Inspection on 16/02/09 for Pines Residential Home (The)

This inspection was carried out on 16th February 2009.

CSCI found this care home to be providing an Adequate service.

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 Residential Home (The) 29/11/07

Pines Residential Home (The) 20/02/07

Pines Residential Home (The) 14/12/05

Pines Residential Home (The) 07/06/05

Pines Residential Home (The) 10/12/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Pines Residential Home (The) 106 Vyner Road South Birkenhead Wirral CH43 7PT Lead Inspector Mr John Mullen Key Unannounced Inspection 16th February 2009 09:45 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 Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pines Residential Home (The) Address 106 Vyner Road South Birkenhead Wirral CH43 7PT 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) 0151 653 7258 Hodge & Wilson Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other categories: Code OP The maximum number of people who can be accommodated is: 24. Date of last inspection 29th November 2007 Brief Description of the Service: The Pines is registered to accommodate 24 elderly people. Users of the service are accommodated in single bedrooms, most of which have en-suite facilities. Bedrooms are available on the ground and first floors and there is a passenger lift. There are two comfortably furnished living rooms and a dining room available for users of the service although there is also another separate area for dining if required. There are two bathrooms on the ground floor and a bathroom on the first floor. Bathing aids are provided. At the front of the home is a large landscaped garden with lawns, flowerbeds and mature trees. Seating is available in the garden. The Pines is privately owned. It does not presently have a registered manager but is being managed by the deputy manager with the support of twenty one care workers and ancillary staff. At the time of this inspection, the weekly fees for the home ranged from £365.00 to £550.00. Additional charges are made for chiropody, hairdressing, dentist, optician, newspapers, clothing and other items of a personal nature. Pines Residential Home (The) DS0000060687.V374220.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 1 star. This means the people who use this service experience adequate quality outcomes. This was a key unannounced inspection of The Pines Care Home which included a site visit. All key standards were assessed in addition to a selection of other standards. This inspection encompassed information received since the last inspection including a Management Review held in February 2008. In addition it included information provided by the agency through its Annual Quality Assurance Assessment document (AQAA). The AQAA gives an overall picture of the performance of the agency as well as factual information about the service. In addition three people who use the service were case tracked; that is they were interviewed and their care considered in detail. Interviews took place with the acting manager and two members of the care staff. Three people who use the service were interviewed and others observed. Comment cards were received from staff. The premises were inspected and a large amount of documentation examined. What the service does well: The Pines provides a comfortable, clean and pleasant environment for the care of elderly people. Interviews with users of the service were universally complimentary about the care they received and staff of the home. Comments included “they do their real best” and they are “exceptionally kind”. They could give examples of staff going out of their way to be helpful and considerate. The home has a stable staff group who are experienced and are recruited properly resulting in an effective workforce. Basic training is being provided and staff appeared well motivated towards their work. One said the staff are “very happy here”. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 6 The premises are of a good standard being spacious and well maintained. In particular, there are well apportioned gardens which can be used by users of the service for their recreation. Despite the lack of a registered manager, the home is generally being managed effectively and appropriately. What has improved since the last inspection? What they could do better: Within the context of a safe recruitment and selection policy it would be preferable if police checks are renewed every three years to confirm staff suitability. The home does provide information to prospective users of the service but this needs be improve so that they can make a choice based on full information. Medication practices and policies are essentially sound but the audit of medicines in the home could still be improved to confirm safe practice. Staff feel themselves well supported but formal supervision has lapsed and needs to be reintroduced to further develop and support them. Equally, training needs to be refreshed regularly so that staff remain up to date. There are elements of a quality assurance system but these need to be developed and brought together so that improvements can be planned. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 7 Within the context of a generally safe service, there are matters of concern relating to the storage of potentially hazardous substances and risk assessments which need attention to ensure a safe environment. Most of all, the home has not had a registered manager for some considerable time and this clearly is having an impact on management functions and the development of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 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 Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided and the assessment procedures result in people who use the service being adequately cared for within the home. EVIDENCE: The AQAA stated that a brochure had been improved and sent to prospective users of the service so that they are aware of the care provided. The site visit confirmed that there was an up to date brochure and also that there was a full statement of purpose to further inform them. In addition, the home has a standard information pack which is given to prospective users. This information pack does provide a great deal of relevant information but lacks all the required information required in the service user guide to give a complete picture of the service. A tour of the premises found that the complaints’ procedure was easily accessed by visitors and users of the service interviewed had no complaint about the information available to them. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 10 The site visit confirmed the home undertakes assessments on prospective users of the service as part of its admission procedures and to prepare staff. These assessments were found in all of the people using the service who were case tracked to confirm a standard approach. An interview with the acting manager revealed that she was particularly committed to only accepting admissions and continuing to care for those users of the service whose needs could be met by the home. Interviews with staff found them knowledgeable about the needs of people using the service although they confirmed that those needs have changed due to the increasing disabilities of people using the service. This was also confirmed by interviews with people using the service who did state that the mental and physical conditions of some people using the service has meant that conversations are limited with other residents. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The health and personal care needs of people using the service are met individually and sensitively. EVIDENCE: The AQAA confirmed that care plans are in place and reviewed monthly to confirm relevance. The site visit showed this to be the case with documented evidence of a monthly review of care plans. The care plans themselves were detailed and covered a full range of issues with desired outcomes specified to confirm progress. The care plans also included a history of people using the service and an assessment of their daily living skills to give a complete picture. Interviews with care workers found them appreciative of the care plans and, in particular, the histories which, given the increased disability of people using the service, they have found particularly useful in increasing their knowledge of residents. Interviews with people using the service confirmed that they were happy with the delivery of care to them. Comments included “carers are very good” and “exceptionally kind”. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 12 The AQAA stated that full policies and procedures are in place to attend to the health needs of people using the service. This was confirmed by the site visit where in the case files of those case tracked users of the service there was detailed assessments of need and a full recording of how needs are being met. The care plans also individually made reference to the specific health needs of users of the service and the actions required to meet these. An interview with the acting manager confirmed the home has good relationships with the health professionals visiting the home and that there have been no problems in accessing healthcare provision. The acting manager stated there had been an incident of theft of medicines in the home which had been reported to the police and had resulted in extra security precautions being taken in respect of certain medicines. We can find no trace of this incident being reported to us although the acting manager stated that the responsible individual had written to us. Medication records seen were correctly recorded although there could be an improvement to the auditing of medicines received so this is easily checked. The acting manager said she would discuss this with the visiting pharmacist the day following the inspection to improve practice. A tour of the premises confirmed that medicines were being correctly stored and an examination of training documents showed that appropriate staff have been trained in the administration of medicines to ensure their competence. Interviews with users of the service found them very appreciative of the skills of the care workers within the home and, in particular, with their ability in the area of personal care. One user of the service was particularly appreciative describing the staff as “absolutely excellent” in personal care and another said “the carers are very good”. The former also confirmed that the staff responded to his disability and to his suggestions as to how care could be enhanced. The AQAA stated there had been a significant increase in training in the area of privacy and dignity and this was confirmed by the site visit and training documents seen which showed that professional training has significantly improved. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home allow people using the service an individualised living experience. EVIDENCE: Discussions with users of the service found them happy with the range of activities on offer. On the morning of the inspection an aerobics class was taking place and the acting manager confirmed a variety of activities that are available so that users of the service have a choice. A tour of the premises found that activities were being publicised prominently in the home so that people are aware of their availability. Discussions with care workers confirmed that they felt there were good activities available although they also confirmed that a lot of people using the service prefer not to participate through personal choice. Two of the people using the service who were case tracked had visual impairments and both confirmed that they were amply supplied with talking books to meet their individual needs. The AQAA stated that the home encourages visitors and they can join in activities and meals if they so wish. A tour of the premises found that there is Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 14 a request that visitors do not call during mealtimes but, otherwise, they can visit freely so that access is not restricted. This was confirmed by interviews with people using the service who stated that their relatives can visit at any time within reason. A number of surveys have been taken of families and these revealed a positive view of the home by them. Care workers interviewed stated that families visit a great deal to maintain contact, although few were seen during the site visit. The AQAA stated that the home does try to promote independence although this is limited by the increasing confusion of some people using the service. This was confirmed by observations during the site visit and by discussions with the acting manager and care workers who were aware of the specific risks associated with some users of the service. Those people using the service who were spoken to, however, did confirm that their wishes were respected in the home. This included their ability to have a key to their own bedroom, to engage in activities as they wish and to choose their own menu. Observations during the inspection confirmed that people using the service were encouraged to make choices but staff were aware of the risks associated with those using the service who have a degree of confusion. An interview with the acting manager confirmed that choices are available during the tea time menu and that although there is a set menu for lunch this can be changed on request. This was confirmed by interviews with people using the service who generally thought the food was good although one thought there had been some deterioration, although it remained acceptable. An interview with the cook confirmed an individual approach to food and observation of a meal taking place during the site visit found it a calm and pleasant occasion. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures and policies of the home ensure that users of the service are protected. EVIDENCE: The AQAA stated there was a full complaints’ procedure and the home also uses a customer satisfaction survey to gauge satisfaction. The complaints’ book showed that there had been one complaint over the last twelve months which had been initially referred to us and has been dealt with speedily and properly. A tour of the premises found that the complaints’ procedure was prominently displayed and easily accessible to both people using the service and visitors. Interviews with users of the service resulted in no complaint about their care but rather a positive view of the home. An examination of the results of a survey of people who use the service and their families undertaken in January 2009 confirmed this view. The AQAA stated there had been no safeguarding issue over the last twelve months and also stated that staff are being trained in this area every twelve months. However, an examination of training records found the latter not to be the case although staff have had training in this area some years ago to familiarise themselves with the procedures. An interview with the acting manager confirmed that there had been no safeguarding issue over the last twelve months and a review of information sent to us confirmed this to be the Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 16 case. Since the last inspection the home has reviewed its methods of recording financial transactions of people who use the service. The acting manager demonstrated that there were now individual records and accounts to ensure a full audit trail is available. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is pleasant and clean for the care of people who use the service. EVIDENCE: A tour of the premises found it fit for purpose. All bedrooms are for single occupancy and were well furnished, decorated and carpeted to maintain standards. Interviews with people using the service found them happy with the quality of their bedrooms in particular. The home has two lounges which provides a quiet room as an alternative to television. There are two separate dining areas and there was a wide range of space available for the use of people using the service. Two users of the service who were interviewed have visual impairments but both confirmed they have no problems in managing the premises. The home has an appropriate amount of aids to assist users of the service, including three bath hoists. The kitchen is of a good standard and the Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 18 laundry is properly equipped to maintain standards. However, during the site visit, the latter was found to contain potentially hazardous substances which could be accessed by people using the service. Given the confusion of some people who use the service this is potentially dangerous and must be addressed. The grounds of the home are particularly pleasant and users of the service were particularly complimentary about this and the uses to which this can be put, particularly during the summer period. The AQAA confirmed the home’s commitment to maintaining a high level of hygiene with appropriate policies and training. A tour of the premises found them clean and hygienic. An interview with the acting manager revealed that the home employs two domestic staff a day with one during the mornings at weekends to maintain standards. Training documents seen confirmed that staff are being trained in matters such as infection control so that risks are minimised. One user of the service who was interviewed expressed very positive views about the lack of odours in the home which she confirmed was a constant and pleasant feature of life in the home. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home recruits and trains staff appropriately resulting in an effective workforce. EVIDENCE: A meeting with the responsible individual following the last inspection resulted in a commitment to increase staffing levels and the AQAA confirmed that this has been done. An interview with the acting manager revealed that there are now three care workers working until 8.30pm plus one domestic worker which represents an improvement and now is sufficient to meet the needs of people using the service. This was also confirmed by care workers who stated that the increase in numbers had been highly beneficial, enabling them to work more effectively. They also felt that the numbers of staff were now sufficient particularly as the home continues to accommodate numbers below its maximum. The last inspection found a low level of trained staff within the home. The AQAA confirmed this had been significantly improved; of the twenty one staff, ten having been trained and five undergoing training. An interview with the acting manager confirmed this to be the case. In addition, she could also show that a number of care staff have received certificated training in dementia care Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 20 which also represents a significant improvement. Interviews with care workers found a varying attitude towards professional training but an acceptance that there had been a significant increase in numbers who have been trained to the benefit of people using the service. An examination of staff files found that most included full recruitment and selection procedures to confirm a correct approach. The exception was in the file of the acting manager who has been employed in the home for over twenty years and, therefore, was appointed prior to the standards being implemented. All files included a police check although not all had been undertaken within the last three years which would be preferable to ensure ongoing suitability of staff. Comments cards received from staff and interviews with them during the site visit confirmed that they felt they had been recruited in a fair and robust manner. People using the service who were spoken to were highly favourable about the quality of the care workers employed in the home. Comment cards received from staff were favourable about the training being provided in the home which they felt was relevant and appropriate. This was also the case with care staff interviewed who were positive about the training being offered. An interview with the acting manager revealed that she had arranged an amount of extra training, particularly in the area of dementia care, to help staff. However, she was not particularly aware of the need to regularly refresh training in order to keep staff up to date. An examination of training documents held in the home showed that staff had received basic induction and foundation training but these largely dated from the years 2005 and 2006 and, therefore, needed some refreshing. An interview with care workers confirmed that they felt their induction to the home, which included shadowing an experienced member of staff, had been good and helped to prepare them for their work. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of a registered manager results in some management functions not being fully met. EVIDENCE: This home does not have a registered manager and we have written to the responsible individual to ask for his plans in this respect. The home is currently being managed by the acting manager who does not want to apply for the full post and confirmed that she is having difficulty in covering all the responsibilities. The lack of a registered manager is having some effect on the operation of the home and management functions. The AQAA for this service was significantly late which illustrates the point. The home was subject to a management review in February 2008 to discuss outstanding matters including Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 22 the lack of a registered manager. The acting manager in interview confirmed that the lack of a registered manager was impinging on certain management functions, including staff supervision and that she would welcome an early appointment. The site visit revealed there were some elements of a quality assurance programme in place to monitor standards. These included a survey of people using the service in respect of food, a general survey of people using the service undertaken in January 2009 and more regular visits by the responsible individual to monitor the progress of the home. There was no evidence during the site visit of an overall approach to the question of quality assurance whereby the home regularly collects information as a basis for continual improvement. The acting manager confirmed that she had improved the arrangements for recording the finances of people using the service. The site visit confirmed this. The financial records for the three people who use the service who were case tracked were examined and found to be correct. In addition, the acting manager has made arrangements whereby monies are individually held for people using the service and, therefore, a clear audit trail is available. A tour of the premises confirmed that the monies are appropriately stored in a safe facility. An interview with the acting manager confirmed that she felt that formal supervision was a matter that had had to lapse due to the lack of a registered manager. She stated that she “only has supervision with new staff” and that she “has not got the time”. Records examined during the site visit found no evidence of any formal supervision being undertaken in the home to direct staff. Interviews with care workers, supported by comment cards, confirmed that they felt themselves generally well supported in the home and felt that the acting manager was very supportive to them informally. A tour of the premises found that the home was generally a safe place for the care of people using the service. The exception was the laundry area which was found unattended and open and containing potentially hazardous substances. This needs to be corrected particularly as the home is accommodating a number of users of the service who have a degree of confusion and could access this area. There is a need to ensure that all potentially hazardous substances in the home are secured for the safety of people who use the service. An examination of documentation found that there had been full checks on gas and electricity to confirm their safety. A random check of the water temperatures found them to be correct for the same reason. However, the fire risk assessment was out of date despite a letter from the Fire Officer and there was no general risk assessment of the home to minimise risk. The home has trained a member of staff to undertake electrical equipment tests and has provided equipment for this purpose. An Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 23 examination of documents found that this was now being done on a regular basis for the safety of users of the service. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 25 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 OP31 Regulation 8 Requirement An application for a registered manager is urgently required so that all management functions of the home can be addressed. (Previous timescale of 6th March 2008 not met). Timescale for action 01/06/09 2. OP9 13 Further improvement to the 01/04/09 recording of medicines received in the home is required to ensure a clear audit trail. (Previous timescale of 6th December 2007 not met). A full training programme for staff is required to include refresher training so that they remain up to date. A system of formal supervision to be introduced so that staff are further developed and supported. All potentially hazardous substances to be safely stored to ensure the safety of people using the service Risk assessments of the building including fire risk assessments, to be updated regularly so that DS0000060687.V374220.R01.S.doc 3. OP30 18 01/08/09 4. OP36 18 01/09/09 5. OP38 13(4)(b) 01/04/09 6. OP38 13(4)© 01/04/09 Pines Residential Home (The) Version 5.2 Page 26 unnecessary risks to users of the service are eliminated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP33 OP29 Good Practice Recommendations The information provided to people using the service should be expanded to meet all that is required. The quality assurance arrangements to be expanded and consolidated so that there is a clear basis for continual improvement. Police checks on staff to be renewed every three years so that their continuing suitability is kept under review. Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Pines Residential Home (The) DS0000060687.V374220.R01.S.doc Version 5.2 Page 28 - 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. 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