Inspection on 30/04/07 for Pinehurst House Nursing Home

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 House Nursing Home 05/01/06

Pinehurst House Nursing Home 14/06/05

Pinehurst House Nursing Home 20/01/05

Pinehurst House Nursing Home 05/05/04

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 House Nursing Home Pinehurst Off Filmer Lane Sevenoaks Kent TN14 5AQ Lead Inspector Elizabeth Baker Key Unannounced Inspection 30th April 2007 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 House Nursing Home DS0000026196.V336671.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 House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinehurst House Nursing Home Address Pinehurst Off Filmer Lane Sevenoaks Kent TN14 5AQ 01732 762871 01732 763922 coetzeeh@bupa.com www.bupa.com BUPA Care Homes (BNH) Limited 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) Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (0), Terminally ill (0) of places Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Pinehurst House Nursing Home is a care home providing nursing care for 30 Older People. BUPA Care Homes Limited is the registered provider. Pinehurst House is a purpose built establishment, which was first registered in 1986. Resident accommodation comprises 30 single bedrooms and three sitting/dining rooms all of which are on the ground floor. All bedrooms have a TV and telephone point. Bedrooms do not have ensuite facilities. All rooms used by residents are connected to the nurse call system. There is a central inner courtyard, which provides appropriate seating and a sensory garden. There is ample car parking. The home is located near to the main A25 trunk road and approximately two miles from Sevenoaks Town Centre. Sevenoaks has a good range of amenities including shops, banks, and places of worship, restaurants, a cinema and theatre. Sevenoaks is well served by public transport. Current activities include armchair exercises, quizzes, talk and slide shows. External entertainers provide keyboard, piano and singing sessions. Current fees are £954 per week and include a daily newspaper of choice. Additional charges are payable for hairdressing, chiropody and private taxi hire. A copy of the latest inspection report is kept in the main reception. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2007/08. Link inspector Elizabeth Baker carried out the site visit. The visit was carried out on the 30 April 2007 and lasted just over eight hours. As well as touring the home, the visit consisted of talking with some residents, staff and visitors and inspecting some records for case tracking purposes. Four residents, one visitor and two members of staff were interviewed in private. . Feedback of the findings was provided to the Home Manager at the end of the visit. At the time of compiling this report, in support of the visit, the Commission received survey forms and comment cards about the service from nine residents, eight relatives/advocates/visitors, five health care professionals and four care managers. At the Commission’s request the home manager completed and returned a pre-inspection questionnaire. Some of the information gathered from these sources has been incorporated into the report. At the time of the visit, 28 residents requiring nursing care were residing at the home. Since the last visit, the Commission has not received any complaints about the service. What the service does well: The home manager was receptive to advice given and demonstrated an eagerness to improve the service where shortfalls were identified. Good interaction was seen between residents and staff. The design of the home promotes independence for self-propelling wheelchair users. The provider continues to demonstrate its commitment to ensure all care staff are appropriately trained. Healthcare professionals are confident care staff listen to advice and act on it to the benefit of residents receiving medical and palliative care. The home is kept in a clean and fresh state, which is much appreciated by residents. Comment card and survey responses included “Staff listen and act on what I say even when short staffed” and “All the meals are so delightfully prepared. No fatty or grisly meat, no lumpy mashed potatoes etc. A good variety of puddings and overall choices”. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Pinehurst House Nursing Home DS0000026196.V336671.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 House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents move into the home knowing their needs can be met. The current statement of purpose needs further enhancement to provide prospective and current residents with more detailed information about the home. EVIDENCE: At the last visit it was identified that the home’s Statement of Purpose was not wholly individualised to reflect Pinehurst House. Information contained in these documents is essential to prospective and new residents as it should clearly set out what the home is registered for and provide full details of all its services. However this has still not yet been totally reviewed and amended. The copy provided at this visit refers to particular BUPA policies and procedures. This means there is an expectation the reader of the document will have ready access to such documents. A copy of the current document is included in the information pack kept in residents’ bedrooms. However during interviews with residents it was apparent that they did not know or could not Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 9 recall having been informed of its availability. Indeed one resident commented that they thought that the two black books were medical files as she had noted staff using them. To assist the new home manager in expanding the Statement of Purpose, a copy of the Commission’s guidance was provided at the visit. To welcome new residents into the home, fresh flowers, greeting card and complimentary toiletries are provided in bedrooms as part of the home’s admission process. Where practicably possible, registered nurses undertake pre admission visits to prospective residents in their current environment. Details of prospective residents’ needs are recorded on a specific document. The assessment determines whether the prospective residents’ needs, can be met at the home. Where this is established as being the case, the information is used to inform the care plan. If the admission is due to an emergency, the home endeavours to obtain as much information as possible from the prospective residents’ medical practitioner. If a local authority or primary care trust sponsors a resident, then the home would obtain information from these sources also. The home is not registered for intermediate care. Standard 6 is not applicable. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of residents are met with evidence of good multi disciplinary working taking place on a regular basis. Improvements in medicine storage facilities would reduce potential risks to residents. EVIDENCE: The provider has recently developed and provided all its care homes with new care documentation. At the time of this visit Pinehurst was in the midst of undertaking the transfer of all care information onto the new documentation. From the information available, and which was obtained from a mix of the old and new models, it was established that residents are provided with a care plan. To support the plan of care, clinical and health and safety risk assessments are used to monitor the effectiveness of the planned care. However some of the information seen in both models was not always up to date or indeed complete. This included skin integrity assessments, specific preferences with regard to frequency of baths or showers and minimal social and biographical information. None of the records contained specific details of residents’ spiritual and or cultural preferences and wishes in respect death and dying. The home manager said these are kept separately. The new Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 11 documentation requires that this information is included in the main records. This should provide the reader with a complete picture of the residents needs, wishes and preferences. Daily records varied in content. While some provided information on the resident’s quality of day as well as medical condition, others contained meaningless statements such as “given paracetamol regularly”; “all care given”; “no concerns” and “appears cheerful”. For a resident who required two types of pain relief, one of which is a controlled drug, the supporting pain assessment was blank. For a resident seen with extensive facial bruising there was no daily record entry to reflect this. The corresponding care plan had not been updated to include subsequent preventative action taken described by the home manager. There was no body map either. An accident report had been completed. Medications, nursing aids and sundry equipment are currently stored in a room also used as the nurse’s office. This arrangement does not promote a clinical and secure environment for medicine management. Indeed the room was cluttered with administration materials and personal affects, preventing effective cleaning of the room; the security was jeopardised because the door was propped open most of the visit and a window was left open. The provider has developed temperature charts so practitioners can monitor the temperature of the room and drug fridge. This is to ensure that medicines are stored in accordance with manufacturers instructions to maximise efficacy of the treatment. However despite evidence that staff were recording the temperatures on a daily basis, the form was not completed as intended, which did not produce the intended purpose. A resident said they had to have telephone conversations with their relatives in the corridor because the home does not have telephones installed in all bedrooms. This was a great disappointment to them. A comment card respondent that there is no private access to a telephone. All rooms have a telephone point and residents can have a telephone line installed at their cost. This is useful if residents are long-term or permanent placements. However the home manager reported that recently the home is admitting more respite residents, which does not make it viable for residents to organise telephone lines to be installed. The home’s statement of purpose includes a comment in section 13 informing the reader that “[residents can]… make or receive telephone calls without being overlooked or overheard (unless an Adult Protection Order prevents the same)”. The home ensures specialist input is obtained from hospice doctors and palliative care nurses, when there is an assessed need. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home are good offering both choice and variety. Generally most residents are able to spend their time as they wish to. EVIDENCE: Since the last visit one of the activities co-ordinators has left and the other one has resigned. The home manager is just about to appoint two new coordinators. On the day of the visit there were no structured activities. Residents were seen sitting in their rooms listening to the radio, reading newspapers or watching TV. Other residents were seen sitting in the day rooms or secluded garden with their visitors. Visitors were seen coming and going throughout the day. Refreshments are provided to guests. Residents can invite guests to have meals with them, and this arrangement is appreciated. The current programme of activities includes armchair exercises and quizzes. External entertainers visit the home to play the keyboard and piano. The home manager has arranged for a manicurist to visit the home on a fortnightly basis to provide a free manicure to residents who would like this treatment. One comment card correspondent indicated how much they had enjoyed armchair keep fit, as well as sneaking a facial on Ladies Day. Despite this other respondents indicated they felt more attention could be paid to stimulating residents and thereby helping to alleviate some of the boredom Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 13 and frustration and it would be good to see more entertainment/social interaction outside of mealtimes. An interviewee also mentioned that they sometimes get bored. Residents are encouraged to individualise their bedrooms with personal affects, to make the rooms cosier. Since the last visit the home manager has re-arranged the day rooms so that the home now has a dedicated dining room. Residents are free to choose where to eat their meals, and some like to have them in the privacy of their bedrooms. Meals are appetising and well presented. Staff were seen assisting residents with their meals in an unhurried manner, where there was a need. Choices are available at all meals. Residents were particularly complimentary of the breakfasts. Indeed one comment card respondent added “I remember my first breakfast which I had promised myself would be an English cooked breakfast after my two weeks of hospital food – EXCELLENT. I even had fried bread, something you can’t get in some café’s nowadays”. Menus were seen on the dining tables. Copies of the menus are also kept in the information books kept in each resident’s bedroom. However as mentioned previously, not all residents are aware or could recall being informed of this book. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most residents can be sure all their concerns are listened to and acted upon. Residents are supported in exercising their civil duties. EVIDENCE: A complaint’s procedure describing how complaints are dealt with is displayed conspicuously in the reception room. Residents spoken with indicated what they would do if they had a problem or complaint. The home keeps a record of complaints received and action taken. During discussions with the home manager it transpired that has not been the home’s practice to keep a central record of all types of adverse comments and niggles. Doing this may enhance the home’s quality assurance process. Indeed a comment card respondent added that they had raised a concern several times, but little seems to have been done about it. The home manager was unaware of any outstanding concerns. Arrangements are made for residents to vote in elections if they wish to. Since the last visit a number of staff have received Adult Protection training. During interviews with two members of staff both indicated they had not received such training during their employment at the home. However they were both able to describe appropriately what they would do if they had suspected abuse had taken place. More POVA training has been arranged. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider continues to demonstrate a commitment to improving the home’s environment, making Pinehurst a nicer place for residents to live. However current facilities do not ensure residents’ privacy is maximised. EVIDENCE: Since the last inspection an Environmental Officer of the local authority has inspected the home. The home manager said that the requirements made have now been complied with. Following a fire safety audit, bedroom and other doors have been replaced to confirm to fire safety regulations. However during the visit it was noted that some doors had been propped open by rubber door wedges. As technology has moved on with regard to doorstops, this method is now deemed unacceptable and should no longer be used. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 16 The provider’s commitment to ensuring the environment is maintained to a good standard continues. Certain rooms have been redecorated, a number of bedroom carpets have been replaced, all residents now have adjustable beds and some bedroom patio doors have been replaced. It is the home manager’s intention to replace all the remaining bedroom carpets. Gardens surround the home. Garden maintenance time has increased and the gardens looked well kept. Indeed residents stated that they enjoy walking around the grounds. Seating is available in the gardens and secluded courtyard enabling residents and visitors to sit and enjoy the good weather. Although bedrooms are for single occupancy, none have en suite facilities. The home does has a range of toilets, bathrooms and a shower room suitable for residents with a physical disability. However not all residents are aware that the home has a shower room. A comment card respondent added the comment that although they understood there were a number of well-equipped bathrooms there was not a single shower-room. Another comment card respondent stated in their opinion the handrail provision in the lavatories are not really adequate although some improvements have been made. All rooms used by residents are connected to the nurse call system. Where there is a special need, the buzzer in left in close proximity to the resident for easy access. A comment card received by a correspondent made the point that they cannot always join in activities because of their hearing impairment. The pre inspection questionnaire indicates a third of residents have a hearing impairment. However none of the day rooms has a loop-system, which might improve the situation for some residents. During the visit two registered nurses handled a delicate situation in a sensitive manner but in a public place. Because the home does not have a dedicated quiet room, their conversation was continually being interrupted with the normal hustle and bustle routines of a reception area. Confidentiality was also compromised. All areas of the home were fresh and clean. Indeed comment card respondents indicated this is always the case. Residents were complimentary of the laundry service. The laundry and separate sluice rooms are suitably equipped to ensure infection control practices are maintained to a good standard. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff morale is good resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: The home currently employs eight permanent registered nurses and 20 health care assistants. In additional care staff, staff are employed for catering, activities, administration, maintenance and gardening. Staffing numbers generally follow the levels set by the original regulatory authority. Dependency assessments were seen in a number of care records inspected. This assists the home in ensuring staffing levels are appropriate for the current residents’ assessed needs. Residents spoken with indicated the response to the nurse call system is usually good. Currently 90 of unregistered care staff are trained to NVQ level II in care. This demonstrates the provider’s continued commitment in ensuring healthcare assistants are appropriately trained. Staff files inspected contained evidence that systems are in place and followed for recruiting and appointing staff. This includes references and Criminal Record Bureau vetting checks. New staff are required to undertake in-depth Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 18 induction programmes, which includes supernumerary shifts. The induction programmes generally follow the Skills for Care specifications. Pinehurst House Nursing Home DS0000026196.V336671.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new home manager has a good understanding of the areas in which the home needs to improve. The home reviews aspects of its performance through a programme of self-review and consultations, which include the views of residents, staff and relatives. EVIDENCE: The home manager has been in post for about 10 months and is a qualified registered general nurse. The home manager is currently undertaking the Registered Managers Award course and expects to complete this by September 2007. Although the home manager has not managed a care home before, she was the deputy manager of an associated care home for two years. Comment card respondents and people interviewed during the visit were complimentary Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 20 of her style of management, which is more “hands on”. Indeed one respondent added, “Under the excellent guidance of [the home manager] I consider Pinehurst to be one of the best care homes. The home manager has introduced cheese and wine evenings and these are much appreciated by residents and visitors. The gatherings enable residents and visitors to meet with one another, as well as interacting with staff. The home has received many compliments following this initiative. The provider has recently revised, updated and republished its Policies and Procedures. The home has copies. However during discussions with staff there was some confusion as to where they are kept. It transpired that they are kept in the home manager’s office, which may prevent all staff accessing them when required, if the home manager is not on site, as the room is kept locked. Residents and relatives are invited to complete annual satisfaction surveys. The findings are then published by BUPA and are available on request. Care staff have their practices observed by their line managers to ensure they carry out their duties properly. However structured supervision has not yet commenced. It is the home manager’s intention to ensure this is developed and implemented in the near future. The home maintains small amounts of monies on behalf of residents, where there is a request for this service. Computer records of the transactions are maintained. Receipts are obtained for services provided or purchases made on residents’ behalf. Residents’ monies are held in a special account. The account is interest bearing and interest is proportionately distributed. Residents and or their advocates are informed when balances fall below a certain amount so that the funds can be topped up. A small cash flow is kept if residents’ require cash at short notice. However this is not readily available out of normal office hours. Informing prospective residents of this restriction would enhance the current situation. Residents are able to deposit small items of importance with the home for security purposes. A register is maintained when the facility is used to ensure a proper audit is maintained. As stated previously, not all care records are completed as required. However when fully implemented the new care documentation should assist care staff in recording the actual level of care and support they are delivering. The pre inspection questionnaire indicates that in the majority of cases the home’s equipment is serviced and or inspected as is required. However it was noted that the home’s fixed wiring installation certificate expired in February 2007. The home manager explained that a staff member from the organisation’s Estate Department has visited the home and arrangements are now in hand for the survey to be carried out. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 21 Staff receive mandatory training on topics such as food hygiene, moving and handling and fire safety. The pre inspection questionnaire indicates that 6 staff hold a current first aid certificate. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 22 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 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 2 Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 2 3 4 Standard OP1 OP9 OP19 OP38 Regulation 4 13(2) 23(4) 23(2)c Requirement The statement of purpose must be individualised to reflect Pinehurst House Nursing Home. Medicines, nursing aids and sundry equipment must be securely and hygienically stored. Fire doors must not be propped open. The home’s fixed wiring installation must be surveyed and maintained as directed by appropriate electrical installation contractors. Timescale for action 31/08/07 31/07/07 31/05/07 31/07/07 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. 2. Refer to Standard OP7 OP7 Good Practice Recommendations Care plans must be complete of all assessed medical and social care needs and problems. Decisions affecting resident’s safety must be appropriately risk assessed and recorded. DS0000026196.V336671.R01.S.doc Version 5.2 Page 24 Pinehurst House Nursing Home 3. 4. 5. 6. 7. 8. 9. 10. 12. 13. 14. OP8 OP8 OP10 OP12 OP16 OP20 OP22 OP33 OP35 OP36 OP37 Body and wound maps must be used where there is an identified need. Daily statements should contain meaningful information on residents’ quality of day and experiences. Residents should be able to make and receive telephone calls in private. The range of activities should be reviewed to reflect the diverse needs, preferences and abilities of the all the residents. The recording of complaints should be expanded to include all adverse comments and niggles. Facilities should be readily available for residents and or their visitors to meet for private conversation. The home should have suitable equipment to meet the identified needs of all residents. Policies and procedures should be easily accessible to all staff at all times. Details of restrictions to residents’ personal monies should be available to prospective and current residents. All care staff should receive regular and structured supervision and the discussions recorded. All records relating to residents must be complete of all information. Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Pinehurst House Nursing Home DS0000026196.V336671.R01.S.doc Version 5.2 Page 26 - 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!