Inspection on 26/10/06 for Pine Trees

This inspection was carried out on 26th October 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 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 15/11/07

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 Key Unannounced Inspection 26th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pine Trees DS0000062885.V311953.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.V311953.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.V311953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 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 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 smoke free 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 £293.35 to £450 per week; this information was supplied to the Commission by the registered manager on 04/10/06. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Pine Trees DS0000062885.V311953.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 26 October 2006 and spent seven and a half 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. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 20/02/06. All of the key standards were inspected. On the day of inspection 22 residents were living in the home and 1 was receiving day care. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered manager to gain their views on the services offered by Pine Trees Care Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered manager has worked hard to comply with the requirements set at the last inspection and she has progressed with the implementation of the Company policies and documentation. Residents and relatives expressed satisfaction with the care and services provided at the home. 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 residents. Residents are very positive about their care and facilities provided. Staff are perceived as kind and caring and provide a friendly atmosphere for residents and visitors. Residents said they are able to live their lives as they choose and the daily routines are flexible. Prospective residents are invited to visit the home prior to admission. They are assessed and given information about the home. One resident and her daughter said the process was very thorough and they were given plenty of time to ask questions. The environment is warm, comfortable and homely; it is clean, free from offensive odours and well maintained. It is all on one level and offers spacious communal areas and corridors. The grounds are accessible and kept very tidy. There is an appropriate medicines system in place and all care staff receive medication training. Residents say their care needs are met and the staff are very kind. Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 6 Records, policies and procedures are maintained to a good standard. Health and safety precautions are well maintained. There are suitable systems for dealing with complaints and abuse. 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: There is still work to be done to improve the care documentation and the registered manager is aware of this. There is other Company documentation she is trying to implement and the introduction of annual training updates and the new induction programme. The appointment of a deputy manager should help the registered manager cope with her workload. Statutory training is provided for staff but it is not possible to ascertain that all staff have attended according to legislation, in particular fire training and this must be addressed It is recommended that a matrix be compiled for statutory training to demonstrate that staff attend according to the legal requirements. The registered manager said she would do this. Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 7 The food records need to ensure that any alternatives to the set menu are recorded, the registered manager said she would talk to the kitchen staff to make sure they remember to do this. The medi bath should be removed and the registered providers are looking for a suitable replacement. The home would also benefit from the installation of a sluice with a washer disinfector. 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. Pine Trees DS0000062885.V311953.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.V311953.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 at least once during a 12 month period. 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: Evidence was provided in the form of records, case tracking two new residents and discussion with a resident, her daughter and the registered manager. Prospective residents and their family are encouraged to visit the home to have a look around. During their visit the registered manager undertakes an assessment of their care needs. If necessary she goes out to visit the prospective resident in his or her own home. One resident and her daughter explained the assessment process to the inspector. The format for recording the assessment is comprehensive and covers all of the areas listed in standard 3.3. Assessments 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.V311953.R01.S.doc Version 5.2 Page 10 Pine Trees DS0000062885.V311953.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 at least once during a 12 month period. 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. Individual care plans are generated for each resident that reasonably inform and direct staff in the care provision these are improving with use. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines that assure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, case tracking three residents, interviews with residents, relatives, staff and registered manager. The Company care planning documentation has been implemented and training has taken place. The documents are very detailed with several risk assessments included. Some of the pre-printed plans are now in use but are not really conducive to holistic care; some of the hand-written care plans are more directive for staff. The registered manager said there is still work to be done on the care plans to include all of the individual care needs. The profiles Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 12 of residents included in their files are very informative and give a good description of each resident and their life story. There is some evidence that the care plans are compiled with the resident or their representative and some have been signed by the resident. Daily records are maintained and vary as to the amount of information written. Reviews take place monthly or six monthly depending on the individuals needs and the registered manager is expected to audit 25 of the care documentation each month. Staff have received some training in the use of the company’s care documentation and said they are getting more used to it although the general opinion is that there is a lot of paperwork. Doctors and other healthcare professionals visit residents as appropriate and records are kept. A community nurse, optician and chiropodist visited during the inspection. The chiropodist said the home operates to a very good standard. The home has sufficient equipment for moving and handling and pressure relief. Residents are weighed regularly according to their individual requirements. The home has a suitable medicines policy that staff are aware of. There is a homely remedies policy and the approved list is ready to be signed by the GP. Care staff have undertaken training in the safe handling of medicines and another course was being held the day after this inspection. One resident is administering her own medicines and has a container for storing her medicines in her room. The registered manager agreed to provide a lockable facility for her. The resident said the system works well and she is pleased to keep her independence. The receipt, administration and disposal records are up to date. The medicine round was observed and undertaken professionally. There are no controlled drugs held at the moment. There are plans to move the position of the medicines trolley from the hall and to provide a new medicines storage cupboard. Residents’ privacy was upheld during the inspection. Each bedroom has a telephone line and residents can receive visitors in private. Residents said they are treated with respect and their privacy is upheld at all times. Pine Trees DS0000062885.V311953.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 at least once during a 12 month period. 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 home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family and friends are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives, staff, including the cook and registered manager. Activities and entertainment are on offer and a weekly plan is displayed. The registered manager has interviewed for an activities co-ordinator and hopefully the post will be filled soon. Activities include bingo, singers, entertainers, crafts, art and games. The home won a cup at a local show in the summer when some residents made a card and one resident did some crochet. Records of activities are maintained but give information on a group of residents undertaking activities together it is difficult to ascertain what individuals are doing. The registered manager intends to implement individual Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 14 records for each resident, these will be completed by the co-ordinator or staff if they do any activities or one to one chats. A Halloween party is planned and a firework display for bonfire night. Residents talked about the activities provided, some would like more but others said the present arrangement is sufficient. 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 in the home. Residents said they choose when they get up and go to bed within reason. One resident said, “I do what I want, I go to the lounge or I stay here. I can stay here for meals as well if I want”. Residents choose what clothes to wear and how they spend their day. Staff encourage residents to be independent and said they choose how they live their lives. All residents manage their own finances and they all have their own possessions around them. Each resident has a nutritional assessment and his or her weight is recorded accordingly. Individual likes and dislikes are recorded and staff are aware of these. There is a menu that spans seven weeks, it is a set menu but residents said they could have something different if they did not like what was on offer. The registered manager said that records of who has an alternative should be recorded but this had lapsed. She said she would make sure this is implemented again. Residents said the food is good and it was observed to be good at lunchtime. One resident said, “ I don’t know what’s for lunch but I like it that way”. Another said “There is no choice for lunch but plenty of choice at tea time”. Roast pork was served on the day of the inspection. Fresh fruit and vegetables are included and the cook said that she makes homemade cakes. Meals are served in the lounge or individual bedrooms; special cutlery and plate guards are available if required. Staff were seen to offer drinks regularly. One resident said she had a cake made for her birthday and it was lovely. Pine Trees DS0000062885.V311953.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 inspected at least once during a 12 month period. 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 home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation and discussion with the registered manager, staff and residents. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There has been one complaint to the home in the past year that was suitably dealt with. There has been one concern raised to CSCI in the past year regarding the standard of care and poor communications, the department for Adult Social Care dealt with this. Thank you letters and cards are kept in the home and there were several displayed on the notice-board in the entrance hall. The home has an appropriate adult protection policy that staff are aware of. In house training takes place and staff are required to read the policy and sign to confirm that they have done so. The registered manager said she would try and obtain a copy of the adult protection training video. Residents said there are no barriers to raising concerns with the staff. Pine Trees DS0000062885.V311953.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 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 and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean with no unpleasant odours making it a pleasant place for residents to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, discussion with residents, staff and registered manager. The home is warm, homely and comfortable it is well ventilated and there is domestic style lighting. The home is spacious and on one level with suitable grab rails provided. It is well furbished and decorated throughout. The registered manager has requested that more chairs and bedside lamps be purchased. Residents said they are happy with their rooms and the facilities provided. New curtains, bed linen and towels have been supplied; some residents pointed out that although their bed covers match the curtains they do not go well with the dark colour of the carpet. There are adequate bathing Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 17 facilities however the medi bath is very old and a suitable replacement is being sought. The grounds are tidy and the swimming pool has been covered and fenced off. There is a patio with garden furniture that is accessible for residents. The home is clean and free from offensive odours. The laundry facilities are suitable with one washer and one drier. Residents said that the laundry system works well. Suitable hand washing facilities are provided for staff along with alcohol cleansing gel and protective clothing. There has recently been a hand hygiene audit and posters on correct hand washing are displayed. Infection control training is included in the induction programme and the registered manager intends to provide regular updates for staff. Pine Trees DS0000062885.V311953.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 at least once during a 12 month period. 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. Staffing levels meet the needs of residents and staff are motivated to provide a high standard of care. Residents are in safe hands and they benefit from the 50 of care staff trained to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles; further induction training will soon be provided. EVIDENCE: Evidence was provided in the form of documentation, records, and interviews with residents, relatives, staff and registered manager. The registered manager said there are no staffing issues and sufficient staff were on duty during the inspection. Residents said there are always enough staff in the home and they are very kind and caring. There are generally three care staff in the mornings, two or three in the afternoons and two awake at night. There is a vacancy for one carer and a cook. Interviews have taken place for an activities co-ordinator and an administration post has just been filled. 50 of care staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. All care staff are encouraged to undertake NVQ training. Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 19 Two personnel files were inspected; the records required by legislation were included. Relevant CRB and POVA checks are undertaken and references obtained prior to employment. 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. The ‘skills for care’ induction pack is ready for use in the home. To date new staff have undertaken orientation to the home and the registered manager or person supervising the new employee has signed a checklist. Statutory training takes place in the home and external courses are sometimes on offer. The registered manager has a book where she records when she has given instruction to staff, for example she had recently shown a carer how to do the drug ordering and this was recorded. The registered manager was advised to record this in the individuals’ file. Pine Trees DS0000062885.V311953.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 at least once during a 12 month period. 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 Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they will benefit from the Quality Assurance systems in place. Residents’ control their own finances; with the help of their families they maintain their independence. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff; extra vigilance in respect of statutory training and staff attendance will ensure further protection. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives, staff and registered manager. The registered manager was in charge and very competent in running the home. She is a registered nurse and she has achieved the Registered Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 21 Managers’ Award and she is an assessor for staff undertaking NVQ training. She attends statutory training in the home regularly and is attending the next medicines training day. She also attends external courses when appropriate. She keeps up to date with current medical issues by reading relevant magazines. Residents, visitors and staff said the home is well run, the registered manager is organised and works hard. One resident commented “Fran is excellent, she keeps everyone in order”. Although someone from the Company visits each month some people were unaware and no one seemed to have spoken with her. The Company have undertaken a quality assurance survey with residents and relatives and the results are awaited. The registered manager said she would send a copy of the Pine Trees results to the Commission. There are various documents for auditing produced by the Company and the registered manager has started to use these. Audits include care planning, medicines, infection control, health and safety, fire safety and the kitchen. Accidents would be audited but there are very few. Staff meetings take place but they are not regular, the registered manager said she tends to talk to the staff on a daily basis. There has not been a resident’s meeting for some time but the registered manager again said she talks to residents, she notes any comments or suggestions in a file. The regional manager undertakes monthly inspections and reports to the Commission in line with Regulation 26 of the care Homes Regulations 2001. There is a Company policy for dealing with resident’s money and valuables. The registered 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 at the moment. The management endeavour to ensure that working practices are safe and staff confirmed this. There are health and safety policies, procedures and risk assessments for the home. The risk assessments are to be updated using the Company documentation. There is a fire risk assessment and fire safety procedures and checks are in place. Relevant service checks and maintenance takes place as required. Statutory training is provided for staff but it is not possible to ascertain that all staff have attended according to legislation, in particular fire training and this must be addressed. It is recommended that a matrix be compiled for statutory training to demonstrate that staff attend according to the legal requirements. The registered manager said she would do this. There is a person trained in first aid on duty at all times. The cook has received food hygiene training and moving and handling training takes place in the home regularly. The “Making food safely pack” has been well implemented and complimented on by the Environmental Health Officer. Appropriate cleaning takes place in the kitchen with records maintained and fridge and freezer Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 22 temperatures are recorded daily. Accident reporting complies with data protection, the home has very few accidents, there were four in September and two in October. Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 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 X X 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.V311953.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP38 Good Practice Recommendations There needs to be a sluice with a washer disinfector in the home A matrix should be compiled for statutory training to demonstrate that staff attend according to the legal requirements Pine Trees DS0000062885.V311953.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 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.V311953.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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