Inspection on 05/09/06 for Pinehurst

This inspection was carried out on 5th September 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

Pinehurst 29/09/08

Pinehurst 08/12/05

Pinehurst 26/10/04

Pinehurst 06/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pinehurst Pinehurst National Trust Road Boxhill Mickleham Surrey RH5 6BY Lead Inspector Deavanand Ramdas Key Unannounced Inspection 5th September 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 Pinehurst DS0000013745.V310300.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. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinehurst Address Pinehurst National Trust Road Boxhill Mickleham Surrey RH5 6BY 01306 889942 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) Theresa Schneider Theresa Schneider Care Home 19 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (19) Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Up to three Service Users may be in the category DE(E) and a maximum of one may be in the categaory MD(E) 17th May 2005 Date of last inspection Brief Description of the Service: Pinehurst Rest Home is registered with the CSCI (commission for social care inspection) to provide accommodation and care to nineteen service users. The property is located on Boxhill in Surrey and accommodation is on three floors which can be accessed by stairs or a chair lift and comprises of an entrance hall, office, lounge, dining room, laundry, kitchen, bathrooms, toilets and nineteen single bedrooms. The home has a garden which is private, secure and overlooks National Trust land with beautiful views of the surrounding areas. Private parking is available. The scale of charges range from £355 to £685 per week. The registered manager is Mrs. Therese Schneider. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a site visit as part of the homes key inspection by the CSCI (Commission for Social Care Inspection) and carried out by one inspector over a period of six hours. The site visit commenced at 10:00 hours and finished at 16:00 hours. A partial tour of the premises took place, staff and service users were spoken to, and documents and care records were examined. The inspector would like to thank the manager, staff, service users, relatives and other professionals for their contribution to the inspection. Information leaflets and booklets pertaining to CSCI was left with the manager. What the service does well: What has improved since the last inspection? The provider has made a significant investment to improve the quality of the premises for the comfort and enjoyment of service users. The inspector noted the home had new carpets, curtains, furniture and the manager stated bedrooms were decorated and refurbished. A relative commented ‘‘Pinehurst Rest Home is a wonderful home to visit and the home has a lovely atmosphere’’. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 6 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. Pinehurst DS0000013745.V310300.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 Pinehurst DS0000013745.V310300.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service guide needs improving to ensure prospective service users’ and their relatives have up to date information on which to make decisions about admission to the home. The arrangements for the assessment of needs are good ensuring service users’ needs are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide which is written in plain English, nicely presented and copies are available to service users for information. Following discussions a requirement has been made for the service user guide to include information about fees and the scale of charges by the home. The manager stated service users are admitted to the home on the basis of an assessment of needs and the home had an assessment and admissions policy. The inspector sampled records and noted the home had a pre-assessment form which is used to assess service users’ needs and covered the areas of personal care, social support and healthcare needs. Further evidence indicated the home had copies of community care assessments and Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 9 the manager and deputy managers have responsibility for assessing the needs of prospective service users. The home does not offer intermediate care and this standard was not assessed. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. Care planning at the home is good promoting the health, personal and social care needs of service users. The systems for accessing healthcare are good ensuring service users healthcare needs are assessed and met. The management of medication at the home needs strengthening to promote the health of service users. The arrangements for privacy and dignity are good ensuring service users privacy is upheld. EVIDENCE: The deputy manager stated service users have individual care plans which are drawn up following an assessment of needs and the inspector noted the home had care plans which sets out in detail actions to be taken with regards to personal, social and health care needs. The inspector noted care plans and risk assessments were regularly reviewed, dated and signed by key workers. During discussions a service user commented ‘‘I am happy with care, staff are quite perceptive and can tell when service users are in difficulties’’. The deputy manager stated service users have access to healthcare professionals to meet their needs and the inspector noted service users are registered with a local GP (general practitioner) and have input from a district nurse and a continence Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 11 advisor to promote the personal hygiene of service users. The deputy manager remarked the home had a policy on medications and a service level agreement with a local chemist. The inspector noted medication record sheets were dated and signed by staff and a list of staff specimen signatures was available for information. The home had controlled drugs which were recorded in a controlled drugs register and up to date and correct. Following discussions with the manager a requirement has been made for a proper record to be kept of medications returned to the pharmacy to prevent mishandling of medications and prescriptions taken by telephone are witnessed, dated and signed by a second member of staff to promote health. The deputy manager stated the home had a policy on privacy and dignity and the inspector noted the home had information on the GSCC (general social care council) code of conduct for care staff. Observations confirmed staff addressed service users by their preferred names and bathroom doors were closed during personal care to promote the dignity of service users. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 12 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 this service. The arrangements for activities are good however information about activities need to be in a format which may be understood by service users with a memory impairment. The systems for family contact are good ensuring service users maintain links with family, friends and the local community as they would wish. Opportunities for exercising choice are satisfactory ensuring service users are helped to exercise choice over their lives. Meals at the home are excellent and offer variety and choice. EVIDENCE: The deputy manager stated the home had a weekly activity programme displayed on the service user’s notice board for information. The inspector sampled activity records and noted the home employed a music therapist twice a week, a musician once a month and a volunteer provided entertainment for service users. Further evidence indicated the home provided a range of social activities in the community including visits to pubs, cafes, restaurants and a local vineyard. During discussions a service user stated ‘‘I visit a café for afternoon tea, it is a nice occasion and I never pay’’ and ‘‘I like to play scrabble with staff which is very therapeutic’’. Following discussions with the deputy manager a requirement has been made for information about activities to be in a format suited to the capacity of service users with memory impairment. The Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 13 manager remarked service users maintained contact with family, friends and the local community and the inspector noted the home had contact with a local school and the headmaster and students visited the home to promote participation in community life. Further evidence indicated a vicar visited the home for communion to meet the religious needs of service users in the home. The manager stated the home had a policy on advocacy and a review of records indicated an advocate was involved in safeguarding the financial affairs of one service user in the home. The inspector noted service users were entitled to bring personal possessions to the home and observations confirmed service users had their own television and bedroom furniture for comfort and enjoyment. The home has written menu plans and service users participated in planning the menu. Observations confirmed service users had pork chops, mashed potatoes, cabbage and broccoli for lunch. Dessert was a choice of apple tart, ice cream or fresh fruits and a range of fruit juices were available. Mealtime was relaxed, unhurried and meals were nicely presented. The inspector noted staff supported service users throughout lunch using verbal and physical prompts. During discussions a service user stated ‘‘the food is very good, if you make suggestions they take it on’’ and a staff commented ‘‘I have never heard anyone complaining about food’’. It is recorded by a relative ‘‘the food is great’’. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The complaints process is satisfactory with complaints information available to staff, service users and relatives. The arrangements for protection need strengthening to ensure staff have refresher training in safeguarding adults to protect service users from harm and abuse. EVIDENCE: The manager stated the home had a complaints policy which is available in the home for information. The inspector noted no complaints were recorded about the home since the last inspection by the CSCI (commission for social care inspection) and confirmed by the manager. During discussions a service user commented ‘‘I am quite happy, I have no complaints’’. The inspector noted complaints information was displayed in the hallway and accessible to relatives, visitors and other professionals. The home had a policy on safeguarding adults and a whistle blowing procedure to safeguard the welfare of service users. The inspector noted no concerns or allegations in respect of safeguarding adults were raised since the last inspection by the CSCI (commission for social care inspection) and confirmed by the manager. A review of records indicated staff were in need of training in safeguarding adults and action has been required in respect of this matter to protect service users from harm. During discussions a service user stated ‘‘staff are very caring even when service users are being difficult’’. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 15 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&26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises are excellent ensuring service users live in a safe and comfortable environment. The systems for hygiene are good ensuring the home is clean and hygienic for service users. EVIDENCE: The manager stated the home had a programme of routine maintenance and the inspector noted the provider had made significant investment to improve the quality of the premises. The home had new carpets, curtains, chairs, bedroom furniture, and the gardens are well maintained, attractive and accessible to service users for their pleasure and enjoyment. The inspector noted routine maintenance to the outside of the property is being carried out and a new fence has been installed in the garden to promote the safety of service users. A relative commented ‘‘Pinehurst Rest Home is a wonderful home to visit’’ and ‘‘the home has a lovely atmosphere’’. On the day of the inspection the home was clean, nicely presented, free from mal odour and observations confirmed the domestic assistant cleaning the home and Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 16 practising infection control measures by wearing an apron and gloves. The home had an infection control policy and a service level agreement with an approved contractor for the disposal of clinical waste. Further evidence indicated the home had adequate laundry facilities and staff washed their hands regularly to prevent the spread of infection in the home. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring there are sufficient number of staff to meet the needs of service users. NVQ (national vocational qualification) training for staff is good ensuring service users are in safe hands at all times. The systems for recruitment of staff need strengthening to protect service users from harm. Induction training is good ensuring staff are trained and competent to do their jobs. EVIDENCE: On the day of the inspection the home was adequately staffed with the registered manager, two deputy managers, two support workers, a cook and domestic assistant on duty which was reflected on the staff duty roster. During discussions the deputy manager stated ‘‘I am happy with staffing levels’’. The inspector noted the home operated an on-call system on night duty to promote the safety of service users and during discussions a service user commented ‘‘staff are doing an admirable job. I wouldn’t say this lightly’’. Staff working at the home have completed NVQ (national vocational qualification) training and it was positive to note the home had exceeded Standard 28 of the NMS (national minimum standard) with over 50 of staff having the qualification. The manager stated the home had a policy on recruitment and the inspector sampled recruitment files which had completed application forms, references, statement of terms and conditions, CRB Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 18 (criminal records disclosure) information and a recent photograph of the employee. Following discussions with the manager a requirement has been made for staff application forms to be revised to include a full history of employment and CRB (criminal record bureau) information to include disclosure numbers only to protect service users from harm. The manager stated the home had a policy on staff induction and an induction handbook. The inspector noted staff working at the home have induction and foundation training which covered aims and objectives of the home, policies and procedures, and safe working practices. The inspector noted staff foundation training has been reviewed to include training in dementia awareness to meet the needs of service users with memory impairment. During discussions a member of staff stated ‘‘I am happy with training opportunities’’. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 19 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&38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are good ensuring service users live in a home which is run and managed by a person fit to be in charge of the home. The systems for quality assurance are adequate ensuring the home is run in the best interests of service users. Policies and procedures for managing service users’ money are good ensuring the financial interests of service users are safeguarded. The arrangements for safe working practices are good and promote the health and safety of staff and service users. EVIDENCE: The home has a registered manager who provides management stability, leadership and direction to the staff team. The inspector noted the manager has the RMA (registered manager award) qualification and there are clear lines of communication and accountability in the home with two deputy managers Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 20 assisting the manager in day to day operations. During discussions a staff stated ‘‘the manager is very good, supportive and helpful’’ and ‘‘we have regular meetings with the manager’’. The manager remarked the home had a policy on quality assurance and a review of records indicated the home had regular meetings with staff and service users to participate in the running of the home. Further evidence indicated the home used questionnaires to obtain feedback from visitors, relatives and other professionals about the home. It is recorded in a feedback form ‘‘all the staff are so friendly and caring, the food is great, I always look forward to coming here’’. The manager commented the home had a policy on service users money and provided a safe for money and valuables. The inspector sampled finance records and noted it was up to date, correct, signed by two members of staff and available in the office for information. The home had a health and safety policy and staff have training in first aid, food hygiene, fire safety and client handling. The inspector noted the home had a policy on COSHH (control of substances hazardous to health) and observations confirmed products were stored in a locked cupboard to promote the health and safety of staff and service users. The kitchen appeared clean, hygienic and food was appropriately stored. Fridge and freezer temperatures were within normal limits to promote good food safety and the manager stated the home had a legionella bacteria test carried out on the 04/09/06 to safeguard the welfare of staff and service users in the home. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 21 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 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 X 3 X 3 X X 3 Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5(1)(b) Requirement The registered person must ensure information about fees and the scale of charges by the home is included in the service user guide to ensure prospective service users have up to date information on which to make decisions about admission to the home. The registered person must ensure a proper record is kept by the home of medications returned to the pharmacy to prevent mishandling of medications. The registered person must ensure prescriptions by telephone are witnessed, dated and signed by a second member of staff to promote the health of service users. The registered person must ensure information about activities is in a format which may be understood by service users with memory impairment to promote social and recreational interests. The registered person must DS0000013745.V310300.R01.S.doc Timescale for action 01/10/06 2. OP9 13(2) 01/10/06 3. OP9 13(2) 20/09/06 4. OP12 12(2) 01/10/06 5 Pinehurst OP18 13(6) 01/12/06 Page 23 Version 5.2 6. OP29 17(2) Schedule 4 ensure staff have refresher training in safeguarding adults to protect service users from harm. The registered person must ensure staff application forms are revised to include a full employment history of the prospective employee and CRB (criminal records bureau) information is reviewed to include staff disclosure numbers to protect service users from harm. 01/12/06 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 *RCN Good Practice Recommendations No recommendations were made at this inspection. Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Pinehurst DS0000013745.V310300.R01.S.doc Version 5.2 Page 25 - 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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