Inspection on 10/01/06 for Pines Care Home

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Pines Care Home 08/01/09

Pines Care Home 04/09/07

Pines Care Home 12/09/06

Pines Care Home 26/10/05

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pines Care Home 56-57 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE Lead Inspector Denise Rouse Unannounced Inspection 10th January 2006 10:25 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 Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pines Care Home Address 56-57 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE 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) 01423 565633 Queensland Care Limited Post Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (26) of places Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Any service users in the category of (PD) must be:1. aged over 50 years 2. require nursing care 26th October 2005 Date of last inspection Brief Description of the Service: The Pines is a care home offering nursing and personal care to 26 residents. It is two converted Victorian semi-detached houses within reasonable walking distance of Harrogate town centre and a shorter walk away to local shops and amenities. It is set in a quiet residential area facing the green space of Harlow Moor Drive. Since the previous inspection Queensland Care Ltd have taken over ownership of the home. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 hours and was carried out by one inspector, following a day’s preparation. The acting manager was on annual leave on the day of the inspection, and no application has been received in regards to the registered managers position, this must be completed immediately. The inspector rang the doorbell, it was not evident if the staff had heard this, and after 4 minutes the maintenance officer let me into the home. All the staff were busy and it took a further 6 minutes for the nurse in charge to come to reception. The kitchen assistant informed me “this was not a good day to inspect the home as there was a problem with the dishwasher which meant that breakfasts were still being given out. ” A tour of the premises was completed, which included bedrooms, kitchen areas, laundry, offices, storage areas and the main lounge. A number of service users were spoken with. The view of a visiting professional was sought. Some records were inspected, including staff rotas, service users care profiles, staff files, accident book, kitchen records and maintenance records regarding water temperatures. The inspection concluded with a feedback session involving the nurse in charge and administrator with the Regulatory Inspector. What the service does well: What has improved since the last inspection? Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 6 Staff have been recruited for administration, housekeeping and maintenance. There is an acting manager in place. An activities co-ordinator is starting at the home within the next few weeks. A complaints register has been commenced. There is a notice displayed in reception outlining the complaints procedure, this includes information on how to contact the Commission for Social Care Inspection. Repairs to a corridor carpet have been made. Some valves have been replaced to the hot water taps in service users bedroom. Fire training has commenced; a fire drill took place at 10.00pm the evening before this inspection. All necessary pre employment checks are carried out and recorded before new staff commence work at the home, to help ensure service users are protected. What they could do better: Staff levels were not adequate for the complex layout of the building, and the high dependency of service users. Care plans and risk assessments, blood pressures and service users weights, were not reviewed at least monthly or as service users needs changed. There were no social care plans in place for any client. Meaning vital important information is not communicated throughout the staff team. One service user had an out patients appointment, due to care staff being under pressure a member of the domestic team had been sent upon escort duty. This practice does not ensure the safety of the service user. Staffing must be provided so that designated care staff can escort service users out of the home for appointments, without utilizing domestic staff. A regular programme of activities has not yet commenced. The acting manager does not appear to have any supernumerary time allocated for managerial duties. This must be addressed to ensure that the number of shortfalls identified during the inspection can be addressed. Hot water temperatures in some bedrooms, kitchen and laundry were still too high; there were no risk assessments available. Management must ensure the necessary work is authorized so that service users and staff are not placed at risk from scalding. Access to the laundry and the cleaning storeroom must be restricted, to comply with the Control of Substances Hazardous to Health. Bleach should not be available. Adequate room must be provided to ensure ironing is not undertaken within a narrow corridor. These practices could be a risk to confused or unsupervised service users. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 7 Lunch was cooked too early, and service users requiring a puree diet were being given the same meal for lunch and tea. Vegetables should not be ready to be served at 10.45 for lunch. Lunch was served at 12.00-12.15pm. Service users requiring a puree diet must not be given the same meal for lunch and tea. Quantities of puree food must be adequate to ensure service users do not loose weight and gain adequate nutrition. Adequate storage areas for equipment and wheelchairs must be identified to ensure that corridors remain free from obstruction. More care staff should be encouraged to undertake the National Qualification in Care level 2 or 3.To ensure all staff are suitably trained to meet the needs of service users. 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. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 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 Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None assessed at this inspection. EVIDENCE: Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 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 the following standard(s): Standard 7 Service users health, personal and social care need are not adequately recorded or reviewed, this places service users at risk. EVIDENCE: A folder of new documentation was inspected; it was planned that this would be implemented for each service user to ensure all the documentation was accurate and up to date. This as yet is not in place. The records for six residents were inspected, all had care plans in place but they had not been re-assessed at least monthly or as the service users needs changed. One service user had a history of weight loss, a nutritional care plan was in place but this had not been reviewed since 23 October 2005. There was no weekly weights being recorded which were documented as being required. Another service user had recently had a fall, there was a care plan in place, which had not been reviewed monthly, there was no risk assessment documented regarding falls and how these could be reduced and managed. Service users who were admitted in March and November 2005 had no social interests recorded in their documentation. There was no care plans in place for Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 11 any client in regards to their social needs. This was a requirement from the last inspection. The nurse in charge stated that she was aware that the care plans; risk assessments and social care plans were not completed or reviewed. She stated, “Nursing numbers had been decreased by the new owners which had placed added pressure on the nursing and care staff to provide basic care. The layout of the building and high dependency of service users does not enable the staff to have the time to keep the nursing documentation up to date.” This was confirmed during the inspection. The nurse in charge was due to finish her shift at 2.00pm but was staying on until 4.00pm to undertake further work. Care staff stated, “ due to occupancy being lower, staff numbers have been decreased by the new management. This means that there are still two clients waiting to get up at 11.30am.” “ We do not have the time to spend with clients other than to give them basic care. Having less staff means that the care we are able to give is more basic, because we have to rush round to get everyone up, its not the same now the staff levels have dropped.” Whilst looking round the building it was difficult to see any staff, a service user had not been shaved, and stated, “ the staff are very busy, they are pushed for time, they will come back later to give me a shave.” It was noted that some service users fingernails were dirty and in need of cutting. Service users stated “ the care staff work very hard, they are good, but they are never done” Another stated “ The girls are good, they are too busy now to spend any quality time with you, a lot of staff have left since the home was taken over. I have a full strip wash twice a week, due to staff shortages I don’t always get this.” A member of staff had been taken of the laundry and domestic duties to take a service user to an out patient appointment. The nurse in charge stated she felt this was the best solution, as she could not deplete the home of any of the care staff, as this would have further negative impact on the service users. Enough staff must be present within the home to ensure that service users care needs are fully met. Care documentation must be completed, reviewed and reassessed as required, to ensure that service users are not placed at risk. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12 15 Service users social care needs are not met. The early preparation of food, quantity and quality of puree food, and serving methods may place service users at risk. EVIDENCE: The new activities co-ordinator will be commencing at the home within the next few weeks. There had been a Christmas party, which service users stated they had enjoyed. A coffee morning was planned for Saturday 28 January 2006. There were 6 service users in the main lounge, 3 were asleep. The other 3 stated they “didn’t have much to do, just sit and watch television.” One service user asked the inspector to pass them the nurse call bell as it was hanging on the wall and no service user could reach it. The kitchen was inspected; records of temperatures relating to food storage and cooking were recorded. The kitchen area was clean and tidy. There were home baked cakes prepared in the kitchen for the service users, these looked very nice. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 13 The chef had prepared the lunch, at 10.45 am the vegetables and potatoes were already cooked. The food for the service users requiring a puree diet had been prepared and it was the same for both lunch and tea. Food was colourful and not mixed together. The chef stated “ if the tea menu cannot be pureed then the lunch menu for that day is given to the service users again for tea.” Portion sizes plated looked very small for nutritionally challenged service users, approximately a level tablespoon of mash and a level desert spoon of vegetables per serving. The cook stated that the lunch portions were bigger and this was just for tea. The lunch was plated up individually and held in a hot trolley. The meals were sent upstairs to the servery on the ground floor and served between 12.00 12.15 am. All the plates of food were placed on a cold metal trolley to be taken throughout the home. The meals were on hot plates and were covered, this had to be taken out quickly by staff, and if staff were delayed the food would not be served hot. Food was also served in the lounge at individual tables. There were only two tables available in the small dining room area on the ground floor to seat eight service users. This area was not utilized. All other service users ate in their bedrooms. Service users stated, “ Meals are quite good” “Agency chefs provide food on a weekend, this food is poor.” Nursing staff were seen washing up by hand as the dishwasher had to be removed that morning. The maintenance officer had also assisted. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 Service users are protected by the homes policies and procedures relating to the recording of complaints. EVIDENCE: There is documented evidence on file regarding complaints received, action taken and the outcome of the complaint. There have been no complaints received internally recently. Service users stated they would speak to the manager or the nurse in charge if they had any complaints. One service user stated, “ things have changed since the new owners took over, the home is run more like a business, its less personal. I have not complained but am watching to see if things get any better in regards to staffing. I will complain if I feel I need to, you have to give new people time to settle in.” Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 22 25 Service users live in a home that is clean and maintained, however staff and service users are placed at risk due to high water temperatures and inadequate storage. EVIDENCE: Since the last inspection a housekeeper and maintenance officer have commenced at the home. There was a door entry system in operation to restrict access to the home. Upon pressing the doorbell it was unclear if this had activated, and if staff were aware that someone was waiting to gain access. It took 4 minutes for the maintenance officer to open the door for the inspector to gain access. Maintenance of the building was being undertaken on a daily basis. The maintenance officer appeared competent and was very helpful on the day of the inspection. Records pertaining to the hot water temperatures within service users bedrooms were examined. These were recorded monthly. Rooms 8 11 12 13 Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 16 14 16 and 17 were all recorded as having hot water temperatures at 60.0 degrees centigrade. The inspector checked these with the maintenance officer present and found them to be ranging from 63.0 to 65.0 degrees centigrade, posing a high risk of scalding to service users. All the rooms had a notice above the sink stating “very hot water.” These rooms had been mentioned in the previous inspection report. The maintenance officer could not provide the inspector with the relevant risk assessments, the acting manager was not available, and the nurse in charge and administrator did not know where these could be found. The nurse in charge assisted the inspector by informing her which clients could gain access to their bathrooms. The administrator went out to purchase three valves and the maintenance officer commenced fitting these to rooms 8 13 and 17.All the other rooms stated were occupied by clients who were immobile. Valves must be fitted to the other rooms, to prevent staff being placed at risk. The laundry and kitchen hot water supply was also checked and temperatures were recorded at 65.4 to 66.1 degrees centigrade. Mobile service users could access these areas. The maintenance officer was informed of this and stated he would take action to ensure the temperatures were maintained within the correct range. One service users bedroom door was held open by a wooden wedge. The resident’s relative had made this and had placed it there. The inspector and maintenance officer discussed the reasons for having to remove this with the relative. A suitable doorstop device was immediately fitted. The home appeared clean and was free from any malodour. The new housekeeper stated she had made a number of improvements to the cleaning schedule within the home. The laundry was inspected, it was very small, the ironing board was located outside the laundry, within a narrow corridor. There were cleaning chemicals under the sink, which included bleach. Mobile service users could access these. The cleaning cupboard storage room opposite the laundry was also unlocked, full access was gained to a multitude of chemicals, including bleach. The housekeeper was informed of this and she stated “ these areas are usually locked or manned by a house keeping assistant, due to a service user having to go out for an appointment I have had to work on my own, as the housekeeping assistant has been sent on escort duty.” She stated that she had worked hard to improve the cleaning services at the home, but felt it was unfair that her assistant had been taken away from the department to carry out an escort duty, the home should provide enough care staff to ensure escorts can be covered.” It was confirmed that the assistant housekeeper worked as a carer occasionally. Enough care staff should be allocated to ensure that other departments are not compromised at short notice. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 17 The corridor outside room 17 was blocked by the storage of a stand aid hoist and wheelchairs. This was pointed out to the nurse in charge and the maintenance officer, who immediately moved the items to ensure better access could be gained. Appropriate storage of items, especially within corridors featured as a requirement in the last report, it was clear this issue had not been resolved. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 Service users are placed at risk, due to inadequate care staff being allocated for the complex layout of the building and high dependency of service users. Recruitment policies and procedures are adhered to. EVIDENCE: The home had 2 qualified nurses and 3 care staff on duty for 22 service users. Care is provided to service users situated over 4 floors. There were a number of highly dependant service users. During the tour of the building the inspector found it difficult to find any care staff. Comments were received from service users who stated, “ The care is basic.” One service user had to wait until later in the day to get a shave, his fingernails were dirty and long. Service users needs were not being met adequately. Care documentation, including risk assessments, blood pressures and weekly weights were not up to date or reviewed. The staffing levels fall short of the required staffing notice. There was insufficient staff to provide adequate care for the service users. Morale was low, staff were thinking of leaving due to the constant pressures of work. Staff spoken with were obviously committed to the service users but felt frustrated that they did not have the time to provide the quality of care they would like, due to time restraints. Service users also stated, “ the staff are wonderful, they are never done”. “The girls are good, they are too busy now, to spend any quality time with you.” Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 19 Having to allocate domestic staff to escorting service users to out patient’s appointments highlights the fact that the current staffing notice was not being adhered to. Care staff were also seen washing and drying the lunchtime crockery and cutlery. The staff rota indicated that a new carer would be working a night shift on Saturday 14 January after receiving 1 induction night shift. This carer would be on duty with 1nurse and could be working unassisted and unsupervised. The staff rota also indicated that agency staff were utilized for night duty. Although the same staff were requested, this was not always possible, this may place service users at risk and does not provide good continuity of care. Having 1 nurse and 1 carer on duty at night does not allow staff to have a break and leave the home adequately covered by the registered nurse. This does not comply with the staffing notice, which clearly states there should be 1 trained nurse, 2 care staff. There appears to be 206.0 hours of registered nurse hours upon the rota for the week of inspection, this includes the acting manager. The staffing notice states there should be 233 hours. Care hours totalled 342.0 including agency carers, the staffing notice states 399.0 hours should be provided. The registered provider must address these shortfalls. More care staff must be encouraged to attain the National Qualification in Care level 2 or 3, to ensure all staff are trained to an appropriate standard. At present the home does not meet the 50 requirement. The home has a new administrator, who appears competent. Three staff files were examined all contained the necessary pre –employment checks. Staff were not permitted to commence work before the checks were received. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33 38 There are shortfalls in the management of the home. This results in continued practices that do not ensure the health, safety or welfare of residents. EVIDENCE: There is an acting manager employed at the home, who has not yet completed and submitted their application to be considered as the registered manager with the Commission for Social Care Inspection. This must be addressed immediately. The administrator contacted the Commission for Social Care Inspection to apply for the application pack at the time of the inspection. The acting manager was not available at the unannounced inspection he was on annual leave. The acting manager does not appear to have any managerial time allocated upon the staff rota, to ensure that audits of care practices can take place. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 21 Staffing levels must be increased in line with the current staffing notice. This would help to ensure that the safety of service users is maintained. There was no evidence that care plans risk assessments or social care plans were being audited or implemented. Early food preparation and method of delivery of hot food within the home is inadequate, this requires auditing, and an action plan must be implementing to address poor practices. The control of Substances Hazardous to Health must be addressed to ensure unsuitable chemicals are not used or stored within the care home. Access to chemical storage areas must be restricted and service users protected. Ironing within the narrow corridor should not be undertaken, as this may place service users at risk. A suitable area for ironing should be identified and utilized. Equipment and wheelchairs must not be stored in corridors, which impede access or exit for staff or service users. This must be addressed. Hot water valves must be fitted to all outstanding taps identified in this report. These valves must be provided, health and safety of the service users and staff must be paramount. Water temperatures must continue to be monitored and recorded upon a monthly basis. . Staff meetings have commenced. The administrator was about to send out a relatives and residents survey to seek their views of the home. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X 1 X X 1 X STAFFING Standard No Score 27 1 28 1 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 1 Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 12 Requirement Timescale for action 10/01/06 2. OP15 16 (2) (i) The registered provider must ensure that; • Care plans, risk assessments, record of weights and blood pressures, are reviewed at least monthly or as the service users needs change. • Care plans must be implemented to ensure service users social needs are met. • PREVIOUSE INSPECTION REQUIREMENT NOT MET. The registered provider must 17/01/06 ensure that; • Hot food is not cooked too early. • Variety and adequate quantities of food must be provided for service users receiving a puree diet. • Any advice gained from Environmental Health must be followed. • The method of transporting cooked food to service users, must be reviewed. DS0000063852.V275713.R01.S.doc Version 5.1 Pines Care Home Page 24 3. OP22 23 The registered provider must ensure that suitable storage areas are allocated for all aids, adaptations and equipment. PREVIOUSE INSPECTION REQUIREMENT NOT MET. The registered provider must undertake a risk assessment of water temperatures in; • Bedrooms numbered 11 12 14 and 17. • Also the kitchen and laundry. • Valves must be fitted to these hot water taps to ensure service users and staff are not placed at risk. • PREVIOUSE INSPECTION REQUIREMENT NOT MET. The registered provider must ensure that staffing levels within the home are maintained in line with the current staffing notice. To ensure the needs of the service users can be met. PREVIOUSE INSPECTION REQUIREMENT NOT MET. The registered provider must ensure that; • Care staff are encouraged to undertake the National Vocational Qualification in Care level 2 or 3. • 50 of care staff hold this qualification. The registered provider must ensure that the acting manager completes the application form to become registered manager and submits this to the Commission for Social Care Inspection, for consideration. 10/01/06 4. OP25 13 10/01/06 5. OP27 17, 18 & schedule 2 10/01/06 6. OP28 18 10/10/06 7. OP31 9 17/01/06 Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 25 8. OP38 4 (a) The registered provider must ensure; • Safe storage of chemicals within the home. • Ironing takes place within a suitably designated area 10/01/06 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 OP12 OP19 Good Practice Recommendations The activities co-ordinator should commence as soon as all pre employment checks have been completed. The home should be audited to see if there is any way better dining facilities could be provided. The door entry system should be reviewed to ensure visitors to the home are aware that the bell has been activated, and staff are aware they are seeking access. Pines Care Home DS0000063852.V275713.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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