Inspection on 30/11/06 for Pinehurst Care Centre

This inspection was carried out on 30th November 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 Care Centre 17/11/08

Pinehurst Care Centre 19/12/05

Pinehurst Care Centre 11/08/05

Pinehurst Care Centre 09/01/05

Pinehurst Care Centre 08/07/04

Pinehurst Care Centre 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Pinehurst 38 - 44 Duke`s Ride Crowthorne Berkshire RG45 6ND Lead Inspector Jill Chapman Unannounced Inspection 30th November 2006 09:45 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.V321712.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. DS0000011081.V321712.R01.S.doc Version 5.2 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.V321712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 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. The current fees for the home range from £455-515 per week. Chiropody, hairdressing, newspapers, personal toiletries, and taxis are additional costs. DS0000011081.V321712.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 9.45 am and was in the service for 7 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. A tour of the communal areas of the building was carried out and some service users bedrooms were seen. The inspector was introduced to most of the service users and spoke with some in detail. A visiting relative also gave a view on the home. Discussion took place with the registered manager, the cook, the laundry assistant and some of the care staff on duty. Records relating to staff, service users care and health and safety were sampled. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service users guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. What the service does well: Service users know what they can expect from the service and how much it will cost them. The home only admits service users whose needs thay can DS0000011081.V321712.R01.S.doc Version 5.2 Page 6 meet. The home would be able to identify any different religious or cultural needs. Service users care and health needs are well documented and are met. Service users medication is well looked after and given safely. Staff protect service users privacy and dignity. Service users benefit from a variety of activities and entertainment. They have good contact with the local community and choice in their daily routines. The home would be able to meet the needs of service users from different cultural or religious backgrounds. Service users receive a varied and nutritious diet and any concerns service users express about food are responded to positively. The home deals well with service users concerns or complaints and service users know who to talk to if they have a problem. Staff are trained to know how to protect service users from potential abuse. Service users benefit from a well furnished, warm, comfortable and well maintained home. The home is kept clean and hygienic to prevent the risk of infection. There are enough staff on duty to meet service users needs. Recruitment checks make sure that staff are suitable to work with vulnerable service users. There are excellent on site training opportunities to help staff meet service users needs. The home is well managed and communication between managers and staff is good. Service users views are sought for the development of the service. The home makes sure that the equipment and environment is kept safe for service users. What has improved since the last inspection? What they could do better: DS0000011081.V321712.R01.S.doc Version 5.2 Page 7 Risks for individual service users have been considered but need to be better documented to make sure that staff know how to fully protect them. The system for producing Regulation 26 reports need review to make sure they give an independent view of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000011081.V321712.R01.S.doc Version 5.2 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 DS0000011081.V321712.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 6. Quality in this outcome area is good. Service users know what they can expect from the service and how much it will cost them. The home only admits service users whose needs thay can meet. The home would be able to identify any different religious or cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector spoke with service users and staff and case tracked three service users as part of a themed probe. DS0000011081.V321712.R01.S.doc Version 5.2 Page 10 Service users confirmed that they had received a copy of the service users guide which gave them information to help them decide to come and live in the home. It was seen that service users have a written statement of terms and conditions to show their rights and obligations, what services are included and what are extra charges. In discussion with service users and a relative they said that they had written information about the fees they have to pay and the home lets them know the reason for any increase. It was seen that the home fully assesses service users needs before offering them a place. Written assessments were seen on file and service users confirmed that they were visited by a duty manager to discuss their needs. It was seen that the home are monitoring the changing needs of some service users to make sure it is still a suitable placement. The home does not currently have any service users with other cultural or religious needs but the assessment procedure would identify these. Standard 6 does not apply to this home, they offer respite care but not intermediate care. DS0000011081.V321712.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users care and health needs are well documented and are met. Risks for individual service users have been considered but need to be better documented to make sure that staff know how to fully protect them. Service users medication is well looked after and given safely. Staff protect service users privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A previous requirement that care plans and risk assessments are regularly updated and reviewed has been met. There are detailed care plans in place and these were found to be up to date. The home have developed a summary of these in a document called a Care Plan Profile to give staff a quick overview of service users needs. Routine care is evidenced in daily notes which also DS0000011081.V321712.R01.S.doc Version 5.2 Page 12 record service users health, mood, meals taken, activities and any visitors. Service users confirmed that staff meet their needs well. There are individual risk assessments on service users files but not all had them in place for risks other than mobility. It was clear in discussion with the manager that other risks had been considered but these need to be documented to fully inform staff how to protect service users. Health care needs and health appointments are well documented. There are weight charts and other health records on file. Service users confirmed that they see health professionals in private and this was observed when the Chiropodist visited on the day. The homes medication system was seen and enables safe storage and administration. Staff receive a medication induction and are observed by senior staff to make sure they are competent to give this. They also are given formal medication training. In discussion with service users, a relative and staff it was found that service users privacy and dignity is respected. Service users confirmed that staff knock on their bedroom doors before entering and protect their privacy when assisting them to bathe. It was seen that staff relate well to service users and service users were complimentary about how they cope with difficult situations. A room in Fern House is being made available as a hairdressing room to maintain privacy, although a group of service users in another house prefer to have their hair done in a quiet semi private area of their lounge to make this a more sociable event. DS0000011081.V321712.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users benefit from a variety of activities and entertainment. They have good contact with the local community and choice in their daily routines. The home would be able to meet the needs of service users from different cultural or religious backgrounds. Service users receive a varied and nutritious diet and any concerns service users express about food are responded to positively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a programme of seasonal activities such as garden parties, barbeques, Christmas and New Year parties, Carol concert, occasional trips to garden centres and theatres. They also provide regular activities, visiting entertainers, seniorcise (excersise classes) Pat Dogs, Parrot feeding, manicures, card games, dominos and reminiscence. Service users said that they particularily like playing cards, I Spy and the visiting dogs and parrot, DS0000011081.V321712.R01.S.doc Version 5.2 Page 14 they enjoy stroking the pets. Some service users felt that there could be more day to day activities and the home is planning to develop these. A large amount of new activity equipment has just been delivered to enable more choice and opportunity for service users. There are training sessions planned to help staff develop activities generally and for service users suffering from dementia or impaired memory. There is good contact with the local community with pupils from a local college visiting weekly and volunteers from a church group visiting fortnightly. The home supports service users to attend church services on Sundays. There are no current service users who have different cultural or religious needs but it was clear that the home would be able to meet these. A relative confirmed that visiting times are flexible and that visitors are welcomed by staff. In discussion with service users it was clear that the routines of the home can be flexible to enable choice. They said that they can get up and go to bed when they like and choose whether to sit in their room or in their lounge. Service users confirmed that they can bring personal possessions into the home to personalise their bedrooms. A previous requirement that food stored in the fridge be covered and dated has beeen met. The arrangements for food were satisfactory and menus show that a balanced diet is on offer. Some special diets are catered for, it was seen that the cook and staff make particular effort and are patient with service users who change their minds or who do not like what is on the menu. Some service users felt that improvements could be made to portion size but it was seen that second helpings are offerred. Records show that any concerns about food are dealt with appropriately. DS0000011081.V321712.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home deals well with service users concerns or complaints and service users know who to talk to if they have a problem. Staff are trained to know how to protect service users from potential abuse. The development of cross gender care plans and risk assessments would further protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that service users are given information about the complaints procedure in the Service Users Guide, however this information was not recorded in their files. Service users spoken with were unfamiliar with the term Complaints Procedure but knew who to talk to if they had a concern or compliant. Staff spoken with knew what to do if a service user had a concern or complaint. The Commision has received no information about complaints made by service users or their relatives about the service. The homes complaints record shows that service users complaints are dealt with appropriately. In the last year there have been 19 concerns or complaints made to the home about a variety DS0000011081.V321712.R01.S.doc Version 5.2 Page 16 of day to day issues. The record shows that these have been dealt with appropriately and outcomes are clear. Staff confirmed that they have received training in the Protection of Vulnerable Adults. They were aware that the home has a policy that protects them if they should need to report poor practice. The homes training programme includes training on the Protection of Vulnerable adults. Service users said that staff treat them well and have patience in difficult situations. The home has a cross gender care policy but it was noted that there are no cross gender care plans or risk assessments in place. It was clear in speaking to staff that potential risks had been considered. It is recommended that these are developed. DS0000011081.V321712.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. Service users benefit from a well furnished, warm, comfortable and well maintained home. The home is kept clean and hygienic to prevent the risk of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas of the home and some bedrooms were seen. The home is warm, well furnished and maintained. The following improvements have been made since the last inspection, a new enclosure for the shower area, about 50 of bedrooms have been recarpeted, there are new dining room table and chairs in Hurst House, new lounge side tables, a new garden area and new DS0000011081.V321712.R01.S.doc Version 5.2 Page 18 patio doors to access the decking area in Fern House. Service users in Fern House said that they have enjoyed using this area to sit in the sun and that the new patio doors have improved the light in their lounge. Routine decorations have been carried out. Some service users had commented that it is difficult to walk on the uneven gravel drive and it is planned to renew the driveway early next year. The home was found to be clean and hygenic. Domestic staff are employed and there were some comments on surveys that said the standard of cleanliness was not as good at weekends because the domestic staff only work in the week. There is a laundry assistant employed during the week and service users commented on the efficient laundry service,your clothes go there in the morning and are back washed and ironed by the evening. There are systems for handling potentially infectious linen or waste. DS0000011081.V321712.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. There are enough staff on duty to meet service users needs. Recruitment checks make sure that staff are suitable to work with vulnerable service users. There are excellent on site training opportunities to help staff meet service users needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas were sampled and these show the staff cover for each house in the home. During the day, there are two care staff in Hurst, one in Cedar and two for Pine/Fern. At night there is one waking night care staff in Pine/Fern and one in Hurst and one in Cedar. There is a manager on duty during the day and a manager sleeps in at night and can be called to assist if necessary. From observation and from speaking to staff and service users, staff deployment meets service users current needs. Service users were very complimentary about staff in the home, they are very good, they are very patient. Staff spoken with said there is good communication and morale. DS0000011081.V321712.R01.S.doc Version 5.2 Page 20 The home has a programme of National Vocational Qualification training in place. 45 of staff have achieved level 2 or above and another 52 are taking this training. It is planned to achieve 97 by March 2007. The home operates a thorough a recruitment procedure and carries out checks and references to make sure staff are suitable to work with vulnerable people. Some staff are recruited from overseas and checks are made to make sure they have the relevant visas. One service user survey said that it was sometimes difficult to understand certain staff due to their accent. It was noted that an Adult Literacy Course is on the homes training list and some staff have already taken this. Training to improve spoken English could be considered for those who need this. Records show that staff receive Induction and Core training that meets National Standards. The home has its own training room on site. The training given includes Food Hygiene, First Aid, Fire Safety, Manual Handling, Infection Control, the Control Of Substances Hazardous to Health, Medication, Health and Safety, Dementia and Activities Workshops. DS0000011081.V321712.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The home is well managed and communication between managers and staff is good. Service users views are sought for the development of the service. The home makes sure that the equipment and environment is safe for service users. The system for producing Regulation 26 reports needs review to make sure they give a more independent view of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000011081.V321712.R01.S.doc Version 5.2 Page 22 The manager is experienced in the care of the elderly and has been managing the home for many years. She is in the process of taking the Registered Managers Award and this will further improve her skills. The home operates a 24 hour duty management system, there are three assistant managers who cover this rota. Staff spoken with felt that there was good communication between the management team and the staff teams. Although managers are based in a seperate administartive block, it was seen that managers are frequently in the houses and are well known to the service users. Records show that the manager and assistant managers undertake periodic training to update their skills. The home uses questionnaires for seeking the views of service users and their families, recently they have conducted a survey about menus to look at ways of improving the food on offer. Service users meetings are held four times a year and a service user and relative spoke of being involved in a recent meeting. Regulation 26 visits are carried out and the home manager is involved in the preparation of the reports. Regulation 26 reports should be prepared by the person delegated to carry out the visit and not by someone directly involved in the management of the home. There is a system for the safekeeping of service users personal money. This was spot checked and found to be accurate. Arrangements for ensuring the health and safety of service users were satisfactory. The Pre- Inspection checklist shows that equipment is regularily serviced and health and safety and fire safety checks are carried out. These records were sampled and found to be accurate. DS0000011081.V321712.R01.S.doc Version 5.2 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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 DS0000011081.V321712.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4) c Requirement The registered person should ensure that potential risks to individuals need to be documented to fully inform staff how to protect service users. Timescale for action 30/01/07 2 OP33 26(2) c 26(4) c Regulation 26 reports should be 30/01/07 prepared by the Responsible Individual, one of the Partners or person delegated to carry out the visit and not by someone directly involved in the management of the home. 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 OP18 Good Practice Recommendations That cross gender care plans and risk assessments are developed. DS0000011081.V321712.R01.S.doc Version 5.2 Page 25 DS0000011081.V321712.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011081.V321712.R01.S.doc Version 5.2 Page 27 - 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!