistencies in the domestic and kitchen staff rota. There were insufficient numbers of domestic staff on duty at weekends, and the kitchen staff rota showed inconsistent numbers of staff on Mondays and Tuesdays. This was discussed with the care manager, and a review of staffing levels in those areas will be undertaken. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 17 Bedrooms seen were personalised, and had been adapted to suit the needs of the service users. The inspector and the care manager confirmed during a tour of the building, that all wardrobes were either fitted, or fixed to the wall for safety. For safety reasons, and following risk assessment, some residents had been provided with beds which were of the `futon’ type, and were situated lower to the floor (some with crash mats). As a directive from Four Seasons Health care, these are now being used by the home instead of divan beds with bedrails. Various aids and adaptations were in place including assisted baths, mobile hoists and other equipment used for moving and handling of service users. There was a nurse call bell in operation, which was seen and heard to be working at the time of the inspection. One of the assisted baths had been renewed/replaced. The home employs a full time maintenance person, and has an ongoing programme of carpet replacement, and room redecoration. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. The numbers of care staff provided were found to be sufficient to meet the needs of the residents at the time of the inspection. Staff training is well underway. However, domestic and kitchen staffing levels were inconsistent, and not maintained. Care staff spoken with confirmed that they are not receiving supervision as per the National Minimum Standards (NMS). EVIDENCE: Staff rotas and recruitment records were examined, and 5 members of staff were interviewed. Staff training records were not examined on this occasion. The inspector requested that the home’s training schedule is forwarded to CSCI. Staffing levels are based on the dependency levels of service users in the home and these are reviewed on a regular basis. Rotas showed that care staffing levels were sufficient to meet the needs of the residents, and have been maintained. However, staffing levels had not been maintained in regard to sufficient housekeeping hours for domestic cleaning and laundry, and kitchen staffing hours, which were inconsistently maintained, this was discussed with the care manager. It is a requirement of this report that domestic and kitchen staffing levels are reviewed, and that sufficient levels of staff in those areas are maintained. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 19 Discussions with various staff members identified that mandatory staff training had taken place on a regular basis including moving and handling, fire safety and fire drills. Kitchen staff spoken with confirmed that they had not received food hygiene update training, but had received in house training updates for food hygiene. The care manager confirmed that this will be undertaken in the next few months. This will be monitored at the next inspection. POVA training was discussed and the deputy care manager confirmed that he has been delivering this to all disciplines of staff. He also confirmed that all members of staff on the EMI unit had received Dementia Awareness training and the management of difficult aggressive behaviours. NVQ training was on going, and 37 of care staff had undertaken this, with 5 care staff currently undertaking the award. COSHH training had been delivered and all staff spoken to were aware of the relevance of the data sheets. The manager confirmed that the home does not currently employ RMN nursing staff. This had been discussed in depth, at the previous inspection, and it was recommended by the inspectors that qualified staff should undertake appropriate training in regard to dementia care, and the management of aggressive and or violent behaviour. The inspector noted that the care manager had received information from a College in respect of this training, and a course is due to commence within the next few months. This will be monitored at the next inspection. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. The home employs a full time administrator – 3 part time activities coordinators, and a full time maintenance person. Staff spoken with and the care manager confirmed that care staff are not receiving regular supervision as per the National Minimum Standard. It is a requirement of this report that all care staff must receive supervision 6 times yearly, as per the NMS. A sample of recruitment files were made available for inspection purposes, from those seen there was evidence that the home’s recruitment practices were satisfactory. The care manager confirmed that staff meetings and residents/relatives meetings are held on a regular basis. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 20 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): 31,32,33,34,36, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The stability and effectiveness of the management at the home is ensuring that the home runs smoothly and in the best interests of the residents who live there. However, there is a shortfall in regard to the maintenance of staffing levels for domestic and kitchen staff, and care staff are not receiving supervision as per the NMS. EVIDENCE: The inspector had received a poor response to CSCI’s request for feedback. 1 ‘Have your say’ document, and 4 comment cards were received. This was discussed during the inspection visit, with the care manager. The general theme of these was that residents and relatives were happy and satisfied with the service that they and their relatives receive in the home. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 21 Financial systems were spot checked and found to be in good order due to the robust recording systems in place and positive management of the home. Records relating to the servicing and testing of equipment, fire alarms and emergency lighting were up to date and well documented. There is one full time maintenance person responsible for servicing and maintaining the home. The care manager and staff spoken with confirmed that staff have attended mandatory health and safety training and moving and handling. The home’s staff training schedule was not inspected on this occasion. The inspector requested that a copy of the schedule is forwarded to CSCI. Staff, residents and visiting relatives spoken to were complimentary about the care manager and confirmed that she was approachable and supportive. The care manager was well supported by a deputy manager, who had worked at the home for several years. The CSCI receives a monthly report from the home’s operations manager as per Regulation 26 requirements. Care staff spoken with stated that they were not receiving formal supervision, and the care manager confirmed this. Domestic and kitchen staffing levels need to be reviewed, and consistent levels of staff in those areas maintained. Accidents and Complaints had been appropriately dealt with, documented, recorded and audited on a regular basis. Complaints are being dealt with appropriately, and in a timely way, using the home’s internal complaints procedure. Residents and their relatives are aware of how to make a complaint if they wish to. The manager, staff, and residents spoken with confirmed that resident and staff meetings are being held. 20 Quality assurance questionnaires are sent out to relatives each month, and feedback is audited by the care manager. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 X 2 Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 23 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 OP27 Regulation 18 (1) Requirement Housekeeping and kitchen staffing levels must be reviewed, and sufficient levels of staff must be maintained in all areas over a seven-day period. Agency and bank staff must be used where shortfalls cannot be covered. Previous timescale of 01/02/06 not met All care staff must receive supervision as per the National Minimum Standards. Timescale for action 30/01/07 2. OP36 18 (2) 30/01/07 Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 24 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 OP30 Good Practice Recommendations Specific wishes in regard to terminal illness should be recorded and documented in residents’ care plans. Qualified staff should undertake appropriate training in regard to dementia care, and the management of aggressive and or violent behaviour. Pine Meadows Care Centre DS0000066464.V316648.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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