CARE HOMES FOR OLDER PEOPLE
Pinehurst Residential Care Home Pinehurst 14 Chambercombe Park Road Ilfracombe Devon EX34 9QN Lead Inspector
Clare Medlock Unannounced Inspection 8th January 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 Residential Care Home DS0000062484.V318387.R04.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 Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 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 Julie Farrell 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.V318387.R04.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is to be registered to accommodate 23 service users in the categories OP Old Age and DE(E) Dementia over 65 years of age. 19th June 2006 Date of last inspection 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. The range of fees varies at the home from £287 to £ 421. These fees do not include charges for hairdressing which varies from £5.00 to £25.00; chiropody which is charged at £10 per Service User; Newspapers, toiletries and treats whilst out on trips. (E.g. Ice creams, refreshments of choice) The Statement of Purpose and Service User Guide are located in the entrance hall of the home. Brochures are also available. Commission for Social Care Inspection reports are also located within the entrance hall. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection. It occurred on Monday 8th January 2007. The inspection consisted of speaking with residents, relatives, staff and management at the home. A full tour of the building took place. Records, Care Plans, staff files and other documents were inspected. No staff questionnaires, relative questionnaires or resident questionnaires were sent or received regarding Pinehurst on this occasion. However the Manager produced a detailed pre inspection questionnaire. What the service does well: What has improved since the last inspection?
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 6 The Provider, Manager and staff at Pinehurst were very responsive to the last inspection when eight Requirements were set. The Provider, Manager and staff at the home have worked extremely hard in a short timescale to make sure all these Requirements were met. Fourteen Recommendations were also made. Twelve of these recommendations were met in a short timescale and the remaining two are still being worked on. In addition to these Requirements and Recommendations the Manager, Provider and staff listened to feedback from the Commission for Social Care Inspection, residents and changing work practices to make sure the quality of care is good. The most obvious change at the home was training of the staff. The Provider, Manager and staff have worked hard to make sure staff have attended necessary training. Recognition must be given for this achievement in a short timescale. The Manager has introduced a system where she can see who has and has not received mandatory training in subjects such as moving and handling, first aid, fire safety and food hygiene. Staff have now received this training, which makes sure they are fully aware of the safest way to care for residents. Staff have also received training in the recognition, prevention and correct way of reporting allegations of abuse. This makes sure residents are protected and if allegations are made the correct procedures followed to protect residents. Residents, staff and visitors to the home are also more protected by the risk assessments performed on the environment. These have been done by the Manager, Provider and outside health and safety consultant. These risk assessments have highlighted areas of potential risk and show areas where changes are needed. The recommended changes have been or planned into the maintenance plan. Water temperatures are recorded at the home, which shows the risk of legionella (bacteria) is kept to a minimum and the risk of scalding is reduced. Environmentally the Provider, Manager, staff and Maintenance man have worked very hard to improve the appearance and safety of the home. The outside of the property has been cleaned and a new sign put up. A porch at the rear has been completed and new fire door installed. Many areas of the home have been redecorated and re carpeted with the programme continuing. The majority of radiators have been installed and all but three doors have fire safety door stops installed. New Kitchen drawers and cupboards have been installed and storage in the home improved. The storage of medicines has improved at the home. Old stock is now discarded and current stock is well managed. The recording of medicines has also improved. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 7 All areas of the home have become tidier and less cluttered which reduces the chance of infection being spread. Unwanted items have been removed from bathrooms. Infection control audits have been done at the home to make sure staff are doing all they can to prevent the spread of infection. Care Plans have also been another area where staff have worked hard. New Care Plans and records have been introduced which now show the level of care that is given at the home. New staff have started working at the home and the recruitment procedure and recording of information on staff has improved. The office at the home appeared more organised and the manager was able to locate documents with ease. All changes the Manager said she was going to introduce have been done as well as additional changes that have taken place following checks, surveys and audits. The Manager has also begun to work through the quality assurance workbook. This has made sure that all the things that are done at the home are safe and in the best interest of the residents and staff. Staff supervision has started at the home again. This has involved speaking with and working with staff to make sure the care they give is done in an appropriate and safe way. What they could do better:
The Manager, Provider and staff at the home should continue with the changes they have made at the home and must continue to be open to new ideas if they are to benefit residents lives. The risk assessments, audits and quality assurance checks performed at the home have been very useful in identifying areas where improvements and changes are needed. These should be maintained and kept under review to check for changes that may be needed. The planned environmental maintenance plan should also continue as this will improve the quality and safety of the home for residents. The Manager should continue to improve records and systems at the home. This should include making sure references obtained on new staff are suitable and from a last employer. In addition, the resident assessments performed on admission could be repeated and reviewed to monitor any changes in condition. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 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.V318387.R04.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, families and Representatives are given sufficient information to decide whether Pinehurst is the right place for them to be. Staff at the home obtain adequate information on residents to ensure they are able to care for the residents. EVIDENCE: A Tour of the building confirmed that the home have a Statement of Purpose and Service User Guide available for Service Users, visitors and Healthcare Professionals to access. Inspection of these documents confirmed that all information required was present. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 11 Discussion with the Manager confirmed that changes to the Pre admission questionnaire have been implemented and now include an in depth history regarding mental health issues are obtained. Inspection of care plans confirmed the homes assessment tool is used where possible but where residents are admitted from other parts of the country information is gathered from health care professionals, families and friends. Contracts were not inspected on this occasion, however discussion with the Manager confirmed that the storage of these is more organised. Records confirmed that the Manager’s request from social service Care Managers to review the care given to the Residents has been done. This ensures that the package of care is meeting the resident’s needs. Observation of records and discussion with residents confirmed that most Residents are admitted from hospitals or their home in an emergency. Residents spoken with said they knew they could visit the home before admission but that families did this for them. One resident stated that they had been admitted from another care home and found Pinehurst to be far superior. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The greatly improved individual plan of care means the residents’ health and social care needs are fully met. The residents are treated with respect and their privacy is upheld. The improved policies and management of medicines help protect the residents from harm. EVIDENCE: Observation, Records and discussion with residents and the Manager confirmed that staff at the home access services from heath care professionals. These include General Practitioners, District Nurses, Speech and language therapists, continence specialist, sensory team and physiotherapist. Records confirmed that these services are arranged within the home or within the local community. During the inspection the care staff called the GP to see a resident who was unwell. Another resident said they had not seen their GP for a long time, but that staff would see to this if it were needed. One resident said they are
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 13 relieved to leave this sort of thing (the care) to the staff and it made their family more relaxed. Residents spoken to said they felt very well cared for. One resident said her confidence had improved since being at the home. Residents consistently said staff were kind and caring and did not rush them when personal care was being given. Residents said staff encourage them to do as much as they can independently and do not take over. Residents said they have a choice of a bath or shower and staff protect their privacy when this is done. Discussion with staff confirmed that staff have an understanding of the likes, dislikes and preferences of the residents and were able to give specific examples of how care is given. Records confirmed that weights of residents is monitored where necessary. One resident said they had put on weight because of the good food. Three resident’s care plans were inspected. Inspection of these showed the Manager and staff had worked extremely hard at improving the way care is planned, given and reviewed. Records showed that the changes discussed at the last inspection had been introduced and as a result reflected the care that was given. Observation and discussion with staff confirmed care is recorded in a variety of ways. This included the care plan, a variety of assessments, daybook, night book and daily kardex (record written each day by care staff). Minor improvements to the assessments were suggested. A tour of the building and discussion with the Manager also showed that there have been major improvements in the way medicines are managed at the home. The storage and stock control had improved which now reduces any potential risk to residents. Observation confirmed that the homes medication administration system continues to be provided in a pre packed blister pack system that the local pharmacy delivers. In addition to this, additional boxed or liquid medicines are stored in individual storage boxes. The storage area of the medicines were, clean, tidy and secure and the systems for the collection and disposal of medicines were well managed. The recording of medication was well completed with no gaps in the record seen. Discussion with staff and residents confirmed that residents are able to self medicate if they chose to do so and if they are able to do so without risks which are assessed by staff. The recording of insulin levels for the residents with diabetes had also improved with the introduction of a special form. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 14 Staff seen on the inspection were polite, helpful and were seen and heard to interact well with residents. Laughter was heard during the inspection. Residents spoken with said that staff were like family and that they just had to ask and staff would do anything. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to maintain contact with their family and friends and the local community. The residents receive a balanced diet in a choice of venue either in the homes dining room or in their own private rooms. EVIDENCE: Residents spoken to said there was plenty going on in the home. Some residents said they liked to attend all the activities and others said they attended if they wanted to. A board displaying the date and day of the week was within the lounge area, which helps remind residents what day of the week it is. All residents said the Christmas activities were enjoyed. One resident said they really enjoyed the local school coming in to sing carols. Another resident said they liked the Christingle service. One resident said she loved singing to the entertainer who regularly visits the home. Other activities mentioned by residents included trips out in the bus, having her nails painted and hair done. Other activities included reminiscence, bingo and watching TV. All residents
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 16 said the thing they enjoyed most was seeing family and friends. Some residents spoken to said they went to family on Christmas day. One resident stated that they go out daily to meet with friends and do shopping. Residents who were not able to go out were observed reading newspapers, watching TV and DVD’s. A Tour of the building showed many pictures of residents and staff enjoying trips out around the community and enjoying other festivities. One photograph showed the local school singing in areas of the home where residents who were bed bound were able to enjoy the singing. Confirmation of formal entertainment was displayed within the office and discussion with the manager confirmed other formal events are arranged at the home. Resident’s files which include assessment and personal history information included details of resident’s interests, preferences and religious following. One resident said they had been offered to go to her chosen place of worship but had declined and the minister visited her at the home. Records confirmed the Manager has access to a number of local religious leaders of different denominations. Evidence was seen to show that the homes manager had asked residents or their representatives if they were happy for care to be delivered by two male carers. This was highlighted at the previous inspection. Residents spoken to said they liked all the carers and the male were lovely. One resident said the two new carers from overseas were also kind and caring and the language was not a problem as they were more than happy to repeat and words. The homes kitchen was clean and tidy and the care staff spoken to were able to describe residents preferences and any special diets such as low fat or diabetic diets. There were no ongoing records of what the resident’s meal choices had been so that it was difficult to determine the range of foods available to residents. Discussion with staff and the Manager confirmed that breakfast is served between 7.30 and 8.30 depending on resident choice. Morning coffee and biscuits follow this at 10.00 and a hot lunch from 12.00 onwards. Afternoon tea and biscuits or cake is served mid afternoon and tea between 5pm and 6pm. Prior to bed residents are offered a warm milky drink and snack between 7.30 and 7.45. Discussion with the manager confirmed resident have access to refreshments overnight and a record of snacks is now kept to show that residents at risk or those with diabetes have regular meals. On the day of inspection sausages, croquette potatoes and beans were served with lemon meringue pie for dessert. All residents spoken to about food said they did not mind not having a choice as staff know what they like and will always get something else. One resident said it would be nice to meet the new chef and discuss ideas.
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 17 Observation and the visitor’s book confirmed that residents are able to receive visitors at any reasonable time. One relative comment card was received. This stated that staff welcome them to the home and that families can visit their relative in private. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel able to complain knowing the manager will act on them appropriately. The adult Protection training given ensures staff are aware of how to recognise, prevent and report any allegations of abuse. EVIDENCE: Observation confirmed that the complaints procedure is displayed within the Statement of Purpose, Service User Guide and on a poster within the entrance hall. The Manager stated that no complaints have been received since the previous inspection. The Commission for Social Care Inspection has received no Complaints. All residents spoken to said they had not needed to complain. One resident said the Manager sorts anything minor out immediately before it becomes a complaint. Another resident said that if the Manager did not sort things out they would get their family to do this. Training records and discussion with staff confirmed that POVA(Protection of Vulnerable Adults) Training has been given. The Manager has worked very hard to ensure all staff have received in-depth training to ensure staff are
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 19 aware of the different types of abuse and are aware of how to prevent and correctly report them should they arise. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean, pleasant and homely environment. EVIDENCE: A Tour of the building confirmed that the Provider and Manager had worked hard to meet previous Requirements and Recommendations set at the last inspection. Records were seen of continual programmes of updating and repair to the home. The Manager stated the Provider gave permission for the routine and ad hoc repairs to take place. Observation confirmed that the Provider had invested greatly in the home. A health and safety consultant had been asked to perform a risk assessment on the home. Actions identified during this risk assessment have been included
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 21 in the maintenance plan. In addition to this the Manager had introduced written risk assessments for the premises. These demonstrated that the home has identified and addressed health and safety risks in the home and taken steps to make sure these are minimised. The improvements to the home have been numerous in the short period of time since the last inspection. These included: On the outside of the property brickwork has been cleaned and a new sign displayed. Flowerpots were planted with winter shrubs. A porch at the rear of the property had been completed. Inside the home, a fire door had been replaced, double-glazing had been replaced on some windows and redecoration had taken place in many areas of the home. The kitchen had been fitted with new drawers. All but three radiators had been covered and doorstops had been installed on resident’s doors that wished to keep them propped open. All areas of the home were clean and tidy. Storage had been re arranged to ensure clean equipment was stored away from cleaning materials. A tour of the building confirmed the laundry was well stocked and had been fitted with a wash hand basin. Gloves, aprons and hand soap dispensers were available throughout the home. The cleaner’s cupboard was located on the ground floor. The Manager stated that she had got an infection Control manual from the Health Protection Agency and had performed an audit to see what needed to be done at the home to reduce the risk of infection being passed from one resident to another. All areas of the home appeared homely with private areas of the home being personalised with photographs, small items of personal furniture, flowers and pictures. Observation confirmed there are grab rails and ramps throughout the home to promote independence. Call bells were available and were within reach of those who were sitting in bed and their chair. Response to call bells was quick during the inspection, with staff anticipating what the request would be for in some cases. The home is arranged over four floors, which can be accessed by stair lift, or independently using grab rails. The Home employs a maintenance man who performs regular and ad hoc repairs around the home. During the inspection the maintenance man was redecorating the middle landing. Action plans and records were seen which showed the areas identified for change or improvement. Records also confirmed that the maintenance man records temperatures, which reduces the risks of residents from scalding. water Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improved recruitment procedure and training programmes will protect residents. The planned staff induction programme will protect residents by ensuring staff are aware of how to safely care for residents. EVIDENCE: On the day of inspection all staff appeared professional and polite. Many staff have worked at the home for many years and discussion confirmed they are reluctant to do NVQ courses but were happy to do mandatory training. Residents said generally they thought there were enough staff but sometimes they were rushed if staff go off sick at the last moment. Discussion with the Manager confirmed that agency staff are used where necessary and the same staff requested where possible. Four staff files were inspected on this occasion. All information required had been obtained and Criminal Records Bureau (police checks) had been requested. Records showed that POVA (Protection of Vulnerable Adults) checks had been performed. Inspection of files confirmed that although two written references had been obtained two of these were not suitable. This was discussed with the Manager.
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 23 The Manager confirmed that staff induction had been reviewed in recent weeks and the package used was too bulky and not suitable for Pinehurst. The Manager confirmed this would be looked at. Records confirmed that supervision and appraisals had stated again and supervision consisted of monitoring the care practices of staff. The Manager stated that she has completed her NVQ 4 in care and is encouraging staff to do NVQ training but staff were reluctant to do this at present. The manger confirmed that she was looking at NVQ training packages, which would be based at the home rather than at college. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pinehurst is a well managed home. EVIDENCE: All residents and staff spoken to were extremely complimentary about the Manager. One visiting health care professional stated briefly that they were happy with the care at Pinehurst and had no concerns. The Manager confirmed that she has completed the NVQ 4 in Care and is half way through the Registered Managers award and is finding this interesting. Records showed that supervision had been introduced at the home since the last inspection and involved monitoring the care practices of the staff. Policies and procedures have been purchased for the home.
Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 25 Staff training had also dramatically improved in a short time scale. Records were seen to show that staff had received training in moving and handling, first aid, food hygiene and fire safety. The Manager has worked extremely hard in making sure staff have received this training. Certificates were seen and training records for 2007 are present so the manager is able to see which staff need which training. The home has an effective system of recording and administrating residents finances, which was well managed and well recorded. Recent improvements in this, ensures the Manager and residents are even more protected from errors. The Provider also checks the process regularly. At this inspection the Manager was not on duty but was the designated key holder and was at the home within minutes. Staff said this system is used if there are problems at the home or additional management support is needed. Discussion with the Manager and records confirmed that certain members of staff have responsibility of assisting the manager with certain tasks. Contact details were also available for the Provider. The Management of the home has continued to improve since the last inspection. Records, files and office management have improved. Risk assessments and other systems have been introduced which now help protect the safety of residents, visitors and staff. Risk assessments were seen for fire safety, environment, use of stairs and ladders, moving and handling, health and safety and COSHH (Control of Substances hazardous to health). Accident books were present and correctly completed. Observation confirmed that the fire safety risk assessment had not been reviewed since September. Staff spoken to said there were not formal staff meetings but suggestions and ideas were listened to on a daily basis. Observation confirmed that staff were able to approach the manager and interrupt at appropriate moments. Discussion with the manager confirmed the formal quality assurance workbook is being used. In addition to this separate audits were seen for health and safety issues, environmental issues and training issues. All records and evidence showed that the Manager is receptive to change and new ideas and is continually looking at ways to improve the way the home is run and managed. Residents spoken to said they have not filled in any forms but have asked the staff to do things differently which have been done. During the inspection all staff showed a knowledge of the small ways residents liked their care being given or their routines, which were respected. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 26 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 3 4 5 6 Refer to Standard OP7 OP25 OP29 OP30 OP38 OP38 OP33 Good Practice Recommendations The Manager should review all assessments performed on admission to monitor trends, improvements and deterioration in condition The Manager should continue with the planned programme of covering radiators The Manager should ensure the references obtained on new staff are relevant The Manager should continue with the planned induction programme The Manager should ensure the fire risk assessment is reviewed on a regular basis The Manager should continue with the quality assurance programme and risk assessments done at the home. Pinehurst Residential Care Home DS0000062484.V318387.R04.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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
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