CARE HOMES FOR OLDER PEOPLE
Pinehurst Residential Care Home Pinehurst 14 Chambercombe Park Road Ilfracombe Devon EX34 9QN Lead Inspector
Adele Adams Unannounced Inspection 10:00 15 March 2006
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 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 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 Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Pinehurst Residential Care Home Address Pinehurst 14 Chambercombe Park Road Ilfracombe Devon EX34 9QN 01271 862839 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) Pinehurst Care Home Ltd Post Vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Pinehurst is a large, detached Victorian house with large grounds to the rear, having a spacious raised decked balcony area having pleasant views across the North Devon coastline. The home is on four levels; a stair lift provides access to each of the floors. There is a choice of three lounges one of which is a conservatory; each has an individual feel to them. One lounge is adjacent to the dining room, this is situated off the reception hall, and the third also provides a dining area and is located on the lower floor. The home has 17 single rooms and 3 double rooms, these are personalised with residents personal possessions, and each room has its own bathroom and toilet facility. The home is registered to meet the needs of service users aged over 65 and those with a dementia type illness. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced “Key Standards “ to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home it is recommended that all reports written within an inspection year (1st April to 31st March) be taken into consideration. This inspection was announced and took place between 10:50 and 15:50. During the inspection, the inspector spent time speaking with residents and staff. The inspector toured the home and was invited into the rooms of two residents. During the tour of the home the inspector spent time observing residents and staff. Time was also spent time reading a variety of records, which included resident records and health and safety records. There was no access to financial and staff records on this occasion. The former manager has retired and an application for the new manager to be come the Registered Manager has been received by the Commission. The manager and provider were not present at this Unannounced inspection. What the service does well:
This inspection found that Pinehurst provides a homely, caring environment for residents, visitors and staff. The residents at Pinehurst are treated with courtesy and respect and importance is placed on residents’ privacy and dignity. Residents told the inspector that they enjoy the food at Pinehurst and that they are well cared for by staff. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
The information contained in the assessment of residents before they enter the home and in the residents’ care records should be improved to clearly show the level of care that is actually provided by staff and received by residents at Pinehurst. The recording and monitoring of residents’ nutritional needs should be improved to show that there is an individual approach to meeting nutritional and dietary needs. The menu system and food record that is currently in place should be improved to clearly show that residents are offered a snack each evening, this will clearly show that the home do offer food and drinks between the evening meal and breakfast. Residents, visitors and staff at Pinehurst would benefit from a clear and up to date complaints policy and procedure being in place. This must contain essential details such as contact names and addresses and timescales in which action will be taken and who to contact should anyone not be satisfied with how a complaint has been managed. Residents and staff at Pinehurst will benefit from staff receiving suitable adult protection training. This training must be undertaken and will provide staff with the information and guidance necessary to ensure that residents living at Pinehurst are protected from abuse by well-informed staff.
Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 7 Improvements to the environment will benefit residents at Pinehurst. A handrail to a section of staircase should be installed to improve safety on the stairs. Attention to the double-glazing in residents’ rooms at the rear of the home is needed and once complete will reduce drafts and improve residents’ comfort in the winter months. The service’s approach to infection control must improve. The installation of a separate hand-washing sink in the laundry plus the provision of essential staff training such as food hygiene training and infection control training together with the provision of up to date infection control information will benefit residents and increase staff confidence by making sure that infection control practices in the home are adequate and up to date. Doors in the home must not be propped open unless an appropriate recognised device is used to do so, by ensuring this does not happen, fire risks will be reduced and Residents, visitors and staff better protected. The service must make sure that there is appropriate access at all times to staff records ensuring that inspection of these can take place at any time. In order to ensure the safety of residents and to reduce risks within the home, all staff working at the home must have had an appropriate police check undertaken before starting work at the home. Quality Assurance practices should be developed and introduced at the home this will make sure that the service continuously moves in the best interests of the residents. The service must make sure that there is appropriate access at all times to financial records ensuring that inspection of these can take place at any time. Improvements to Health and Safety at the home are needed these include: Essential fire checks must be undertaken as specified and records of these checks must kept and the fire risk assessment for the service must be undertaken and reviewed regularly to ensure that risks are identified and minimised and appropriate action is taken and planned for. All certificates received from contractors must clearly show the contractors’ details and the date the certificate is valid from. There must be a person who has a valid and up to date first aid qualification on duty on every shift to ensure that any person requiring first aid is treated promptly by a suitably qualified person. All staff must receive suitable annual manual handling training to ensure that risks to residents who need assistance with moving are minimised. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 9 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 Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 10 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): 3 Not all residents’ needs are included in their assessment on admission to Pinehurst. EVIDENCE: This standard was not fully inspected and findings link to Standard 15. Please also refer to Standard 15 – Meals and mealtimes. The inspector read 3 residents’ records when inspecting ‘Meals and mealtimes’ and found that the residents’ weight is not recorded in their care records on admission to Pinehurst. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The information in residents’ care records is not always adequate. EVIDENCE: This standard was not fully inspected and findings link to Standard 15. Please also refer to Standard 15 – Meals and mealtimes. The inspector read 3 residents’ records when inspecting ‘Meals and mealtimes’ and found that residents’ weight is not routinely monitored or recorded and the plan for nutritional needs tend to focus on residents’ dietary preferences and do not address dietary needs. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents at Pinehurst enjoy their meals, which are varied and nutritious, however the lengthy amount of time between meals needs to be addressed, as does the recording of residents’ nutritional needs. EVIDENCE: The inspector visited the kitchen, spoke with the cook, residents and staff, observed the residents’ lunch time meal, read menus, saw and read the fridge and freezer temperature records and read 3 residents care records. The menu is changed on a monthly basis and the cook informed the inspector that she does ask residents for their views and that food such as curry and pasta has recently been enjoyed. The menus showed that nutritious and varied meals are provided and residents and staff confirmed this. There is also a menu for vegetarian diets and a separate dessert list for diabetics. Fruit, vegetables and meat are delivered on a daily basis and a bowl of fresh fruit is available for residents. Breakfast is prepared by the care staff and taken to residents’ rooms as and when they request – this inspector was advised that this is usually after 8 a.m. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 13 Lunch is served at 12:00 midday and residents eat either in the dining room or their own room – lunch on the day of inspection was jacket potato with cheese and a ham salad with a dessert of apple crumble and cream. The inspector was informed that residents would prefer to eat a little later. Tea is served by care staff at 16:30 and is usually a light meal and a cake with a drink and biscuit being served at about 19:30. No suppertime snacks are available but the cook advised the inspector that residents could have a snack at any time if they would like one – this was difficult to evidence. Hot drinks are served at intervals throughout the day and fresh fruit juices and cordials are also available. Care staff spoken with that prepare residents’ breakfasts and tea have not had food hygiene training. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Pinehurst has a complaints policy and procedure, which is not up to date. The necessary arrangements that support staff to prevent residents from being placed at risk of or suffering from abuse are not in place. EVIDENCE: The inspector spoke with residents and staff, read the home’s policies and procedures, read staff training certificates and found that staff have not received any Adult Protection Training and the policy relating to Adult Protection is out of date and does not contain the latest appropriate guidance. The complaints procedure is posted in the hallway of the home and the policy provides greater detail of the way in which complaints will be managed – for example provides timescales, however the procedure is in need of review as is the policy as some of the information such as the name of the provider is out of date. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Some improvements to the environment and staff training would benefit residents at Pinehurst. EVIDENCE: The inspector toured the home and observed the environment, spoke with residents, spoke with the person employed to undertake maintenance at Pinehurst and spoke with care staff. Generally, the inspector found the home to be comfortable and homely, some maintenance work has continued and this has resulted in increased storage space, easier access on the lower floor and improved fire safety as freezers have been re housed. All radiators in the home except an inaccessible one in the dining room are covered. Room 21 was in the process of being redecorated. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 16 The inspector noted that the installation of a handrail to a section of the staircase near to the office would improve safety for residents. The inspector also noted that wallpaper was peeling in one resident’s room and that paintwork was peeling in the en suite toilet of Room 2. The double-glazing in rooms to the rear of the home appeared inadequate as extra insulation was being provided with tissues in some rooms – the maintenance person explained how it was hoped that this could be overcome. The inspector observed that 3 doors were either propped open, for example the kitchen door was being held open by a fire extinguisher– the inspector spoke to staff about this and was advised this happened at mealtimes – the door was still held open when the inspector left – this is to be brought to the attention of the provider for urgent action. The inspector viewed the laundry that has a washable floor, an industrial tumble dryer and a washing machine with a sluicing facility – the inspector was informed that staff do however sluice off soiled materials. A new sink was in the process of being installed in the laundry - however a separate hand washing sink should be easily accessible to staff. The infection control manual was dated 1998 and showed no signs of updating or review and the staff spoken with had not received any infection control training. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Recruitment practices at the home do not currently protect residents and staff and staff training needs to improve to ensure residents are in safe hands at all time. EVIDENCE: The inspector spoke with staff, read displayed training certificates and saw that the majority of staff had the necessary CRB checks undertaken, however the inspector could not access staff records to evidence the details provided verbally by staff. One member of staff has not had a CRB check undertaken; the provider was contacted and advised this must be done as a priority. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38 Quality Assurance at Pinehurst needs to be developed, residents’ financial records must be available to inspect and health and safety practices at the home are not adequate. EVIDENCE: The inspector spoke with residents and staff, read the home’s policies and procedures, inspected safety records and made observations whilst touring the home. The inspector on this occasion was unable to access residents’ financial records to undertake a full inspection of this Standard. The inspector did speak with residents x 2 and staff x 2 in relation to the management of residents’ finances that indicated that good practice takes place but this could not be verified without the availability of written evidence to support this.
Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 19 Staff and residents were spoken with about Quality Assurance practices at the home and none had been involved in any quality audits – the last one appears to have been undertaken in June 2003 by the former manager and the outcome of this was evident in the residents information file that is situated in the hallway of the home, the owner of the home does undertake regular visits to the home and provides a regular written report of this to the Commission. The inspector observed fire exits and equipment during the tour of the building and spoke with staff and residents about safety practices at the home. Residents x 2 informed the inspector that they were aware of what the fire alarm sounds like but could not state if this is regularly sounded. Staff had not received recent fire instruction. Doors were found either wedged or propped open and safety checks were not being undertaken regularly. For example the monthly safety lighting check had not been carried out since December 2005, the weekly fire alarm testing had not undertaken since 12th January 2006 and the Primary lighting, which should be tested on a monthly basis had not been checked since 20th December 2005. The Electrician’s installation certificate was read but was not dated. The Fire Risk Assessment was due for a review in September 2005. Two staff certificates stated an Infection control had been attended in 2003 and 2004 – staff spoken with had not attended this training and felt this would be valuable to their development. The infection control manual that staff made reference to appeared to be outdated – dated 1998. Only two staff had valid first aid certificates - these were on display – more staff may have this qualification but staff files could not be accessed to verify this. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X 2 2 STAFFING Standard No Score 27 X 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 1 X X 1 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 18(a)(c) (i) Requirement 18. - (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; (c) ensure that the persons employed by the registered person to work at the care home receive (i) training appropriate to the work they are to perform; This refers to staff that handle /prepare food and have not received food hygiene training. Timescale for action 31/05/06 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 22 2 OP18 13(6) 6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 31/05/06 3 OP19 23(4) This refers to the lack of up to date Adult Protection information, the out of date adult protection policy and the lack of staff training. (4) The registered person 16/03/06 shall after consultation with the fire authority (a) take adequate precautions against the risk of fire This refers to three doors in the home that were either wedged or propped open. 4 OP26 13(3) (3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. This refers to an out of date infection control manual being in place and the lack of infection control training and guidance for staff. 31/05/06 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 23 5 OP29 19(4)(a)( b) (4) The registered person shall not allow a person to whom paragraph (2) applies to work at the care home in a position to which paragraph (3) applies, unless (a) the person is fit to work at the care home; (b) the employer has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 6 of Schedule 2; (ii) except where paragraph (7) applies, paragraph 7 of that Schedule; (iii) where paragraph (7) applies, paragraph 8 of that Schedule, and has confirmed in writing to the registered person that he has done so. This refers to staff (maintainance man) working in the home without having essential criminal record bureau, POCA and POVA checks carried out. 16/03/06 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 24 6 OP29 17(2)(3) (a) 17. (2) The registered person shall maintain in the care home the records specified in Schedule 4. (3) The registered person shall ensure that the records referred to in paragraphs (1) and (2) (a) are kept up to date; and (b) are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. This refers to lack of access for inspection purposes to staff recruitment records. 31/05/06 Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 25 7 OP33 24(1)(a)( b)(2)(3) 24. - (1) The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. (2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. 31/05/06 8 OP35 17(3)(b) (3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. This refers to the lack of Quality Assurance process. 31/05/06 (3) The registered person shall ensure that the records referred to in paragraphs (1) and (2) (a) are kept up to date; and (b) are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. This refers to the lack of access for inspection purposes to residents financial records. (4) The registered person shall after consultation with the
DS0000062484.V264146.R01.S.doc 9 OP38 23(4) 16/03/06 Pinehurst Residential Care Home Version 5.1 Page 26 fire authority (a) take adequate precautions against the risk of fire, including the provision of suitable fire equipment; (b) provide adequate means of escape; (c) make adequate arrangements (i) for detecting, containing and extinguishing fires; (ii) for giving warnings of fires; (iii) for the evacuation, in the event of fire, of all persons in the care home and safe placement of service users; (iv) for the maintenance of all fire equipment; and (v) for reviewing fire precautions, and testing fire equipment, at suitable intervals; (d) make arrangements for persons working at the care home to receive suitable training in fire prevention; and (e) to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. This refers to lack of routine fire safety checks of emergency
Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 27 10 OP38 13 lighting, the alarm system, primary lighting, the lack of fire drills/ trainng and see also Requirement 3 ref doors. (4) The registered person shall ensure that (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, and shall make suitable arrangements for the training of staff in first aid. This refers to the lack of staff with first aid training. 31/05/06 11 OP38 13 (5) The registered person shall 31/05/06 make suitable arrangements to provide a safe system for moving and handling service users. This refers to staff not having received annual manual handling training. 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 OP3 OP7 Good Practice Recommendations The needs assessment should cover the diet and weight. This refers to no record of residents’ weight on admission. The service user’s plan should ensure that all aspects of health, personal and social care needs are met. This refers to the lack of detail in relation to residents’ nutritional needs and monitoring of these. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 28 3 OP15 4 5 OP16 OP19 6 OP25 7 OP26 8 OP28 Service users should be offered 3 full meals a day at intervals of not less than 5 hours. A snack meal should be offered in the evening and the interval between this and breakfast the following morning should be no more than 12 hours. This refers to the length of time between tea and breakfast. The complaints procedure should contain the stages and timescales of the complaints process and should provide up to date information. The location and layout of the home should be wellmaintained and meet service user needs in a homely comfortable way. This refers to broken shutters at the front of the home, peeling wallpaper in a resident’s room and peeling paint in a resident’s en suite toilet. Lack of handrail to a section of staircase. Rooms are centrally heated and heating may be controlled in the service user’s room. This refers to the inefficiency of the double-glazing in rooms to the rear of the home. Hand washing facilities are prominently sited in areas where infected material or clinical waste is being handled. This refers to the need for dedicated hand washing facilities in the laundry. A minimum of 50 of care staff should be trained to NVQ Level 2 or above. This refers to lack of access to staff files. Pinehurst Residential Care Home DS0000062484.V264146.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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