Inspection on 09/10/07 for Pine Meadows Care Centre

This inspection was carried out on 9th October 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.

Other inspections for this house

Pine Meadows Care Centre 01/11/06

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 9th October 2007 11:00 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.V347225.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.V347225.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.V347225.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 November 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 £359.00 up to £589.00 weekly. Additional charges are made for newspapers, toiletries, hairdressing and chiropody. Pine Meadows Care Centre DS0000066464.V347225.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 one day, by one inspector. The inspection had been planned with information gathered from the CSCI database, the Annual Quality Assurance Assessment (AQAA) that had been completed by the care manager/provider, written feedback from residents and relatives via “Have Your Say” documents, and verbal feedback received during the inspection visit from residents and visiting 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, outlining the overall findings of the inspection, and the 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 9 complaints made to the home, since the previous inspection, these had been dealt with in a timely way under the home’s complaints procedure, by the care manager. Four of these complaints were upheld, 3 were partially upheld, and 2 were not upheld. All of the complaints were amicably resolved, and appropriately documented. There was a poor written response from residents and relatives in regard to requests for feedback about the home. At the time of this report there had been 4 `Have Your Say’ documents received, these are sent out by CSCI to residents at the home. However, verbal feedback and comments received were generally positive, for example “The staff work very hard to ensure that residents are looked after”. “The staff should be congratulated for their hard work in ensuring that the home is clean and free from malodours”. “I have only to ask a member of staff, and it is done”. There are two part time activities co-ordinators employed at the home, totalling 38 hours weekly. All previous requirements had been met, and there were two recommendations made as a result of this inspection. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Formal supervision for care staff is now up and running. Staff now have designated supervisors, and the care manager ensures that staff attend regular supervision meetings. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 7 Housekeeping, domestic and kitchen staffing levels had been reviewed, and sufficient levels of staff had been provided and maintained. A housekeeper had been recruited since the previous inspection, to oversee domestic tasks and staffing levels. An RMN has been employed on the Dementia Care Unit. The RMN will assist the care manager with pre-admission assessments, particularly with prospective residents who have mental health needs. Agency staff are no longer employed within the home as the home has no current vacancies 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 Meadows Care Centre DS0000066464.V347225.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.V347225.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): 1,2,3,5 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use this service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: Prospective residents and their relatives are given the home’s Statement of Purpose, and Service User Guide, and are invited to look around the home prior to making a decision. Information about the home is also available in each resident’s room. The care manager confirmed in the Annual Quality Assurance Assessment (AQAA) that each resident has an up to date and signed contract. These were available on the day of the inspection for the inspector to examine. Intermediate care is not provided by this home. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 10 A random sample of six individual pre-admission assessments and care plans were examined. These evidenced that pre-admission assessments are carried out for all prospective residents before they are offered a placement at the home. Pre-admission assessments are usually undertaken by either the care manager, or deputy care manager. In their absence, a senior member of staff will do this. The prospective resident or relative/representative would then be sent a letter to confirm that the prospective resident’s needs can be met by the home. A recently admitted resident met with the inspector, and discussed how pleased she was with her room, and how well she had been treated by staff since moving into the home. She said that she was very pleased with the home, and showed the inspector the information she had been given. She said that she was only to ask a member of staff for something, and it was done. The previous inspection report is also available to read at the home. Pine Meadows Care Centre DS0000066464.V347225.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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: A random sampling of 6 care plans was undertaken. These were sampled from each unit, i.e. Dementia Care, Residential and Nursing units. In line with case tracking, residents, relatives 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 seen were clearly and uniformly set out, and signed. The home continues to work with residents, their families/representatives, and local GP’s to determine a written plan of action/procedure to be taken in regard to `resuscitation’. Decisions made will be documented and included in the residents’ care plan where appropriate. Specific arrangements were also recorded in care plans, in regard to terminal illness. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 12 The GP continues to visit 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 administration on the Dementia Care unit was examined. Medication was appropriately stored, administered and recorded. Staff were observed appropriately and sensitively interacting with residents. Care plans seen evidenced that residents’ personal and nursing care needs were being planned and subsequently met on a continuous basis. The inspector discussed wound care, and the documentation of pressure areas and pressure sores. Information in relation to this was appropriately documented and recorded in care plans seen. Discussions with residents and staff in all units, 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 a poor written response from residents and relatives in regard to requests for feedback about the home. At the time of this report there had been 4 `Have Your Say’ documents received, these are sent out by CSCI to residents at the home. However, verbal feedback and comments received during the inspection visit were generally positive, for example “The staff work very hard to ensure that residents are looked after”. “The staff should be congratulated for their hard work in ensuring that the home is clean and free from malodours”. “I have only to ask a member of staff, and it is done”. Staff and residents said when asked, that dignity and privacy were upheld at the home, and that they were treated with respect by staff. Pine Meadows Care Centre DS0000066464.V347225.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. People who use this service are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The home has an ongoing programme of activities, which is provided by 2 part time activities organisers, totalling 38 hours weekly. The inspector noted that an activities schedule was displayed in the main entrance of the home. There are plans to increase the number of trips out next year for residents. 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. Individual spiritual needs were met by regular visits from both the Roman Catholic priest, and the Church of England Vicar. Residents and visitors spoken Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 14 with were aware of these visits, and confirmed that residents could attend if they wished to. Relatives and visitors spoken with at the time of this inspection confirmed that there were no restrictions in relation to visiting their relatives, and that they were able to visit any time. Visitors were able to see a relative in private. The inspector noted that residents were able to bring in small items of furniture, this was evident in bedrooms seen, and all bedrooms seen were personalised with residents’ possessions, i.e. photographs, ornaments, pictures etc. There is a hairdressing salon at the home, residents said they had the opportunity and choice to have their hair done weekly, the care manager confirmed that most residents at the home were using this service. Staff, relatives 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 sampled the lunch provided that day. This was salmon with mashed potato, and mixed vegetables, followed by home made jam tart and custard. The meal was well presented, tasty and was well balanced. Comments received following the meal, from residents 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 cook confirmed that she had made some alterations to the main menu, and was asked by the inspector that when reviewing the menus, to amend the menus accordingly, so that residents would know what was on offer that day. The care manager confirmed that menu covers for all dining tables were in the process of being ordered. The inspector suggested that menus should also be available in large print for residents. The kitchen and preparation areas were inspected. These areas could have been cleaner, and some of the shelving needed cleaning. This was highlighted and noted by the inspector, the cook said that there had been a kitchen staff member short, the day before. The cook and care manager confirmed that there had been an inspection by the Environmental Health Officer in February 2007. All recommendations from that visit had been completed. The inspector discussed the presentation of pureed food with the cook. The inspector noted that a Food Handling course was to be held on the day of the inspection, with a list of staff attending displayed on the notice board. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 15 Food, fridge and freezer temperatures had been appropriately documented and recorded. Pine Meadows Care Centre DS0000066464.V347225.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. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: There was a clear and accessible complaints and protection of vulnerable adults procedure in place at the home. The care manager confirmed that 9 complaints had been made to the home since the previous inspection. Of these 9 complaints, 4 had been upheld, 3 had been partially upheld, and 2 had not been upheld. All complaints had been appropriately documented and recorded, and had been amicably resolved. The care manager confirmed that she maintains a complaint audit log, which is copied and sent to the organisation’s head office. 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 Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 17 was highlighted at the previous inspection. Staff confirmed that POVA is covered during NVQ training. The home has an ongoing rolling training programme in place, and POVA training will be covered in October. Pine Meadows Care Centre DS0000066464.V347225.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, 22, 23, 24, 25 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The inspector toured the building, spoke with residents, and with visiting relatives. The home was generally found to be clean and well presented. However, there were areas in the kitchen that required further cleaning, these were highlighted by the inspector during the visit and a recommendation made. There had been a review of staffing levels in regard to domestic, housekeeping and kitchen staff, and a new housekeeper had been employed since the Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 19 previous inspection. The care manager confirmed that additional domestic cleaning hours had been implemented. Bedrooms seen were personalised, and had been adapted to suit the needs of the residents. The inspector spoke with visitors to the home, and with a newly admitted resident, they all confirmed their satisfaction with the home, and with the general environment and maintenance of the home. For safety reasons, and following risk assessment, some residents had been provided with beds 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. The care manager confirmed in the completed AQAA document that appropriate safety checks had been undertaken. These included hoists and the lift. 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. The home employs a full time maintenance person, and has an ongoing programme of carpet replacement, and room redecoration. Pine Meadows Care Centre DS0000066464.V347225.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 good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled, and in sufficient numbers to support the people who use the service. This is in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staff rotas and recruitment records were examined, and 4 members of staff were interviewed. The inspector recommended that all care staff should undertake training in relation to Dementia Care. The inspector was provided with a copy of the home’s training schedule to the end of this year, which showed a rolling programme of training for staff in relation to Fire Safety, Dying and Death, Food Handling, Manual Handling, Protection of Vulnerable Adults, Infection Control, Safe handling of Medicines, Health and Safety. 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 Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 21 been maintained. There had also been an improvement in regard to an increase in housekeeping/domestic hours for domestic cleaning and laundry. 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. The inspector noted that 4 Staff were about to undertake the Macmillan “End of Life” Care Pathway training. The AQAA confirmed that NVQ level 2 (or above) training for care staff is ongoing, almost 50 of care staff will have achieved this award by the end of the next intake/year. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. The home employs a full time administrator – 2 part time activities coordinators, a housekeeper, and a full time maintenance person. Staff spoken with, and the care manager, confirmed that care staff are receiving formal regular supervision as per the National Minimum Standard. This is an improvement upon the previous inspection visit. The care manager and staff spoken with confirmed that staff meetings and residents/relatives meetings are held on a regular basis. Pine Meadows Care Centre DS0000066464.V347225.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): 31,32,33,36,37 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: There was a poor written response from residents and relatives in regard to requests for feedback about the home. At the time of this report there had been 4 `Have Your Say’ documents received, these are sent out by CSCI to residents at the home. However, verbal feedback and comments received were generally positive, for example “The staff work very hard to ensure that residents are looked after”. “The staff should be congratulated for their hard Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 23 work in ensuring that the home is clean and free from malodours”. “I have only to ask a member of staff for something, and it is done”. Financial systems were not checked on this occasion. The AQAA document completed by the care manager, confirmed that records relating to the servicing and testing of equipment, fire alarms and emergency lighting were up to date. There is one full time maintenance person responsible for servicing and maintaining the home. The care manager provided the inspector with a training plan to the end of the year. Staff spoken with confirmed that they had attended mandatory health and safety training and moving and handling. 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 deputy manager has been given overall responsibility for the training of staff. 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 receiving formal supervision, and the care manager confirmed this. Domestic and kitchen staffing levels had been reviewed since the previous inspection. These were found to be adequate, and there were consistent levels of staff in those areas. Accidents and complaints had been appropriately dealt with by the care manager, documented, recorded and audited on a regular basis. 9 complaints had been received since the previous inspection. 4 complaints had been upheld, 3 complaints had been partially upheld and 2 complaints had not been upheld. All complaints had been amicably resolved. 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. The home is about to send out quality assurance questionnaires to relatives. That feedback is then audited by the care manager. Pine Meadows Care Centre DS0000066464.V347225.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 3 3 3 X 3 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 X 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Pine Meadows Care Centre DS0000066464.V347225.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. Standard Regulation Requirement Timescale for action 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 OP26 OP30 Good Practice Recommendations The general standard of cleanliness and hygiene in the kitchen and preparation area should be improved. All care staff should undertake appropriate training in regard to dementia care, and the management of aggressive and or violent behaviour. Pine Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Meadows Care Centre DS0000066464.V347225.R01.S.doc Version 5.2 Page 27 - 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!