Inspection on 08/12/05 for Pinehurst

This inspection was carried out on 8th December 2005.

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 05/09/06

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 Announced Inspection 8th December 2005 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.V250051.R01.S.doc Version 5.0 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.V250051.R01.S.doc Version 5.0 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.V250051.R01.S.doc Version 5.0 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) 28th May 2005. Date of last inspection Brief Description of the Service: Pinehurst is care home for older people. The property is secluded and located in Boxhill in Surrey and provides accommodation for 19 people. The home has an entrance hall, office, lounge, dining room, laundry, kitchen, bathrooms, toilets and 19 single bedrooms. Accommodation is on three floors that can be accessed by stairs or a chair lift. The home has a secluded garden that is private and secure and overlooks National Trust land. Private parking is available to the front of the property. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place and staffs, relatives, service users, and visitors were spoken to. Care records and documents were examined. The inspector would like to thank the manager, deputy managers, staff, relatives, service users and visitors for their contributions to the inspection. A CSCI business card was left at the home for information. What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were made at this inspection. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 6 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.V250051.R01.S.doc Version 5.0 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.V250051.R01.S.doc Version 5.0 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. The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for needs assessment are adequate ensuring service users needs are assessed and identified. EVIDENCE: The home had a statement of purpose and service user guide that was dated 3/9/04. The inspector noted the statement of purpose was clearly written and the information was well presented and covered aims of the home, philosophy, rights, quality of life, accommodation, contracts, complaints and admission procedures. The service user guide contained a service users charter and information on staffing and facilities on offer. The home had an admission procedure that reflected the needs assessment of service users. The inspector sampled needs assessment and noted it covered personal care, diet and weight, mobility, social interests, continence, foot care, and medications. Care plans were sampled and the inspector noted each Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 9 service user had a plan for daily living that was regularly reviewed and updated. One service user had her risk assessment reviewed on 1/12/05 and care plans evaluated on the 1/12/05 by the key worker. The inspector noted the physiotherapist and district nurse were present in the home during the inspection. One visitor commented “At all times made to feel welcome by staff. Pleased to see my friend looked after so well. He seems happy and relaxed and it gives me peace of mind to know he is in a safe environment” Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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): 9,10&11. The management of medications at the home is good promoting the health of service users. The arrangements for privacy and dignity are adequate ensuring service users are treated with respect and their dignity upheld. The arrangements for dying and death are satisfactory ensuring service users who are dying are treated with sensitivity and respect. EVIDENCE: The home had a medication registration policy displayed in the staff office that had three metal cupboards secured to the wall and a drug trolley for the storage of medications. The deputy manager stated medicines were supplied by Boots pharmacy using blister packs and the arrangements were satisfactory. The inspector sampled a folder that contained medication record sheets and noted they had a recent photograph of service users attached and were dated and signed by staff. The deputy manager commented the home had controlled drugs that were appropriately stored and records were up to date and correct. One service user was given a controlled drug on the 7/12/05 and the balance of 22 tablets was correct. The inspector sampled records and noted staffs have training in intermediate certificate in safe handling of medicines. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 11 The home had a statement on privacy and dignity reflected in the statement of purpose. The inspector noted staff addressed service users by their preferred names and the manager and deputy manager knocking on doors before entering service users bedrooms. A service user remarked “staff preserve the dignity of residents and behaviours are taken as normal”. The home had a policy statement on continuing care that covered dying and death of a service user. The manager stated the home is committed to supporting service users through illness and dying and offered relatives the opportunity to stay with a service user that is dying. A relative commented “mother is shown a lot of warmth and respect by staff and the owner”. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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): 15 The meals at this home are good that offers variety and choice and caters for the special dietary needs of service users. EVIDENCE: The home had a policy on food safety and nutrition and the manager stated the home is committed to offering good quality meals to service users and had written menu plans. The inspector sampled the plans and noted meals were varied, healthy and wholesome. On the day of the inspection some service users had a glass of sherry before lunch that was roast chicken with gravy, roast potatoes, beans and carrots and dessert was a choice of strawberry cheesecake or fresh oranges and bananas. The inspector noted one service user that was a diabetic had a special meal and another service user with swallowing difficulties had a soft diet. Refreshments, biscuits and cakes were available throughout the day and the inspector noted staff served mid afternoon tea and coffee with biscuits and cakes. Mealtime was relaxed and unhurried and the inspector noted one staff offering assistance to a service to eat her lunch. The inspector noted the home had a meeting on the 20/5/05 to discuss the menu and service users stated they preferred beef or lamb rather than pork for Sunday lunch and the management had taken action. The comment sheets for November 2005 were sampled and it was recorded one service user loves chicken curry and roast beef that was reflected on the Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 13 menu. During a meeting a service user stated the food at the home is very nice and commented “I don’t like fish and have an omelette instead”. A relative stated “ meals are good, there is fresh cooking at lunchtime”. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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 The complaints process at the home is adequate with complaint information available to staff, service users and relatives. EVIDENCE: The manager stated the home is committed to ensuring complaints about the home is properly managed. The inspector noted the home had a complaint policy that was in the statement of purpose and during an interview staff stated they were aware of the complaints policy. The manager stated the home had a complaint book that was sampled and the inspector noted no complaints were made since the last inspection in May 2005. During a meeting a relative stated she “ visited regularly, never found anything to worry about, very happy and long may it continue” and another relative remarked “any suggestions we make are promptly acted on”. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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): 19,21,22,25&26. The home is well maintained ensuring service users live in a safe environment. The toilets and washing facilities at the home are adequate ensuring service users have sufficient washing facilities. The adaptations and equipment at the home is satisfactory ensuring service users have specialist equipment to maximise their independence. The heating and lighting at the home is adequate ensuring service users live in safe and comfortable surroundings. The arrangements for hygiene are satisfactory ensuring the home is clean and pleasant for service users. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour. The manager stated the home had a refurbishment plan and remarked many areas of the home had been decorated. The inspector noted the standard of décor was good throughout the home with nice furnishings and fittings in the communal areas. The gardens were neat, tidy, private and secure with easy access. The deputy manager stated the home had adequate Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 16 lavatories and washing facilities. The inspector noted the home had two bathrooms with showers and toilets and service users had easy access to a toilet on the first floor that was clearly marked and close to the lounge and dining room. The deputy manager stated the home had specialist aids and equipment and the inspector noted the home had assisted baths, hoists, stair lift and bathrooms and toilets were fitted with an aid call system. The inspector noted the home had adequate heating, lighting and ventilation and bedrooms had individual thermostatic control. The inspector noted the central heating system was serviced on the 27/5/05 and the emergency lighting system was serviced on 10/11/05. On the day of the inspection the home was clean, well presented and free from malodour. The inspector noted the home had a control of infection policy and the deputy manager stated the home employed a fulltime cleaner to maintain the cleanliness of the home. Observations confirmed staff washed their hands frequently and the home provided gloves, aprons and hand wash. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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): 28&29. The arrangements for staff training are good ensuring service users are in safe hands at all times. The recruitment practices at the home are adequate ensuring service users are protected for harm or abuse. EVIDENCE: The manager stated all staff had completed the NVQ Level 2 in Care award and were awaiting certificates. The inspector had a meeting with a staff from the John Ruskin College that confirmed eight members of staff at the home had successfully completed the NVQ award and commented “the motivation of staff was 100 ”. During a meeting staff confirmed they had completed the award. It was positive to note that the home had exceeded standard 28 of the national minimum standards. The home had a policy on recruitment and employment including redundancy. The inspector sampled staff recruitment files that were kept in the manager’s office and noted it contained a completed application form, references, CRB disclosure, job description, terms and conditions and a recent photograph. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,35,36&37. The management of the home is satisfactory ensuring the home is well run and managed. The financial procedures at the home are adequate ensuring the business is financially viable. The arrangements for service users, money are satisfactory ensuring service users interests are safeguarded. The systems for supervision are satisfactory ensuring staff are appropriately supervised. The arrangements for record keeping are adequate ensuring the best interests of service users are safeguarded. EVIDENCE: The home has a manager that has completed the registered managers award in 2005. The manager is aware of her role and responsibilities and has introduced clear lines of accountability by appointing two deputy managers that are responsible for the implementation of policies and procedures and clinical standards within the home. The manager and deputy managers have Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 19 completed a training course in dementia awareness to ensure they are familiar with conditions associated with old age. One service user commented “ I consider this to be an extremely well run home in which the staff excel themselves in their duties ”. A visiting professional remarked “ the manager is extremely kind to service users and staff, something you cannot buy ”. The manager stated the home had employers liability insurance that was displayed in the hallway. The inspector noted the certificate of insurance was dated 31st December 2004. The manager stated the home was financially viable and had a financial statement issued by the bank and dated 28/10/05. The home had a policy on the management of service users money and valuables. The manager stated the home provided a safe to keep service users money and valuables and had a register for service users money and valuables that was sampled. The inspector noted the register was up to date and staff dated and signed an entry made on the 28/10/05 to cover hairdressing and chiropody. The manager stated staffs are regularly supervised and supervisions are recorded. The inspector sampled supervision files and noted it contained a supervision agreement dated 6/6/05 that was signed by the manager and employee. One supervision record covered areas of care planning, abuse and IT course. During a meeting staff stated they had regular supervision. The manager stated records in the home are accurate and up to date. The inspector noted business and staff records were kept in a locked cabinet in the manager’s office and service user records were kept in a locked metal cabinet in the deputy manager’s office. The inspector sampled policies and procedures, staff files, finance documents, care plans and noted they were accurate and up to date. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 3 X X 3 3 STAFFING Standard No Score 27 X 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 3 3 X Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 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. Standard Regulation Requirement Timescale for action No requirements were made at this inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No recommendations were made at this inspection. Pinehurst DS0000013745.V250051.R01.S.doc Version 5.0 Page 22 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.V250051.R01.S.doc Version 5.0 Page 23 - 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!