Inspection on 30/07/07 for Pinebeach

This inspection was carried out on 30th July 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

Pinebeach 07/11/06

Pinebeach 08/05/06

Pinebeach 21/11/05

Pinebeach 14/04/05

Pinebeach 02/12/04

Pinebeach 02/07/04

Pinebeach 03/03/04

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 Pinebeach 53 Southcliffe Road Friars Cliff Christchurch Dorset BH23 4EW Lead Inspector Chris Gould Key Unannounced Inspection 30th July 2007 10:00 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 Pinebeach DS0000020485.V347011.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. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinebeach Address 53 Southcliffe Road Friars Cliff Christchurch Dorset BH23 4EW 01425 273122 01425 272876 pinebeach@totalise.co.uk 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) Lifecaring Holdings Limited Mrs Mary Ann Price Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Pinebeach is located opposite the sea and beach at Friars Cliff near Mudeford. The lounge, library and some of the rooms have sea views. The building has a lower ground floor. The laundry, kitchen, boiler room, registered persons office and staff facilities are located on this floor. The ground floor comprises of dining area and annexe, lounge, library, manager’s office, service user bedrooms, sluice room, communal bathrooms and toilets. The first floor comprises of service user bedrooms, a sluice room and communal toilets and bathrooms/shower rooms. There is level access throughout the floors and access by passenger lift to all floors. The outside area has two large wooden benches facing the sea. In the summer month’s additional garden furniture is put out that includes tables, chairs and parasol. The garden attracts wildlife, particularly birds. There is off road parking for staff and visitors. The fees for the home as provided to CSCI at the time of inspection range from £440 to £645. Additional charges include hairdressing, chiropody, toiletries and newspapers. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_c hoos.aspx Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over six and a half hours on one day in July 2007. A tour of the premises took place and two staff files, three residents care records and relevant documentation and policies and procedures relating to the running of the home were inspected. Seven residents, four visitors to the home and the staff on duty were spoken with. The registered manager, Mary price was unavailable but the inspector was ably assisted to complete the inspection process by the staff on duty. Feedback was provided to the registered manager the following day by telephone. The Annual Quality Assurance Assessment form had been completed and returned to the Commission for Social Care Inspection prior to the inspection. What the service does well: The residents live in a home that is well managed and maintained with the appropriate number of trained staff to meet their needs. An assessment is undertaken before admission to ensure that the resident knows that the home they are moving into will meet their needs. The staff treat residents with respect and provide encouragement to pursue their own lifestyle, where feasible, and to make choices about their daily lives. Residents spoken with agreed that they were always addressed in the way they had requested. Activities are provided for those residents who want to participate. One resident said that ‘there are things arranged and sometimes I join in if I feel like it’. The staff encourage friends and relatives to visit and to maintain contact with the home. Both service users and relatives say that visitors are made welcome. Residents are offered a menu that provides a varied and well balanced diet served and eaten in a very relaxed manner at the resident’s own pace. One resident commented following lunch ‘I really enjoyed that’. Comments received by the home as part of a recent relatives survey included ‘mum says she is comfortable and happy at Pinebeach’, ‘wonderful’ and ‘mother has received excellent care and kindness at Pinebeach’ Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 7 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 Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Admissions only take place when the home is confident that they are able to meet the assessed needs of the prospective resident. EVIDENCE: The three care records viewed contained an assessment that had taken place prior to the admission of the resident and included information from professionals previously involved in providing their care. The two assessments undertaken since the last inspection contained sufficient detail to provide clear indication of how the person’s personal care needs are met including how much they were able to achieve for themselves and the level of assistance required with mobility. Residents confirmed that a nurse from the home had been to visit them before they moved in and staff agreed that they were aware of the resident’s needs at the time of their admission. Pinebeach does not provide intermediate care therefore standard 6 is not applicable. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a care plan that meets their needs and they feel that they are treated with respect and their privacy upheld by the care workers. However shortfalls in the administration of medication practices in the home may put the residents at risk. EVIDENCE: The care records of three residents were viewed prior to visiting them in their own room or the communal lounge. The care records included completed manual handling, nutritional, pressure risk and continence assessments. Discussing their care needs and how they are met with the residents confirmed that the care plans are relevant and up to date. The care records for one resident identified that they required bed rails. A bed rails care plan was in place but there was no written risk assessment available to identify how the outcome had been reached. The home has a procedure in place that is followed when bed rails are used but the actual individual assessment is not documented. A risk assessment needs to be completed to Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 10 ensure that their use is appropriate to meet the resident’s needs and they are fitted correctly. One resident had been admitted with a wound and a wound assessment and care plan had been put in place and regularly evaluated. The resident said that it was ‘getting better and more comfortable’. The records included input from health care services including General Practitioners, chiropodist, optician and dentist. All the residents spoken with agreed that they receive the medical support they need. A procedure for the administration of medication is in place and the home operates a monitored dosage system for the safe administration of medicines. The home is now including on residents’ records a care plan relating to their medication needs. The Medicines Administration Records (MAR) charts had a number of gaps where the medication had not been signed as administered. The medication had been removed from the monitored dosage system but it was not clear whether they had been taken or not. Some handwritten directions on the medicine record charts were not checked as correct by a second person and countersigned to protect residents. Through auditing the registered manager has identified the problem of staff not signing at the time of administering medication and is addressing the issue. Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. The name the resident wishes to be known as is recorded on their care records and the residents spoken with agreed that they were always addressed in the way they had requested. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The flexibility of the home and the activities provided enable residents to retain control over their lives where feasible and take part in social activities that meet their expectations. EVIDENCE: Residents’ social and recreational needs are assessed and outlined in their care plans. The three care files seen contained an in depth ‘life story’ of the person mainly completed by relatives. The activities regularly provided include reminiscence, sherry lunches, music and movement, musical entertainment and bingo. The mobile library visits every three weeks. The individual care records identify that a number of residents go out regularly with relatives and friends. One resident said that ‘there are things arranged and sometimes I join in if I feel like it’. The care records and talking to one resident identified that they receive regular visits from a representative of the church. Residents receive visitors whenever they wish. A record is maintained of all visitors to the home. The home encourages friends and relatives to keep in Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 12 contact. Visitors spoken with confirmed that they are always made welcome by the staff. One relative commented ‘everyone is so cheerful and friendly whenever any of the family visit or ‘phone’. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and when they got up in the mornings and went to bed at night. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. Comments from residents were generally very positive about the quality of food provided. The menus were viewed and found to be varied and well balanced offering at least five pieces of fruit or vegetable every day. Meals are served in the ground floor dining room but can be served in the resident’s bedroom if that is their choice. The lunchtime meal was served and eaten in a very relaxed manner at the resident’s own pace. Hot and cold drinks are served at regular intervals. One resident commented following lunch ‘I really enjoyed that’. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place provide residents with the confidence that their complaints will be listened to and acted upon and they are protected from abuse. EVIDENCE: The home has a complaints procedure that complies with regulations and meets National Minimum Standards. The procedure is displayed in the home and is included in the home’s statement of purpose and service user guide. Talking to residents and relatives they all confirmed that they are aware of the complaints procedure and although they have not had cause to complain would know who to talk to if they did. An Adult Protection procedure with reference to the Dorset multi agency ‘No Secrets’ guidelines is in place and staff confirmed that they have received training. One adult protection investigation has taken place since the last inspection. The investigation found the allegation unsubstantiated. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 14 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 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 provides residents with an environment that is safe, clean and well maintained. EVIDENCE: The home is comfortably furnished and well maintained. In the last twelve months a number of bedrooms have been refurbished, carpets have been replaced and the kitchen refurbishment has continued. In the next twelve months it is planned to complete the work in the kitchen and refurbish the library. All areas of the home that were seen during the tour of the home were in a clean condition and free from unpleasant odours, residents and visitors confirmed that this is always the case. Residents confirmed that their bedroom was regularly cleaned. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 15 Infection control training is provided for all staff, this was confirmed by viewing training records and in discussion with staff. The cleaner has recently achieved an NVQ level 2 in cleaning. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Pinebeach has systems in place for the recruitment and training of staff to ensure they are able to meet the needs of the people living at the home. However this may not be the case when agency staff are working at the home. EVIDENCE: The staff rotas record the staff on duty at any time during the day and night and in what capacity. The manager has supernumerary hours each week in order to carry out her management duties. Talking to residents, staff and viewing staff rotas confirmed that the number of staff on duty meets the needs of the present dependency levels of the residents at the home. Residents spoken with generally agreed that they receive the care and support they need and staff are available when they need them. There are additional ancillary staff to cover the kitchen, cleaning, maintenance and gardening. Care workers maintain the laundry. Nine of the thirteen care staff have achieved an NVQ level 2 or the equivalent in care. The staff recruitment files of two recently employed care worker identified that the home continues to ensure all relevant information and checks are in place before the member of staff commences at the home. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 17 There was no evidence to show that the same was true when agency staff are working at the home. The home maintains a training matrix, which details a summary of recent training undertaken by staff. The home’s training programme ensures that staff receive mandatory training and updating including manual handling, health and safety, infection control and elder abuse. The home needs to be aware of the training received by agency staff working at the home. The files of a recently recruited care worker demonstrated that they are undertaking the ‘Skills for Care’ induction programme that has been implemented since the last inspection. The file of one member of staff identified that recent training has included Dementia care, first aid, diabetes, dysphasia awareness and slips, trips and falls. The recent diabetic training had included the staff working in the kitchen. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 18 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 arrangements at Pinebeach and the quality assurance system ensures that the residents live in a home that is well managed and the service provided meets their needs. EVIDENCE: Mr Dedman the responsible individual and general manager supports Mary Price the registered manager in the day-to-day management of Pinebeach. The registered manager is completing the mentors’ course and is planning to commence the Registered Managers Award within the next twelve months. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 19 There is an ‘open door’ management style operated at Pinebeach and this was evident during the inspection. Staff and residents agreed that the manager is very approachable and will listen. A relatives survey has just been completed and the comments received were generally very positive including ‘mum says she is comfortable and happy at Pinebeach’, ‘wonderful’ and mother has received excellent care and kindness at Pinebeach’. Issues identified have been appropriately addressed. The completed Annual Quality Assurance Questionnaire was returned to CSCI prior to the inspection. This will now form part of the home’s quality assurance programme. All residents are assisted by family, friends or professional advisors to manage their financial affairs. The home does not hold money belonging to residents. Records viewed evidenced that all gas installations, central heating, electrical wiring and appliances and equipment used to meet service user needs has been checked. Policies and procedures are available relating to health and safety, Control of Substances Hazardous to Health (COSHH), infection control, manual handling and first aid. A fire risk assessment has been undertaken and fire training, drills and fire safety checks have been completed as required. An accident book is maintained. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 X X 3 Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 13 Requirement The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated including the use of bed rails. The registered person must ensure that staff accurately record the administration of medicines at the time they are given. All handwritten changes to medicine records must be signed and countersigned. Timescale for action 30/10/07 2. OP9 12(2) 30/10/07 3 OP29 19 The registered person must 30/10/07 ensure satisfactory information is available relating to all agency staff working at the home for the protection of the residents. Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pinebeach DS0000020485.V347011.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 - 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!