Inspection on 22/09/09 for Pinehurst Rest Home

This inspection was carried out on 22nd September 2009.

CQC found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pinehurst Rest Home 16/09/08

Pinehurst Rest Home 08/11/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Pinehurst Rest Home 4 Harvey Road Boscombe Bournemouth Dorset BH5 2AD Lead Inspector Martin Bayne Key Unannounced Inspection 22nd September 2009 09:00 DS0000066757.V377938.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinehurst Rest Home Address 4 Harvey Road Boscombe Bournemouth Dorset BH5 2AD 01202 418744 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) Mrs Debra Christine Curtis Mrs Caroline Anne Michelle Rose Brooks Mrs Debra Christine Curtis Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Debra Curtis must obtain an NVQ4 in management and care within 18 months of registration. 16th September 2008 Date of last inspection Brief Description of the Service: Pinehurst is a family run home that is registered to accommodate up to 12 older persons. The home is situated in a residential area of Boscombe and is close to the shops and other local amenities. There are 10 single rooms and one room registered for double occupancy. Residents share communal areas of a lounge, dining room and two conservatories, both of which lead into a wellmaintained, enclosed garden area. The current owners were registered in 2006, however in July of that year, the home was struck by lightning resulting in a fire, which severely damaged the building. In May 2008 the home was reopened. Fees for the home range from £452 to £550 per week. Any additional charges are detailed within the home’s Terms and Conditions of Residence. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. We, the Commission, carried out a key inspection of Pinehurst Rest Home between 9:30am and 3:30pm on 22nd Sept 2009. The inspection was carried out by one inspector, but throughout the report the term ‘we’ is used, to show that the report is the view of the Care Quality Commission. The aim of the inspection was to evaluate the home against the key National Minimum Standards for older persons, and to follow up on the 7 requirements and 4 recommendations made at the last key inspection in September 2008. Since the last inspection, the Registered Providers have appointed a manager to assist in the running of the home. Throughout the morning of the inspection the new manager was available and provided us with records and information as to how residents were cared for and supported. In the afternoon the two Registered Providers were also available and assisted with the inspection. As part of the inspection we spoke to four of the eight residents and carried out a tour of the premises. Additional information that helped form to the judgements contained within this report was obtained from the Annual Quality Assurance Assessment document (AQAA) completed by the home. What the service does well: A pre-admission assessment of need is carried out in respect of any person wishing to move to the home and recorded on their file. This procedure makes sure that their needs can be met if they are admitted to the home. Residents’ health needs are met through the homes care planning and risk assessment arrangements. Residents are treated with respect and dignity. Medication is administered safely by trained staff. Individual activities and some group activities are arranged with residents. Relatives and friends are able to visit the home with no restrictions. Spiritual needs of residents are assessed and met. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 6 The home provides a good standard of food. There is a well-publicised complaints procedure. Staff have been trained in adult protection. The home provides a well-maintained clean environment for residents. Staff receive mandatory training and there is a level above 50 of staff trained to NVQ level 2. What has improved since the last inspection? What they could do better: Care plans should be developed from assessments as soon as possible after a person has been admitted to the home. Care planning could be more concise. Photographs of newly admitted residents should be taken as soon as possible after they are admitted to the home and put at the front of their medication administration records and care plan. The home has partially complied with the requirement made at the last key inspection of ensuring that the home has a controlled drugs cabinet that meets new regulations. A new cabinet has been purchased however it needs to be bolted to the wall to satisfy new regulatory requirements. When recording onto medication administration records, we recommend that there is a differentiation between codes used to indicate whether medication had been taken or not, to that of staff signatures recording that medication had been given. We also recommend that where residents have capacity to ask for their ‘as required’ medication, staff only record on the medication Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.2 Page 7 administration when residents have asked for and been administered this medication. As the occupancy levels of the home increase, we would expect to see more communal activities being arranged with residents. The walls in the laundry room should be re-painted as the paint work is starting to flake. Wardrobes should be risk assessed as to their potential for being toppled and action taken where such a risk is identified. Recruitment procedures need to be improved as not all checks and records were in place for one member of staff recruited to work at the home. The emergency lights need to be tested each month. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home carries out a pre-admission assessment of need in respect of any person wishing to move to the home and this procedure makes sure that the home only admits those residents whose needs they are able to meet. EVIDENCE: At the last key inspection a requirement was made that a pre-admission assessment of needs should be carried out and recorded in respect of any person wishing to move into the home. We looked at a sample of two preadmission assessments that had been carried out by the manager for two residents who had moved to the home since the last key inspection. We saw that the pre-admission assessment looked at all the areas of need identified in the National Minimum Standards for older persons and had been recorded and Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 10 dated. These residents had also had the opportunity to visit the home and they and their relatives had been provided with information about the services and facilities provided at Pinehurst Rest Home through the home’s brochure and Service User Guide. These procedures now ensure that prospective residents and their relatives are fully informed about Pinehurst Rest Home and the home also makes sure that it only admits people whose needs can be met at the home. The home does not provide an intermediate care service. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from their health care needs being met through the home systems of care planning and risk assessment. They also benefit by having medication administered safely by trained staff and by being treated with respect and dignity. EVIDENCE: We looked at the care plans that had been developed from the assessments of need for a sample of three residents. One person had been admitted to the home one month previously and there was no photograph of this resident on their care plan. The manager had started writing up the care plan, however full details of how to meet this person’s care needs had not yet been completed. The manager told us that it was her intention to develop a more concise style of care plan for use in the home, as the ones currently being completed were very complex. From speaking with the manager and also with Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 12 the resident it was clear that staff were working to a consistent plan of care, although the full written version had yet to be completed. We recommend that a written care plan be put in place as soon as possible after a person has been admitted to the home and would also support that a less complex system of care planning be put in place. The care plans we saw were very detailed and there was reference to the fact that they had been developed with the involvement of the resident or their relatives. We also saw that they were kept under regular review to reflected changing needs of residents. Within the personal files we sampled, we saw that various risk assessments had been carried out to minimise risk of harm to residents whilst being cared for at the home. These included a moving and handling assessment and general risk assessments. Where there were concerns about a resident developing pressure areas, we saw that skin-care assessments had been put in place. Through discussion with the manager it was clear that should there be additional concerns such as a person losing weight, nutritional assessment would be put in place. The manager was also aware of the need to record body maps for any bruising or injury sustained by a resident. At the last key inspection we recommended that records be kept of any visits made by district nurses, doctors and other health professionals. We saw that such a record was now in place. From this record, the daily notes, care plans and from speaking with residents we were satisfied that the health needs of the residents accommodated at the home were being met. The residents we spoke with during the inspection told us that the staff were very kind, courteous and were respectful of privacy and dignity. We looked at how medication was administered within the home. At the last key inspection a requirement was made, as at that time the home did not have a controlled drugs cabinet that met new regulatory requirements. We saw at this inspection that a new cabinet suitable for storing controlled drugs had been purchased, however, it had not yet been bolted to the wall as required. A requirement was made that this cabinet be bolted to the wall in line with the new regulations. We saw that the home had purchased a new medication trolley for use on the first floor of the home and this was suitably locked and chained to the wall. At the last inspection a requirement was made that staff who administer medication must be trained in safe administration of medications. We found at this inspection that the requirement was met with all the staff now trained. We looked at the medication administration records for all of the residents. We saw good practice of a photograph of the person concerned at the front of their records together with information about any known allergies. We found Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 13 that the administration records had been completed in full with no gaps within the records. We found however, some confusion regarding the recording of ‘as required’ (PRN) medication. We recommend that where residents are able to request their ‘as required’ medication, staff should only record those occasions whence residents have asked for and been administered these medicines. We also recommend that where a staff signature closely resembles one of the other codes used on medication administration records, a different code is used so as not to confuse whether medication has been given or not. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from activities being provided to meet their recreational and leisure needs, through being able to maintain contact with friends and family, and through being provided with a good standard of food. EVIDENCE: We were shown a recording book where staff record activities undertaken with residents. At the time of the inspection there were only eight residents accommodated at the home. We acknowledged the difficulty of finding communal activities that met the needs of such a small group of residents but we did see that a gentle exercise group was carried out by staff members with residents, and that a range of board games were available. We also saw that daily newspapers were purchased by the home and were available to residents. The home has a pleasant garden with furniture and pet rabbits and one resident clearly enjoyed assisting in looking after these. We recommend that Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 15 as occupancy levels increase, more communal activities are arranged with residents. One of the residents we spoke with told us that there was little to keep them occupied, however we did see that a review had recently been carried out with their care manager when every effort had been made to find activities appropriate for this particular person. Generally all the other residents said that they were satisfied with the activities provided and the interaction they had with the staff. We saw that since the last inspection residents had been consulted about holding a Church of England service in the home and arrangements had been made with the local vicar for a service to be undertaken in the home each month. The residents we spoke with told us that there were no restrictions on visiting arrangements to the home. One resident told us of how the home had been very accommodating in allowing their brother to stay at the home for several days. We saw that when residents were admitted to the home, they were consulted as to their likes and dislikes in respect of food and diet. We saw that individual records are maintained of food provided to residents and that these reflected a wholesome and balanced diet was being provided. The residents we spoke with told us that the food was generally of a good standard. We saw that all staff who are involved in food preparation have taken training in basic food hygiene. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well-publicised complaints procedure and through the staff being trained in adult protection. EVIDENCE: The complaints procedure for the home is detailed within the Terms and Conditions of Residence, within the Service User Guide, as well as being displayed in the front reception area. Residents and relatives are therefore well-informed of how to make a formal complaint. The home has a complaints log where complaints are recorded, however no formal complaints had been made to the management of the home since the time of the last inspection. Two concerns were raised with the Commission within the last year. These were jointly investigated under local safeguarding arrangements with the local Council. The registered provider’s were helpful in resolving these two issues. At the last key inspection the home did not have all relevant policies and procedures relating to the protection of vulnerable adults and a requirement was made that the home obtain copies of these procedures and policies. We Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 17 found at this inspection that all relevant policies and procedures now been obtained and that staff had been trained in the protection of vulnerable adults. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well maintained, ‘homely’ environment. EVIDENCE: The home is located in a quiet residential area of Boscombe and is conveniently located for accessing local shops and other amenities. At this inspection we found the home to be clean, well decorated with furniture and fittings in good repair. Since the last key inspection the home has purchased a hoist to meet residents’ needs who need assistance of a hoist for moving and handling. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 19 As part of the inspection we carried out a tour of the premises, during which time we spoke to some of the residents within their bedrooms. We saw that residents were able to bring their own furniture and possessions to personalise their rooms. We found that wardrobes were currently not fixed to the wall and we recommend that wardrobes are risk assessed as to their potential of being toppled over. Should any pose such a risk, they should be bracketed to the wall. We were told that there were two bedrooms on the first floor where builders, after the refurbishment of the home following a fire had failed to fix window restrictors. It was agreed that before these bedrooms are occupied, window restrictors would be fitted to make sure that there is no risk of a resident falling from their window. The majority of the radiators in the home have been covered or are of a low surface temperature type to protect residents from hot surfaces. It was agreed that two radiators would be covered. Thermostatic mixer valves have been fitted to the hot water outlets of baths, to protect residents from scalding water. We saw that communal bathrooms were clean and provided liquid soap. We recommend however that cotton towels are replaced with paper towels and that foot operated, lidded bins, to minimise the risk of cross infection within the home. We were told that staff uniforms had been introduced to promote good infection control and that staff are provided with gloves and protective clothing and training in infection control. The home has a laundry room fitted with machines and equipment to meet the laundry needs of the home. We recommend that the laundry room walls are re-painted as the paint is beginning to flake in some areas. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures for the recruitment of new member of staff must be improved to meet recruitment legislation to protect residents from unsuitable staff being employed at the home. In other respects, residents benefit from a well trained staff team and there being sufficient numbers of staff to meet their needs. EVIDENCE: At the time of our inspection there were eight residents living at the home. We were told that during the daytime there were always two members of staff on duty, including the manager, and that during the night-time period there was one member of staff awake and one person who carried out a sleep-in duty. We saw duty rosters that reflected the above staffing levels, this meeting a requirement from the last inspection. We were told that as occupancy levels increase, the numbers of staff on duty would also increase, and that current staffing levels met the needs of the residents accommodated. Residents we spoke with confirmed that current staffing levels were satisfactory. We looked at the recruitment records concerning two members of staff who had had been employed to the staff team since the last key inspection. In one Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 21 case we found that all the necessary checks and records required under the Regulations were in place. For the second person, who was well known to the manager at another home where they had formerly both worked, we found that there was no proof of identity or a recent photograph on file. It is acknowledged that proof of identity and photograph would have been seen at the time of applying for a Criminal Record Bureau (CRB) check; however, a copy of these documents should have been retained at that time to comply with the Regulations. A check against the register of persons deemed unsuitable to work with vulnerable adults had been taken up prior to this member of staff working at the home. We found however, that this member of staff had started work at the home subject to the return satisfactory references. Staff must not start work at the home until all references are returned. A requirement was made at the last key inspection that two written references be in place for all staff working at the home, the requirement had therefore not been complied with. We found that core mandatory training had been provided to all the staff and a training matrix was in place to inform when refresher training was due. The home has achieved a level of above 50 of the staff team trained to NVQ level 2 or above. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Apart from failings in meeting Regulations concerning staff recruitment, the home is well managed and run in the interests of the residents. EVIDENCE: As had been agreed at the last key inspection, the Registered Providers have kept us informed of management arrangements for the home and a new Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 23 manager has been appointed to manage the home. The new manager has had management experience, having been a deputy manager of another home. She has applied to undertake training in the ‘Leadership and Management Course’. It was agreed at this inspection that the new manager would submit an application to the Commission to become Registered Manager of Pinehurst be the end of October. With the exception of failings in staff recruitment, (which is reflected in the poor rating for this section of the report), we found the home to be otherwise well managed and run in the interests of the residents. However, staff recruitment practices must be improved, as failure to ensure that all recruitment checks are carried out, potentially puts residents at risk from unsuitable members of staff being employed. This is the second inspection where the taking up of references for new members of staff has been required. We saw returned questionnaires from relatives with positive comments about the way the home cared and supported residents. Feedback from residents was also positive in this regard. We were told that the home does not get involved in residents’ financial affairs and no monies were being looked after on behalf of residents. We looked at the fire log book and found that all tests and inspections of the fire safety system were taking place to the required timescales, with the exception of testing of the emergency lighting every month. A requirement was made that this test be carried out each month. The home has a fire work place risk assessment. The returned AQAA informed that other tests and servicing of equipment was taking place as required. Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 24 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X x 2 Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 25 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 OP9 Regulation 13 (2) Requirement You are required to ensure that the medication cabinet purchased for the storing of controlled drugs is bolted to the wall in line with new regulatory requirements. You are required to: • Make sure that there are records to validate proof of identity and a photograph for all members of staff working at the home. • Make sure that two written references are in place for all staff working at the home. (This part of the requirement is repeated from the last key inspection) Timescale for action 23/10/09 2. OP27 Schedule 2 & 19 23/10/09 Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations We recommend that: • Photographs of residents are taken and put on the front of their care plan as soon as possible after being admitted to the home. • Written care plans are put in place as soon as possible after a person is admitted to the home. • Action is taken to get care plans into one format and template as soon as possible, to improve care planning. We recommend that: • Where residents are able to request their ‘as required’ medication, this is only recorded onto medication administration records when residents have requested and been administered these medicines. • Medication administration records clearly differentiate between a code (for instance that medicines have been refused) to that of staff signatures. We recommend that as the home achieves higher occupancy levels more consideration is given to providing meaningful recreational and communal activities to meet residents’ social needs. We recommend that wardrobes risk assessed as to their potential for being called over, and where such a risk is identified the wardrobe is bracketed to the wall to eliminate this risk. We recommend that; • Liquid soap, paper towels and foot operated, lidded bins are provided in all communal bathrooms to reduce the risk of cross infection within the home. • The laundry room walls are re-painted as the paint is beginning to flake in some areas. We recommend that you carry out a test of the emergency lighting each month to maintain fire safety in the home. DS0000066757.V377938.R01.S.doc Version 5.3 Page 27 2. OP9 3. OP12 4. OP19 5. OP26 6. OP38 Pinehurst Rest Home Pinehurst Rest Home DS0000066757.V377938.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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