Inspection on 15/11/07 for Pine Trees

This inspection was carried out on 15th November 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 Trees 28/05/09

Pine Trees 26/10/06

Pine Trees 27/02/06

Pine Trees 11/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Pine Trees 15 Horsepool Road Connor Downs Hayle Cornwall TR27 5DZ Lead Inspector Diana Penrose Unannounced Inspection 15th November 2007 09:20 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 Trees DS0000062885.V350341.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 Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pine Trees Address 15 Horsepool Road Connor Downs Hayle Cornwall TR27 5DZ 01736 753249 01736 759261 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) Guardian Care Homes (uk) Ltd Mrs Frances Catherine Winsor Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: Pine Trees Care Home is situated in the village of Connor Downs between the towns of Camborne and Hayle. There is ample car parking at the front of the home and a footpath that leads to the main entrance. Well-maintained grounds with colourful flowers surround the home. The building is a detached bungalow with a modern extension. There are 23 single rooms and one shared room. Accommodation and facilities are on one floor. All bedrooms have a door opening onto a walkway surrounding the building. These cannot be accessed from the outside when closed. Suitable ramps and grab rails are in situ. Meals are prepared in a well-equipped kitchen and served in the spacious dining room, or individual bedroom if preferred. There is a large lounge with an adjacent conservatory. There is a patio outside with garden seating and tables. The home provides residential care for up to twenty-five elderly people. The home also provides day care and respite facilities. The Registered Manager is a qualified nurse who, along with a team of suitably experienced care staff, provides personal care within a relaxed and friendly atmosphere. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £358 to £436 per week; this information was supplied during this inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Inspector visited Pine Trees Care Home on the 15 November 2007 and spent eight hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection 23 residents were living in the home, one of these was receiving respite care. The methods used to undertake the inspection were to meet with the residents and the deputy manager to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. The registered manager has completed an Annual Quality Assurance Assessment and the information provided has also been used. This report summarises the findings of this inspection Residents expressed satisfaction with the care and services provided at the home and said they are treated with kindness and respect. Overall the home is providing a good quality of care to the residents placed there. What the service does well: The registered persons provide a very well managed service for the people accommodated and residents are positive about the care provision and facilities provided. Staff are perceived as kind and caring and the home has a relaxed and welcoming atmosphere. Residents said they are able to live their lives as they choose and the daily routines are flexible. The home has a comfortable homely environment that is very clean and well maintained. There is ample sitting and dining space and spacious grounds that are accessible to residents. Residents are only accepted into the home following an assessment of their needs. From this each resident has a written care plan detailing their individual requirements; this directs staff on how best to meet their needs. The plans are compiled with the resident, reviewed regularly and signed. Doctors, nurses and other healthcare professionals visit the home to provide care when necessary. Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 6 Equipment is provided for moving and handling purposes and for the prevention of pressure sores. Resident’s say their privacy and dignity is respected at all times and this appeared to be so during the inspection. A range of entertainment, outings and activities are on offer and residents can join in as they wish. Staff said they try to spend time on a one-to-one basis with residents as well. Residents are able to maintain contact with their family and friends according to their wishes. Visitors are welcome in the home and some residents go out with their families. The food served is to a good standard with homemade cooking, fresh fruit and vegetables. Special diets and individual needs are catered for. All residents spoken with said the food is generally good. Residents said there are enough staff on duty to care for them. 70 of care staff have an NVQ qualification in care or are working towards one. Records, policies and procedures are maintained to a good standard. Quality assurance systems are in place for continuous improvement of the service. Health and safety precautions are well maintained and there are suitable systems for dealing with complaints and abuse; all of these help to safeguard the residents. Residents said they could approach the manager or any of the staff if they had a problem. What has improved since the last inspection? What they could do better: The system for medicines must be reviewed and practice improved to safeguard residents. The medicines policy is held in a file in the registered managers office, it should be more accessible to staff administering medicines Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 7 along with other guidance such as that provided by the The Royal Pharmaceutical Society. Anything handwritten on the medicine administration record charts must be witnessed and signed by the person writing the order and by a witness. This will help to ensure that the correct order has been recorded. The name of the person authorising any change, normally a doctor should also be stated. As the doctor is accountable it is better that he or she makes the changes to the chart It is acknowledged that the community nurses are responsible for the administration of insulin to one resident. The insulin is at present stored in the fridge in the kitchen. Any insulin vials or cartridges which are not open should be stored in a fridge between 2º and 8ºC. Any open insulin vial or cartridge can be safely stored at room temperature. For better injection comfort and insulin efficiency, it is advisable that insulin is administered at room temperature; cold insulin increases the pain of the injection and slows down the insulin absorption. The manufacturers guidance must be referred to. All medicines administered must be signed as given or a reason recorded if they are not given. This is good practice and makes it easier to audit medicine administration. Resident’s medicines must be regularly reviewed and prescriptions updated to ensure best practice. The registered provider must ensure that suitable specialist bathing and showering facilities, are provided. This will ensure the needs of elderly frail people are met. At present the facilities are unsuitable and unsafe. 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 Trees DS0000062885.V350341.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 Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide appropriate care. EVIDENCE: The deputy manager said that prospective residents and their family are encouraged to visit the home to have a look around. During their visit she or the registered manager undertakes an assessment of their care needs. If necessary one of them goes out to visit the person in his or her own home or in hospital. She said that quite often a new admission has already attended the home for respite care. The assessment form is detailed and covers all of the areas listed in standard 3.3. Assessment information from Adult Social Care and discharge information from hospital is obtained where appropriate. On admission to the home another assessment is undertaken and a care plan compiled. Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 10 Two new admissions files were inspected and suitable assessments have been undertaken. The deputy manager was reminded that all paperwork pertaining to an individual should bear their name and should be dated and signed as appropriate. Pine Trees DS0000062885.V350341.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. Residents said their healthcare needs are met and they have care plans to ensure that staff know how to care for them. There is a medicines system that is generally good; extra attention in some areas will ensure a safer system EVIDENCE: Two residents were case tracked and other care plans examined at random. The Company documentation requires a wealth of information and includes risk assessments for pressure sores, falls, nutrition, moving and handling and mobility. Most of the criteria listed in NMS 3.3 has been included for individuals. Staff must ensure that risk assessment information is included in the actual care plan. The plans are pre-printed and not very personalised. The deputy manager has been completing the non-printed sheets effectively to include more information. She is trying to improve the daily records and has compiled report files for each room. The use of these was discussed at a staff meeting during this inspection. A sheet for recording GP requests and visits has been implemented. There is evidence that care plans are compiled with the resident or their representative and some have been signed by the resident. Reviews take place one to six monthly depending on the individuals needs. Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 12 Resident’s said their healthcare needs are met and that doctors and nurses visit regularly. Suitable equipment is available to staff for moving and handling purposes and pressure relief. No resident’s have pressure sores but two have special mattresses. The deputy manager said a continence audit is due but there are no problems with pad supplies. The home has a medicines policy and staff said it is kept in the office. The deputy manager was advised to keep a copy more accessible to staff. Two residents are self administering their medicines and have signed to agree to this. They have a lockable drawer in their rooms. The medicine records were examined, there are some gaps on the administration charts with no explanation recorded as to whether the medicine has been given or not. There are several charts with handwritten instructions on them, some of which are confusing. The instructions have not been signed by the person writing them or witnessed. Some residents appear to need a review of their medicines as they are either not taking a regular prescription as instructed or an ‘as required’ medicine is being administered very regularly. Most charts had a photograph of the resident for identification purposes. There did not appear to be any homely remedies used but staff were not sure; the deputy manager said she would check and ensure the policy states none in use if that is applicable. Reference books are available to staff but the The royal pharmaceutical guidelines for care homes are not. The deputy manager was informed that there are now new guidelines available. Staff administering medicines have received training from the pharmacy and some training is included on induction. One resident has insulin that is administered by the community nurses. The insulin in use should be stored at room temperature and not in the fridge. The fridge is one that is used for food and the temperature has been recorded regularly. No controlled drugs are held. Residents’ privacy appeared to be upheld during the inspection. Residents said they are treated with respect and their privacy is maintained at all times. Residents said they receive their post unopened and the telephone arrangements in the home are satisfactory each room has a direct line. Pine Trees DS0000062885.V350341.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. Entertainment and activities are on offer, visitors are welcomed and residents are encouraged to live a life of their preference. EVIDENCE: Activities and entertainment are on offer and there are posters in the office. A new activities co-ordinator has only just been employed, she was in the home on a training session during the inspection. She was playing a board game with some residents in the lounge and other staff were there as well, they all interacted well with the residents. Her predecessor appears to have worked hard to establish activities in the home and both residents and staff spoke highly of her. Residents spoken with are happy with the activities on offer Activities include bingo, singers, entertainers, crafts, art and games. Outings have been organised and residents talked about a forthcoming fish and chip supper that has been arranged for residents and families. Those not going out can have fish and chips at the home if they wish. A trip to see Christmas lights is planned, with sherry and mince pies on return. A small shop in the home is also planned. Resident’s social activities are recorded the deputy manager Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 14 intends to ensure that these are held in the resident’s files rather than in different places. There is a record of visitors to the home and there were visitors in the home during the inspection. Residents said they could receive visitors in private and at any time. Visitors spoken with said they are made very welcome in the home and can call whenever they like. Residents said there are very good telephone arrangements with a direct line in each bedroom. All residents spoken with said their individual preferences are respected and they are supported to maintain their independence. They said they are free to go out when they wish and some visit their families. The daily routines are flexible to suit them for example going to bed and getting up in the morning. All residents control their own money with the help of their families. All residents have their own belongings in their rooms. One resident said, “It is not like home but I’m getting used to it”. A nutritious menu is on offer, it has a set meal at lunchtime but the cook said there are alternatives available and records are kept of those who have something different. One resident said he could have something different if he likes but another said she doesn’t like beef so just has vegetables. Everyone seemed to enjoy the lunchtime meal, which was roast beef followed by lemon mousse. Fresh fruit and vegetables are included, there was a good stock held the cook said that cakes are homemade. There was a homemade cake for a resident’s birthday in the kitchen. Residents said the food is good and comments include, “The food is wonderful!” “There is no choice for lunch but plenty of choice at tea time”, “The food is basic but we can have something different if we want”, “The veg is lovely, very good for us” and “The vegetables are over cooked and soggy” (two people made this comment). Pine Trees DS0000062885.V350341.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. There are suitable policies in place for complaints and adult protection and staff receive appropriate training to make sure that residents are safeguarded. EVIDENCE: There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been three complaints to the home since the last inspection; they have been suitably dealt with. Thank you letters and cards are kept in the home. The home has an appropriate adult protection policy, staff said they had read this and signed a sheet. In house training takes place and the deputy manager has attended the County Council ‘No Secrets’ training. There was a copy of the alerters guide and posters in the managers office. There has been one adult protection issue at the home since the last inspection regarding the care of a resident. This was referred to the department of adult social care and investigated under their procedures. The allegations were partially substantiated and addressed. Residents said there are no barriers to raising concerns with any of the staff. Pine Trees DS0000062885.V350341.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, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean with no unpleasant odours and the building and grounds are well maintained. It is a pleasant environment but a review of the bathing facilities will make life more enjoyable and safer for the residents accommodated. EVIDENCE: The home is warm, homely and comfortable it is well ventilated and there is domestic style lighting. The building is spacious and on one level with suitable grab rails provided. Several residents said that the fact it is a single storey building helped them decide to live at Pine Trees. It is well furbished and decorated throughout, more new chairs, bed tables and commodes have been purchased since the last inspection. A new fire system has been installed. Residents said they are happy with their rooms and the furnishings provided. Residents and staff said they do not like the bathing facilities. The medi bath is Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 17 very old and not suitable anymore. Staff said it takes a long time to fill up and it is not easy to wash people when they are in it. One bath is not used and the other is very small and not equipped for assisted bathing. A shower room was talked about at the last inspection but has not yet materialised. One resident said she is too old to get in the bath at the home. Residents said the hot water is always going off and makes bathing a bit hit and miss. The hot water was off during this inspection and a plumber came to sort it. He was asked to send a quote for the installation of a new boiler. The deputy manager stated that the Company hope to extend the home and facilities in the near future. This is also stated in the Annual Quality Assurance Assessment submitted by the registered manager. The grounds are tidy; there is a patio with garden furniture that is accessible for residents. The tall pine trees at the front of the home have been removed and the car park has been extended. Both staff and resident said this has been an improvement and has given rooms more daylight. The home is clean and free from offensive odours. The laundry facilities are suitable with one washer and one drier. Residents said that generally the laundry system works well, one lady said her jumper has shrunk slightly so her daughter would do her woollies in future. Suitable hand washing facilities are provided for staff along with alcohol cleansing gel and protective clothing for infection control purposes. Pine Trees DS0000062885.V350341.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 good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust and there are sufficient skilled staff to ensure the residents are safe and their needs are met. EVIDENCE: The deputy manager said there are no staff vacancies at the moment. A set rota is worked and generally there are three care staff in the mornings, two in the afternoons and two awake at night. The deputy manager does a mixture of management and hands on care work. She said she would like to see a keyworker system introduced at the home. Residents said there seem to be enough staff in the home and they are looked after well. Comments include “The girls are very good, always smiling”, “We are well cared for, no problems” and “Some staff are not so nice, they are a bit bossy”. 70 of care staff have an NVQ either at level 2 or 3, an increase of 20 since the last inspection, copies of NVQ certificates are kept on file. All care staff are encouraged to undertake NVQ training. Four personnel files were inspected; the records required by legislation were included. Relevant CRB and POVA checks are undertaken and references obtained prior to employment. The registered manager has been told by one of the Company directors to destroy CRB disclosures after 6 weeks but to keep disclosure numbers and the dates applied for and received. The management Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 19 and administration were informed that CRB disclosures must be held until a CSCI inspector has checked that the CRB / POVA process has been carried out appropriately. Relevant certificates of training are held. There is an equal opportunities policy and a form to be completed on application for work. There are also policies for different races and cultures. All staff have an appropriate job description and care staff are given a copy of the General social Care Council’s code of conduct. An induction pack, in line with the skills for care standards is in use. New staff have these with them so they can work through the paperwork and answer questions. One completed pack was examined and found to be very thorough. A training matrix has been devised to show who has attended training and when, this is a helpful tool for management to see when updates are due. The matrix shows that all staff are up to date with statutory training and some people have attended other training, for example dementia, diabetes and care practice. The deputy manager has very recently completed a train the trainer’s course for moving and handling so she will be responsible for in house training. At present the registered manager does the fire training. Pine Trees DS0000062885.V350341.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, 33, 35 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 team are competent and run the home well. Quality assurance and health and safety systems are in place for continual improvement of the service and the safety of residents, staff and visitors. EVIDENCE: The registered manager is very competent and has run the home for a long time. She is a registered nurse who has achieved the Registered Managers’ Award. She is also an assessor for staff undertaking NVQ training. She is retiring in December and staff voiced mixed feelings about this. The deputy manager was in charge of the home on the day of this inspection and seemed to be confident in the role. Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 21 Residents, visitors and staff said the home is well run. Comments include “Fran is the old fashioned type but runs a tight ship”, “Fran is different, she is a nurse so knows her stuff”, “The home runs well, Tara is OK, I don’t know her too well”, “The home is well managed, the new deputy is good, we get on well with her”. An annual quality assurance survey with residents and relatives is undertaken; the deputy manager said that this year’s is ready to be distributed. Previous results have been positive and comments acted upon. There are various documents for auditing produced by the Company these include care planning, medicines, infection control, health and safety, fire safety and the kitchen. Most of these audits have been done the infection control and kitchen are to be completed. The pharmacist audits medicines. Staff meetings take place but they have not been regular, the last minutes were June 2007. A staff meeting was held during this inspection with good attendance. All staff have a file to receive literature from the management, they have to sign that they have received the documents. There are no resident’s meetings but the deputy manager said that she and the registered manager talk to everyone each day. Letters are sent to families inviting them to events in the home and to join in with outings. The regional manager undertakes monthly inspections of the home and writes a report in line with Regulation 26 of the Care Homes Regulations 2001. The deputy manager said that staff appraisals are to be done but the registered manager holds supervision sessions with staff, the dates are recorded within the training matrix but the records were not seen. There is a Company policy for dealing with resident’s money and valuables but no money is held. The deputy manager said that all residents control their own money or their family take care of it for them. There are no valuables held on behalf of residents either. There are health and safety policies, procedures and risk assessments for the home. There is a fire risk assessment and fire safety procedures and checks are up to date. The maintenance man said he is responsible for the fire checks and record keeping. He also said they are awaiting the new fire doors. He had the zone plans for the new fire system. Relevant service checks and maintenance records were seen and up to date. Statutory training is up to date as covered under NMS 30. Appropriate cleaning takes place in the kitchen with records maintained. The fridge and freezer temperatures are recorded daily. Accident reporting complies with data protection, the home has very few accidents, there were three in August, two in September and three in October. Six of these accidents occurred during the night shift period; an audit of accidents may be beneficial. Pine Trees DS0000062885.V350341.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 1 X X X X 3 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 X 3 X 3 X X 3 Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 23 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 Timescale for action 19/12/07 2 OP9 13 (2) 3 OP19 16, 23 The medicines policy and relevant guidance must be accessible to all care staff. This will ensure staff know what is expected of them Medicine systems in the home 19/12/07 must be reviewed to include: • Transcribing on MAR charts to be witnessed and signed by two staff. The name of the person authorising any change should be stated • Correct storage of insulin • All medicines administered must be signed as given or a reason recorded if not given • Residents medicines must be regularly reviewed and prescriptions updated This will ensure that care practice safeguards the residents The registered provider must 29/02/08 ensure that suitable specialist bathing and showering facilities, are provided. This will ensure the needs of elderly frail people are met Pine Trees DS0000062885.V350341.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 OP26 OP38 Good Practice Recommendations There needs to be a sluice with a washer disinfector in the home for hygiene and infection control purposes An audit of accidents in the home will help to safeguard residents further Pine Trees DS0000062885.V350341.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Trees DS0000062885.V350341.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. 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