CARE HOMES FOR OLDER PEOPLE
Pinebeach 53 Southcliffe Road Friars Cliff Christchurch Dorset BH23 4EW Lead Inspector
Carole Payne Unannounced Inspection 09:30 8th May 2006 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 Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 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.V294103.R01.S.doc Version 5.1 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.V294103.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 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. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 8th May 2006 and took a total of 10.00 hours, including time spent in planning the visit. The inspectors, Carole Payne and Jo Palmer were made to feel welcome in the home during the visit. The manager, Mary Price, and the responsible individual, Mr Dedman, were supportive during the inspection. This was a statutory inspection and was carried out to ensure that the twenty-eight residents who were living at Pinebeach were safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit were reviewed. Statutory Notices, which were issued following the last inspection have also been reviewed during recent monitoring visits to the home and were again reviewed as part of this inspection visit. The progress made by the service is recognised in this report, which reflects the commitment and hard work of everyone working at the home; this must now be continued in order to address outstanding areas of concerns. An improvement plan to meet requirements issued will also support the home to sustain progress. The premises were inspected and records examined. Time was spent in discussion with people living at the home, the management team and staff members on duty. Nine residents, six staff members and one relative were spoken with during the visit. Residents were observed enjoying the communal areas and spending time in individual rooms. What the service does well:
People living at the home are treated with great care and respect, and their right to privacy is upheld. Preferred names are used both within records and conversation. Residents have a lifestyle, which matches their choices, interests and needs. Individual and shared activities are supported in day-to-day life be it making a jig saw, reading the paper in your own room or getting ready to go out on a trip. Families and friends are made welcome to share in the life of the service. Residents enjoy a varied, appealing and balanced diet in surroundings and at times of their own choice. People living at Pinebeach can be confident that their complaints will be listened and responded to and that the home works to protect them from abuse and safeguard their financial interests. Staff members work hard to ensure that good standards of cleanliness are maintained in the general environment. The home maintains a record of the routine checking of fire systems in the home.
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
As at the last inspection the admissions process does not allow for the home to establish a person’s needs prior to moving into the home. This is a key area of practice, which carried out properly ensures that the home can meet
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 7 prospective residents’ needs. Continued failure to meet this requirement will result in enforcement action. Both the responsible individual and the manager expressed their commitment to addressing this outstanding requirement for improvement. It is recommended in this report that the home accesses dementia training for staff members to meet the needs of people living in the home, who have needs in relation to dementia care. Double signatures verifying medicines for disposal and ensuring that individual medicines are moved from blister packs on the day corresponding to the date prescribed should be carried out to ensure the safe administration of medicines. Fluid charts must be used to effectively monitor and care for those residents at risk of dehydration. Participation in activities should be recorded and monitored within individual files, so that participation can be monitored and any shortfalls in meeting residents’ needs can be identified and addressed. As discussed previously with the manager, the induction of new staff members must include documenting support provided, progress, supervision and confirmation of achievement, rather than just signing off competencies. There must be evidence held by the service, confirming that induction has been carried out. The home is continuing to work towards fifty per cent of the care staff holding a National Vocational Qualification. The home must continue to consult people about the service, collate results from consultations and produce responsive action plans to ensure that the home is run in the best interests of residents. The home needs to ensure that all parties are consulted in any surveys that are conducted. The responsible individual must also continue to produce Regulation 26 reports, which will enable the home to monitor, review and improve the service. Attention to some areas within the environment will support the home’s commitment to promote the control of infection; this includes re grouting and the replacement of the plughole in the ground floor bathroom and the provision of cleanable surfaces to steps and shelving in the laundry. A drainage grate needs to be fixed in the kitchen flooring and the chips in surrounding flooring made good and cleanable eliminating the risk of harbouring infection. The testing of portable electrical appliances in the home must be updated. The responsible individual stated that this would be carried out within a fortnight of the inspection visit. He also undertook to ensure that as the provider of fire training in the home he has the appropriate level of training to support all staff members to be fully competent. 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.
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 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 Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 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, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. As at the last inspection the admissions process does not always support the home to establish a person’s needs prior to moving in; a through assessment being carried out on admission. The home is making progress ensuring that staff members have the skills to meet assessed needs. EVIDENCE: Two pre-admission assessments were seen for residents who had recently moved into the service. One assessment was accompanied by information provided on a hospital discharge summary. The homes’ own assessments included very brief details. One was not signed or dated; the other had not been dated. A prospective resident had needs in relation to diabetic care and was assessed as requiring a ‘normal’ rather than a diabetic diet and there were no details of medical history. Some sections of both forms had not been completed. Needs identified on the other pre-admission completed stated ‘all
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 10 care’ but did not clarify what specific care was required, and simply said ‘off feet’ in terms of mobilising. The homes’ assessments, therefore, do not provide sufficient details from which to make an informed decision as to whether the home can meet people’s needs. Both residents were spoken with during the visit and felt that the home was providing satisfactory care. The manager recognised that the assessments were not of a satisfactory standard and expressed commitment to addressing this issue. A more detailed assessment had been completed at the point of the resident moving in, enabling the service to promptly identify care needs. The provider and manager confirmed that prior to moving in a letter is sent to the prospective resident confirming that the service is able to meet their needs, and that a copy of the letter is held on file. Records showed that the home is making progress in ensuring that staff members have the skills to provide care. A number of residents were noted to have needs in relation to dementia care. It is recommended in this report that the home accesses dementia training for staff members. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 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, 10, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Clear and informative plans, based upon thorough assessment, informed the basis of care delivery in the home. Generally the home has effective and supportive systems in place, which promote and meet residents’ healthcare needs. The introduction of fluid charts, will enable the home to monitor the needs of residents at risk of dehydration. Adequate systems are in place to ensure that residents’ safely receive prescribed medication. Double signatures verifying medicines for disposal and ensuring that individual medicines are removed from blister packs on the day corresponding to the date prescribed will support this. People living at the home are treated with great care and respect, and their right to privacy is upheld. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 12 EVIDENCE: Three requirements issued in the last report, have been complied with. Four care plans viewed were based on a processing of assessing peoples’ needs, including potential risks and consideration of individual choices and preferences, regarding for example, when to get up in the morning. One resident said that staff members respect his wish to have a lie in each morning, as stated on the care plan. The care plans had been reviewed regularly or according to changing needs. Although most care plans did not include reference to the involvement of the resident or a nominated representative, one set of care plans seen had been signed by a relative and another stated that the resident was unable to participate in the drawing up of the plans. Assessments included pressure sore risk assessments, nutritional and manual handling assessments. Care plans detailed pressure relieving equipment required for one resident, including an air mattress and pressure-relieving cushion. The resident had both of these in place when they were visited in their own room. Individual records of care supported wound care plans, tracking wound healing. A requirement issued in the last report in respect of the effective care of wounds during healing has been complied with. Healthcare related issues identified within daily recording had been followed through in both monitoring and in contacting external healthcare professionals where appropriate. Records of contacts with specialist services and referrals were made following routine auditing and monitoring of healthcare needs. Throughout the visit residents were offered regular fluids. However there were no fluid charts, in use in order to monitor fluid intake levels, for those residents at risk of dehydration. The manager said that regular fortnightly exercise sessions are held in the home. Good health is also promoted through unobtrusive care giving, which, as detailed in the care plans supports independence. The provider also described how a resident’s general well being had improved since moving into the home, as they were now able to carry out more daily living tasks independently. The home operates a monitored dosage system for the safe administration of medicines. The trained nurse on duty at the time of the visit, who is a member of the bank staff, said that he found the home’s medication records very clear. It was noted that two separate medications for one resident had not been given on the day of the week stated on the individual blister pack.
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 13 The home has good systems in place for the recording of medicines received. It is required that two people verify medications for disposal. Throughout the visit staff members were observed treating residents with care and respect. Preferred names are stated and used both within documentation and interaction. Gentle and sensitive support was provided to people needing help to move about the home. Residents’ right to privacy was respected. During the day some people spent time in their own room, and others, according to their preferences dined in privacy. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 14 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents receive a good lifestyle, which matches their choices, interests and needs. Recording of individual participation in the life of the service will enable the home to address, through monitoring, any shortfalls in meeting people’s needs. People who live at the home maintain regular contact with their families as they wish. Residents are enabled to make choices and exercise control over their lives. A varied, appealing and balanced diet is enjoyed by people living at the service at times, which are convenient to them. EVIDENCE: According to assessments residents’ social and recreational needs are outlined in care plans. The home has made progress, therefore, since the last inspection in identifying and meeting residents’ social care needs. Interests included the receipt of visits from the mobile library, sherry parties, bingo and visits from musicians. On the day of the visit, a trip had been planned to Lepe
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 15 beach. The manager confirmed that regular visits are planned during warmer weather. Residents were also engaged in individual activities; for example doing a jigsaw or reading the daily paper. A relative confirmed that the home takes care to ensure that people living in the home are supported to engage in hobbies, which interest them. It is recommended that participation in activities is recorded and monitored within individual files, so that participation can be monitored and any shortfalls in meeting residents’ needs can be identified and addressed. Care plans seen also included details of people visiting. During the day, visitors were made welcome in the home. The manager spoke of the regular trips out of some residents with their families, be it a short way to the cliff top and the sea or a local café. Residents’ choices were detailed within individual records regarding required care. During the visit a member of staff consulted residents about their choices for the mid-day meal. One resident said that they were able to do what they liked during the day. Individual records and the support of staff members, outlined by the provider enabled the independence of residents. The home has complied with a requirement issued in the last inspection report enabling people to make decisions regarding the care they are to receive and their health and welfare; that they are consulted and their views are sought and acted upon. Lunch on the day of the visit looked appealing and appetising. Some residents enjoyed the companionship of sharing a meal together in the dining room. Menus are displayed on the tables in the dining room for residents to view. The manager confirmed that specialist dietary requirements are met when required. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. This judgement takes into account previous serious issues; the home’s commendable improvements and the commitment of the home to now sustain this progress. People living at Pinebeach can be confident that their complaints will be listened and responded to. Evidence from this visit to the home demonstrates that people living at the home are protected from abuse. EVIDENCE: The home has a complaints procedure, which is provided to people moving into the home and is displayed in the home’s reception area. There is a log for the recording of complaints received. No complaints had been detailed since the last inspection. The service has details of the local adult protection protocol. Training in adult protection is part of the home’s regular programme of mandatory training. There have been recent monitoring visits to the home from social services in relation to adult protection investigations regarding the home. Statutory Requirement Notices have also been issued in relation to aspects of practice in the home, which directly affect the welfare of people living in the service. Evidence from this inspection visit demonstrates that the home has achieved much in the commitment to protect people living in the home and to enable them to enjoy a qualitative lifestyle.
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 17 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, 22, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People living at Pinebeach live in a generally safe and well – maintained environment. Staff members work hard to ensure that good standards of cleanliness are achieved. Attention to some areas within the environment will support the home’s commitment to promote the control of infection. Suitable equipment was provided to ensure that people have access to call alarms enabling them to request assistance as required. EVIDENCE: Generally the environment was well maintained. The home employs a maintenance person who undertakes routine maintenance at the home four days per week. The provider confirmed that the dining room had been redecorated and refurbished since the last inspection and that individual rooms are maintained and there is routine renewal as part of an ongoing programme of maintenance and refurbishment in the home. The ground floor bathroom is
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 18 generally in a satisfactory condition. However replacement of some grouting and the plughole could improve the general environment. During the tour of the environment it was noted that people living in the home have access to their call bells so that they can request assistance as needed. This complies with a requirement issued in the last inspection report. Areas of the home visited had radiators which were appropriately guarded, protecting residents from the risk of scalding. This complies with a requirement in the last report, which resulted in the issuing of a Statutory Requirement Notice. The home was clean and free from offensive odours throughout. The member of ancillary staff on duty had undertaken a National Vocational Qualification in cleaning. A person comes in to carry out general cleaning each day of the week. Paper towels, liquid soap and alcohol gel was available to support the home in providing a good level of hygiene in the home. The manager stated that a training session in infection control was booked for the week following the inspection visit. Wooden steps are located in the laundry. In the last inspection report the home was advised to consult with Environmental Health regarding the provision of these steps, which are used to access the home’s tumble dryers. The steps looked dirty and there was potential for laundry being removed from the machines to come into contact with the steps. It is recommended that the registered persons take advice from the Environmental Health department regarding provision of wooden steps in the laundry room. Some clean laundry had also been placed on wooden shelves. Both these shelves and the area around the home’s only washing machine did not look clean. The provider said that these issues would be immediately addressed and confirmation of action taken confirmed with the Commission for Social Care Inspection. (See Management and Administration, standard 38.) Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 19 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service; this recognises recent progress in relation to Statutory Requirement Notices issued. This improvement must now be sustained. The number of staff on duty satisfactorily meets service users’ needs. The home has an ongoing programme of training, which works towards ensuring that staff members have the skills required to provide effective care; this must include the commitment to monitor and record the process of induction to the service. Staff members are making progress in achieving National Vocational Qualifications in Care. People living at the home are supported and protected by the home’s recruitment practices. EVIDENCE: Rosters seen reflected required staffing levels, in accordance with Department of Health guidelines. Feedback from residents also concurred that there were sufficient members of staff on duty to meet people’s needs. The manager has a minimum of thirty hours supernumerary each week in order to carry out her management duties. The home has complied with previous requirements regarding the provision of adequate staffing and management hours. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 20 One member of staff described how she was working through the service’s induction programme. The provider confirmed that new members of staff starting work in the home would enrol on the new ‘Skills for Care’ programme. As discussed previously with the manager, the recording of the process of induction was outlined, documenting support provided, supervision and confirmation of achievement, rather than just signing off competencies. There must be evidence held by the service, confirming that induction has been carried out. Of the thirteen care staff listed on the home’s training matrix, four staff members have a National Vocational Qualification in Care. The provider said that an additional five members of staff are studying for an NVQ. Recruitment files sampled contained all the items required by legislation. The home maintains a training matrix, which details a summary of recent training undertaken by staff. One file seen also contained a number of corresponding copies of certificates of attendance. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 21 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, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has made progress since the last inspection supporting the provision of good organisation; enabling the manager to effectively carry out her management responsibilities. Progress is being made in monitoring the views of people involved with the life of the service; people need to be widely consulted to ensure that the home is run in the best interests of residents. Residents’ financial interests are safeguarded. People living in the home are appropriately supervised. Generally the health, safety and welfare of residents and staff are promoted and protected. The addressing of issues highlighted within this report will ensure that these areas are fully promoted.
Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 22 EVIDENCE: The addressing of a number of requirements from the last report and subsequent Statutory Notices reflects the home’s commitment to address issues through the effective delegation and organisation of management responsibilities in the service. The home is progressing in meeting a previous Statutory Notice regarding the introduction of a quality assurance system within the home. The home needs to ensure that all parties are consulted in any surveys that are conducted. At the time of the inspection the responsible individual had not complied with a Statutory Notice regarding the production of reports in respect of the running of the home. The provider promised that a report would be sent to the Commission by 10th May 2006, A Regulation 26 visit report has been received. These reports must now be submitted at monthly intervals; failure to comply with this will result in further enforcement action. The manager stated that the home does not hold any monies on behalf of service users, nor does she, or the responsible individual act as appointee for any service user. The home has complied with a Statutory Notice regarding the provision of supervision to all staff working in the home. Examples of formats in use were seen and a copy of a completed record. The responsible individual has also produced a summary record to track completion of supervision. Supervision includes discussion regarding training needs and plans for future training. The home has a training programme in place covering all areas of mandatory health and safety training. A maintenance folder contains confirmation of servicing of equipment and facilities in the home. PAT testing in the home is out of date. The home maintains a record of the routine checking of fire systems in the home, fire training and drill practice. The responsible individual, who provides training, was advised that he must contact Dorset Fire and Rescue to verify that training is of the required standard. Attention to some areas within the environment will support the home’s commitment to promote the control of infection; this includes re grouting and the replacement of the plughole in the ground floor bathroom and the provision of cleanable surfaces to steps and shelving in the laundry. A drainage grate was also noted to be loose in the kitchen flooring was noted to be loose and the surrounding flooring chipped presenting a risk of harbouring infection. Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 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 1 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x 3 x x 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 1 Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Accommodation must not be provided to persons at the care home until their needs have been assessed; assessments must be comprehensive and provide sufficient detail to enable staff at the home to understand the needs that are to be met. Previous time-scale (30.06.05, 31.01.06) not met Failure to comply with this requirement will result in enforcement action. Fluid charts must be used to effectively monitor and care for those residents at risk of dehydration. A minimum of 50 of care staff must be trained to NVQ level 2 with evidence of core and optional National Occupational Standards being attained. Previous timescale (31.12.05, 28.02.06) not met. The induction of new staff members must include documenting support provided,
DS0000020485.V294103.R01.S.doc Timescale for action 1. OP3 14 31/05/06 2. OP8 12 and 16 31/05/06 3. OP28 18 30/09/06 4. OP30 18 30/06/06 Pinebeach Version 5.1 Page 25 5. OP33 24 progress, supervision and confirmation of achievement, rather than just signing off competencies. There must be evidence held by the service, confirming that induction has been carried out. The home must continue to produce Regulation 26 reports and to consult people about the service, collate results from consultations and produce responsive action plans to ensure that the home is run in the best interests of residents. The home needs to ensure that all parties are consulted in any surveys that are conducted. Attention to some areas within the environment will support the home’s commitment to promote the control of infection; this includes re grouting and the replacement of the plughole in the ground floor bathroom and the provision of cleanable surfaces to steps and shelving in the laundry. A drainage grate needs to be fixed in the kitchen flooring and the chips in surrounding flooring made good and cleanable eliminating the risk of harbouring infection. The testing of portable electrical appliances in the home must be updated. The responsible individual must check fire training is of the required standard and take any required action as appropriate. 30/09/06 6. OP38 13 31/07/06 7. OP38 13 31/05/06 8. OP38 23 30/06/06 Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 26 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. Refer to Standard OP4 Good Practice Recommendations The home should access dementia training to meet the needs of some residents in the home who have dementia care needs. Double signatures verifying medicines for disposal and ensuring that individual medicines are moved from blister packs on the day corresponding to the date prescribed must be carried out to ensure the safe administration of medicines. Participation in activities is recorded and monitored within individual files, so that participation can be monitored and any shortfalls in meeting residents’ needs can be identified and addressed. 2. OP9 3. OP12 Pinebeach DS0000020485.V294103.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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