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Inspection on 19/12/05 for Pinehurst Care Centre

Also see our care home review for Pinehurst Care Centre for more information

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Pinehurst is a happy home with a great sense of community. All residents spoken with said they liked living in the home, staff treated them well, always kind and respected their privacy and dignity when providing support with personal care. Relatives said the home communicates with them well and notifies them of any changes without delay. Relatives are welcomed into the home and invited to be involved in social activities.

What has improved since the last inspection?

Apart from a vacancy within the senior team the home has been enjoying a period of stability within the staff team with no other vacancies. This was evidently of benefit to people living within the home as continuity of care was being provided.

What the care home could do better:

Service users risk assessments need regular review and updated to reflect current care needs especially in relation to absconding from the building. Food stored within the fridge must be covered and dated when opened. Complaints recording to detail outcomes following investigation of complaints and dated. Staff to be supported with regular 1-1 recorded supervision.

CARE HOMES FOR OLDER PEOPLE Pinehurst 38 - 44 Duke`s Ride Crowthorne Berkshire RG45 6ND Lead Inspector Debbie Willcox Unannounced Inspection 10:30 19 December 2005 th 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 DS0000011081.V270762.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. DS0000011081.V270762.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinehurst Address 38 - 44 Duke`s Ride Crowthorne Berkshire RG45 6ND 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) 01344 774233 01344 780168 pinehurstcare@bt.com Pinehurst Care Ltd Mrs Christine Hazlewood Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places DS0000011081.V270762.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2005 Brief Description of the Service: Pinehurst is a registered care home with 50 beds providing a residential care service for older people over the age of 65. Pinehust is located within Crowthorne close to the High Street and local amenities. The home consists of four houses - Pine House, Fern House, Cedar House and Hurst House all located on one site. DS0000011081.V270762.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector on a weekday over a period of 4 hours. The majority of time during this inspection was spent talking with people who live in the home, relatives and staff as well as observing daily activities. A variety of documents relating to care planning, health and safety and staff supervision and support were also viewed as part of this inspection. What the service does well: What has improved since the last inspection? Apart from a vacancy within the senior team the home has been enjoying a period of stability within the staff team with no other vacancies. This was evidently of benefit to people living within the home as continuity of care was being provided. DS0000011081.V270762.R01.S.doc Version 5.0 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. DS0000011081.V270762.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 DS0000011081.V270762.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): THESE STANDARDS WERE NOT ASSESSED AT THIS INSPECTION. EVIDENCE: DS0000011081.V270762.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Service users health and personal care needs are set out in a plan of care. Care plans need to be regularly updated to reflect current care needs and risk identified. Service users can be assured they will be treated with dignity and respect and their rights to privacy upheld. EVIDENCE: It was apparent from discussions with service users that all spoken with said staff treat them with dignity and respect when assisting them with personal care tasks. Two service users new to the home said that staff had helped them to settle and feel content about their new surroundings. Care plans are very detailed with a high volume of information provided. There has been improvement in the social history and background details of service users. One service user prone to wandering and absconding from the building did not have information provided within his care plan highlighting the risks and DS0000011081.V270762.R01.S.doc Version 5.0 Page 10 written information to guide staff in handling this situation and limiting the risks. The manager produced evidence of a system she is looking to implement, which would provide a more condensed system of care planning information for staff making this easer for staff to read. The home needs to ensure a system of regular review and updating of care plans and risk assessments to ensure these reflect the current needs of service users. The home is well supported by GP’s and District Nursing staff. Service users have access to chiropody services on a regular basis. Service users weight is regularly monitored and recorded. DS0000011081.V270762.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Service users are supported to maintain contact with family, friends, and the local community and are helped to exercise choice and control over their lives. EVIDENCE: This inspection took place during the Christmas week. Service users and relatives spoke of the several social activities, which had been enjoyed during the last few days such as a Christmas party, a pantomime, visiting groups to entertain such as church groups and college students. One service user spoken with said she did not like to be involved in activities and staff without intrusion respected her wishes. One relative spoken with said she thought that the regularity of social activities provided had improved within the last few months. The home is well supported with church groups visiting the home and assisting people to church with transport. Service users are supported to attend a local day centre if they wish and the day centre provides transport. Some service users are able to access the local shops and amenities independently. DS0000011081.V270762.R01.S.doc Version 5.0 Page 12 It was evident that service users are able to exercise choice as to the time they get up and go to bed and to stay in their room or to join others in communal areas if they so wish. DS0000011081.V270762.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users and their relatives can be confident that the home will listen to their complaints and take them seriously. EVIDENCE: The homes complaints records were viewed. The home has a complaints policy and procedure in place. The home has had four complaints since March 2005. Two complaints related to the standard of food provided. It was evident from discussions with service users and records seen that the home responds appropriately to concerns and complaints and service users feel confident that their complaints will be listened and addressed. The complaints record book did not detail the outcome of two complaints with dates recorded as to when they had been dealt with. However other records held did evidence the homes responses to the complaints made. Discussions with staff evidenced that they receive training in recognising abuse and responding to abuse of vulnerable adults. DS0000011081.V270762.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,25,26 Service users live in a safe, well-maintained environment and have comfortable bedrooms where they are encouraged to bring their personal possessions with them to create a homely environment. EVIDENCE: A partial tour of the homes was undertaken at this inspection. The premises are well maintained with regular updating of decoration and renewal of furniture, and furnishings undertaken. The manager evidenced that whatever is needed she is well supported by the proprietors in requests for renewals. Areas inspected were found to be clean, hygienic and pleasant. Service users are encouraged to bring into the home their personal possessions to help them create a homely environment within their rooms. DS0000011081.V270762.R01.S.doc Version 5.0 Page 15 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 The numbers of staff provided are meeting Service users current needs. Staff are supported in accessing training to equip them in their role and provide appropriate support to service users. EVIDENCE: Staffing levels on the day of this inspection were found to be satisfactory to meet the needs of service users within the houses inspected. Discussions with the manager and staff evidenced stability within the staff team, which has benefited continuity of care for people living within the home. There has been some movement within the senior staff team within the last year and only one vacancy remains at present. Discussions with staff evidenced a variety of ongoing training is being provided to staff including NVQ qualifications obtained or in the process of obtaining. The manager has recently accessed training in dementia care, which she has found informative and helpful. DS0000011081.V270762.R01.S.doc Version 5.0 Page 16 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): 31,32,33,36,38 This home is run in the best interests of service users where the management approach is supportive and their opinions are sought and their health and safety protected. EVIDENCE: Previous attempts to recruit a new manager have failed and the current registered manager has decided to stay in post for the time being. The manager has recently started working towards gaining the NVQ level 4 management qualification. All service users, relatives and staff spoken with said they found the management team approachable and supportive. Staff said they would have no hesitation in approaching a manager with any concerns they may have would value more opportunities for supervision on a DS0000011081.V270762.R01.S.doc Version 5.0 Page 17 1-1 basis. Due to changes within the management team supervision sessions for staff have been sporadic in regularity. Residents meetings are now planned on a 3 monthly basis and service users notified of these on their notice boards within each house. Service users spoken with said they are consulted much more frequently on their views regarding food provided and menu planning. A tour of the kitchen was undertaken. Cooked meat stored within the fridge was found to be uncovered and cooked ham opened from a packet had not been dated. Apart from this the kitchen was found to be clean and orderly. Fire records were viewed at this inspection and found to be in order and up to date. The home has a Fire risk assessment in place. The home has recently had a visit from a Berkshire Fire Officer; several requirements have been made and are currently being addressed such as: * Fire doors to be provided with cold smoke seals as well as intrimescent strips. * Emergency lighting to be provided to the office/accommodation building * Fire doors to be provided to the staircase enclosure in the office building. * Fire exit signage should be provided to the exit corridor in number 44. Other health and safety records audited at this inspection included hoist servicing, lift servicing, gas safety checks and boiler servicing. All servicing was found to be up to date and records in good order. DS0000011081.V270762.R01.S.doc Version 5.0 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 x 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 2 x 2 DS0000011081.V270762.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans ad risk assessments to be regularly reviewed and updated to reflect current needs of service users. Food stored in the fridge to be covered and dated. Timescale for action 01/03/06 2. OP38 13 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000011081.V270762.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000011081.V270762.R01.S.doc Version 5.0 Page 21 - 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. 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