Inspection on 01/08/05 for Pinehurst Resource Centre

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pinehurst Resource Centre 05/01/07

Pinehurst Resource Centre 05/01/06

Pinehurst Resource Centre 07/12/04

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 Resource Centre 141 Park Road Camberley Surrey GU15 2LL Lead Inspector Helen Dickens Unannounced 01 August 2005 09:30 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 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 Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pinehurst Resource Centre Address 141 Park Road Camberley Surrey GU15 2LL 01276 686778 01276 676092 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Surrey CC - Adult & Community Care County Hall, Penrhyn Road, Kingston upon Thames, Surrey, KT1 2DN Mrs Linda Amero Care Home (CRH) 50 Category(ies) of Physical disability (PD) 2 registration, with number Old age, not falling within any other category of places (OP) 50 Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Accommodation and Services may be provided to named persons aged 60 - 65 years with the prior written agreement of the CSCI. 2 Amber Unit will be used exclusively for the provision of Respite Care and/or Intermediate Care to a maximum of 10 Service Users. 3 In addition to Service Users accommodated at the Home, Day Care may be provided on the Day Care Unit to a maximum of 7 persons. 4 Emerald unit will be used for the provision of respite care and/or intermediate care for up to a maximum of 10 Service users. 5 Accommodation and services may be provided for up to six (6) persons with sensory impairment. 6 Accomodation and Services may be provided for a named sevice user with Dementia (DE)(E) with the prior written agreement of the CSCI. Date of last inspection 07 December 2004 Brief Description of the Service: Pinehurst Resource Centre is a single storey residential care home accommodating up to 50 older people. It is managed by Surrey County Council and is close to Camberley town centre, giving easy access to local facilities. All rooms are single occupancy and the home is divided into smaller units to give a more homely feel. Each unit has its own kitchen/dining room and lounge area and there are additional quiet areas throughout the home. The home hosts a day care facility which operates five days a week, with residents free to join the activities. The home is situated in its own grounds with good sized gardens and ample parking. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Caroline Ballard, Deputy Manager, represented the establishment. Craig Chalmers,the Surrey County Council Service Manager, joined the inspection later in the afternoon. A full tour of the premises took place. Three residents and two staff were interviewed and more than a dozen other residents spoken with during the inspection. Comments on returned questionnaires from residents, received by the home during the month of July, were also used to write this report. Three resident’s care plans were also inspected, and other documents and records examined during the day. This was a positive inspection. The inspector would like to thank the residents and staff for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? Most of the requirements made at the last inspection have been met and these include;the Statement of Purpose has been up-dated; care plans and risk assessments have been up-dated and training in risk assessments has been given to staff; water temperatures for bathing are being monitored; storage of medicinal creams in food fridges has ceased and fridge temperatures are being Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 6 monitored; incontinence supplies are now in designated storage areas and none were seen on view in any of the bedrooms inspected;all the minor repairs had been carried out; and there was a criteria for the placement of people working under the supervision of the Community Probation Service. The staff at the home have undergone further training since the last inspection including risk assessment training, and training in dementia care. In addition, the outside of the building had been painted which gave a fresh look from the outside of Pinehurst. 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. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 The information available to residents and prospective residents will enable them to make an informed choice about the services and facilities at Pinehurst. EVIDENCE: The statement of purpose gives a good outline of what Pinehurst offers and the amendments recommended at the last inspection have been included. The files examined showed the home had a contract with residents which was kept on the resident’s file. Only one of the contracts did not have a room number and the inspector will recommend this be included for all residents. Copies of residents initial assessments were on each file examined and these included input from other professionals as well as Care Managers. The home can demonstrate its ability to meet the needs of residents and the work they are doing on promoting independence provided a good example of this. Residents spoken to confirmed the home’s staff offered them good support and the inspector noticed very positive and friendly staff/resident interaction during the day. Prospective residents can visit the home and on the day of the inspection there Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 9 was a 24 hour visit from a prospective resident. This enabled the staff to carry out a more in-depth assessment to confirm they could properly meet the prospective resident’s needs. Dedicated accommodation is set aside for those residents admitted for intermediate and rehabilitative care. Physio and occupational therapy input in this unit assists residents back to independence. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 The system for recording personal and social care needs at the home ensures that residents needs are recognised and their wishes taken into account. EVIDENCE: Resident’s care plans set out the care needs identified for each resident and how these will be met. Risk assessments were on all the files examined and were up to date, being regularly reviewed. There was evidence that resident’s had been involved in drawing up their care plans but one file had a blank life history, with no additional information to say whether the resident had refused to share the life history information needed. Residents were observed to be treated with dignity and respect during the course of the inspection. Staff interviewed had a very positive attitude to residents and their welfare, especially promoting their independence. Examination of the resident feedback questionnaires for July showed that ‘everyone was very helpful’ and one resident was ‘impressed by the care and attention shown by staff.’ Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and14 The home ensures residents have opportunities for social activities and are enabled to exercise choice and control over their lives. EVIDENCE: There was much evidence in notes from residents meetings that residents had input into the day to day activities in the home. Meetings were held in each unit and residents and relatives were invited; members of staff did not stay for these meetings. Either a resident or one of the relatives took the notes and actions required, and this was then given to the manager. Depending on the outcome of the meeting, the home would draw up an action list to show how they would address each issue. Notes from one meeting stated that “Pinehurst was the ‘Ritz’ of care homes” and then went on to list some aspects that could make it even better. Leisure and recreational activities were important in this home and those who were attending the day care session on the day of the inspection had arts and crafts activities to stimulate them. The standard of the work was good and members were clearly enjoying this session. There was a dedicated area available with plenty of room for single or group working, and the area was open at either end making it more welcoming for residents who wanted to pass through and have a look. There was also an excellent little library area with many large print books. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 12 Other activities such as gardening (looking after the tomatoes in the green house in particular) and running stalls at the summer fete were also noted by the inspector. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints at Pinehurst are handled well according to their procedures, and residents can be confident their concerns will be taken into account. EVIDENCE: The Surrey County Council Complaints procedure is in operation in this home and complaints are taken seriously. Two complaints had been received since the last inspection and a good record had been kept of progress. The inspector noted that the delicate nature of these complaints created a particular challenge and commends the Registered Manager for dealing sensitively with all parties. Both complainants were satisfied with the outcome. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24,25 and 26 Residents at Pinehurst live in a safe, well maintained and homely environment. EVIDENCE: Pinehurst was purpose built and offers spacious indoor and outdoor spaces for residents. The premises were well-maintained and the grounds tidy, safe and attractive. On the day of the inspection the roof of Crystal Unit needed attention as some moss and leaves from nearby trees had accumulated on the slates. The communal areas in Pinehurst are spacious with each unit having its own kitchen and dining room, and a lounge area. In addition there were other sitting area and the large ‘concourse’ where the day care activities take place. The home is accessible to wheelchairs both inside and out. There is a separate dedicated unit for the provision of intermediate care and the home is decorated in a homely manner with domestic fixtures and fittings throughout. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 15 Sufficient toilet facilities were provided including some proper disabled facilities. Residents all had hand basins in their rooms, some of which were enclosed in vanity units and could be closed when not in use. The home has a variety of specialist bathing facilities to meet the needs of resident. Bedrooms are well furnished and all single occupancy. Those rooms inspected were very personalised and homely for residents. Arrangements for safe bathing recommended by the previous inspector had been put into place but residents washing facilities in their rooms needed monitoring. On the day of the inspection two hot water taps were hotter than 43C (though not hot enough to scald) and the inspector asked that all resident’s basins have the hot water temperatures checked and recorded on a monthly basis. In the meantime, all basins should be checked initially and the plumber asked to adjust the local thermostats on each basin to around 43C. On the day of the inspection the premises were clean and hygienic with the small exception of one bathroom floor which needed cleaning. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The home’s recruitment practices need further work in order to meet this standard in full and to protect residents. Staff training is taken seriously in Pinehurst and this should ensure residents changing needs are met. EVIDENCE: Recruitment at this home is a shared responsibility with the HR department of Surrey County Council. This means that the Registered Manager does not have complete control over the process, and requirements made will need to be highlighted via the Service Manager, to the HR department. Job descriptions are not up to date for all staff. Some senior posts have recently been reviewed and though this is an ongoing process, potential recruits for other less senior roles are being shown job descriptions which have not been up-dated for some years. In addition, the previous inspector made a requirement that evidence that interviews had actually taken place should be on staff files. The Deputy said this request had been passed on to HR but little progress made, especially given that some staff had been taken on more than a decade ago. On the day of the inspection one of the files examined had a CRB check which showed that the POVA check had not been requested. All staff working in the home, unsupervised, and engaged in personal care must have a POVA check. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 17 Staff had a positive attitude towards training and the home had included both domestic and care staff in the recent dementia care training sessions. Staff had also undergone risk assessment training since the last inspection. Some staff had got their training certificates on file but this was an ongoing exercise following a requirement made at the last inspection. Staff should have current training certificates on file in order to make sure these are available for inspection. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38 Residents can be confident that Pinehurst is a well run home with a good staff team. There are some minor shortfalls with regard to the frequency of staff supervision and health and safety which would need to be addressed to safeguard residents and meet this standard in full. EVIDENCE: The Registered Manager was on annual leave on the day of the inspection but the Deputy Manager and other staff were very accommodating and had a positive approach to the inspection. The inspector felt there was an open and inclusive atmosphere throughout the home. There was evidence that the Registered Manager had the skills and experience to run the home and the staff spoke well of the management of Pinehurst , one saying it was ‘very supportive.’ There were clear lines of accountability and the role of ‘Seniors’ had recently been reviewed. One outcome of this was the provision of more one-to-one supervision for staff. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 19 There were many opportunities for residents to provide feedback on the quality of the service at Pinehurst and both residents meetings, and questionnaires, have already been mentioned. However, the home is part of an internal Surrey County Council quality assurance exercise which involves the other homes for older people run by the Council. Unfortunately, the programme is running behind and therefore all areas which should be reviewed have not yet been covered within the timescale set down. Staff supervision at Pinehurst consists of some one-to-one meetings with a senior member of staff and group supervision on each unit. Notes of these unit meetings identified that all aspects of practice, including health and safety were covered. However, on the day of the inspection the inspector had difficulty in ascertaining whether in fact all care staff had six sessions of formal, documented one-to-one supervision per year. The Deputy Manager will forward a print out to CSCI of supervision sessions carried out and planned for the year 2005/06. The hazardous substances cupboard was locked on the day of the inspection but the sluice areas in each unit contained hand wash which was not contained within a dispenser, and descaler for the sluice machine. The inspector asked that a risk assessment be carried out on the safety aspects of these substances being left in rooms which are accessible to residents. The Service Manager suggested dispensers could be purchased for the hand soap and this would limit their availability. There was also a box of poly filler inappropriately placed in a cupboard and this was removed immediately by the Deputy Manager. The home was asked to review the window restrictors being used as they did not appear to be very strong. In addition, safety certificates for the Parker baths could not be found on the day of the inspection. These need to be available at all times. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 3 3 3 x 3 2 2 STAFFING Standard No Score 27 x 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 2 x x 2 x 2 Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 21 yes 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. Standard 19.1 19.3 25.8 Regulation 23(2)(b) 13(4)(a) Requirement The roof on Crystal Unit needs to be cleared of moss and leaf debris from nearby trees. Water temperatures in areas accessible to residents must be monitored and maintained at around 43C. An initial measurement should be recorded and the plumber asked to adjust any thermostats found to be above the required temperature. The bathroom floor in one unit needs to have a thorough clean and this was discussed during the inspection. Recruitment practices need to be reviewed as detailed in the report and the necessary documentation placed on staff files. Staff files should contain copies of training certificates which are relevant and current. The home must comply with the Surrey County Council quality assurance system set up for care homes and keep within the timescales set. Care staff supervision needs to occur at least six times per year Timescale for action 01.10.05 08.08.05 3. 26.1 23(2)(d) 08.08.05 4. 29.1 29.3 13(6) 01.10.05 5. 6. 30.1 33.2 17(3) Schedule 2 24(1) 01.10.05 01.11.05 7. 36.2 18(2)(a) 01.11.05 Page 22 Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 8. 38.3 38.4 13(4)(a) and should be formal and documented. The home must carry out a risk assessment and review clean materials kept in sluice areas. The home must review the adequacy of window resrictors as discussed on the day of the inspection. The home should ensure that safety inspection certificates for aids and equipment are available at all times. 08.08.05 01.10.05 01.09.05 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 2.2 7.6 Good Practice Recommendations The written contract between the home and each resident should state which rooms they are to occupy. The life history section on one residents file had not been completed. If the resident does not want to share life history information then this should be recorded, otherwise these sections should always be completed. Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pinehurst Resource Centre H58-H09 S33540 Pinehurst V239097 010805 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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