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Inspection on 20/02/07 for Pines Residential Home (The)

Also see our care home review for Pines Residential Home (The) for more information

This inspection was carried out on 20th February 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents have their needs appropriately assessed before moving to the home, which, ensures that a service is only offered to people whose needs can be met. Residents` benefit from being able to make trial visits. This assists residents to make a decision about whether the home is right for them. Staff are aware of the needs of residents and how to meet them. Residents spoken with reported that a good standard of care is provided. Relatives and health professionals reported that staff are caring and have a good understanding of the care needs of residents. Observations and discussions with residents indicated they consider they are treated with respect. The wellbeing of residents is promoted by the flexibility of the daily routines, visitors being made welcome to the home and the provision of well balanced, appealing meals. Activities are available for residents to take part in should they so wish. The home has a satisfactory complaints system which residents know how to access. The procedures at the home and training provided to staff around adult protection safeguard residents. The home is clean and well presented and provides a comfortable and pleasant atmosphere. A number of staff have worked at the home for several years and know the needs of the residents well. This promotes continuity of care. The friendliness and kindness of the staff was commented on by residents at this visit. When asked about the care they receive from staff, residents said "the care is verygood" and "we are well cared for." Questionnaires returned by relatives indicated that the "staff are really caring and helpful."

What has improved since the last inspection?

Since the last inspection there has been improvements to the decoration of the premises. The recommendations made around recording changes to medication have been put into practice. A record is being made of the social history of residents. This gives staff a better understanding of residents` previous life experiences and can inform how staff encourage residents to pursue hobbies and interests.

What the care home could do better:

The home does not have a manager who is registered with CSCI. There has been a delay in a complete application being made to CSCI, which has resulted in a delay in assessing the competence of the manager to run the home. A complete application to register the manager needs to be submitted to CSCI so that this application can be assessed without any further delay. Contracts between the home and the residents need to be made available at the home so that an assessment can be made as to whether the wellbeing of residents is supported by the contracts. Information from fact sheets on specific health conditions should be written in to care plans to provide easier reference for staff. This should identify how symptoms present themselves and the action to be taken by staff. It continues to be recommended that the competence of staff to administer medication be recorded in staff training records. A safe environment needs to be provided at the home at all times. Fire doors are not to be wedged open as this makes them ineffective in the event of a fire. Portable appliances need to be regularly checked by a person who is qualified to do so, so as to ensure that these appliances are safe for use. The Health and Safety Executive must be notified of significant injuries that occur at the home in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. This is to ensure that this legal requirement is met and enable the Health and Safety Executive to assess that appropriate action has been taken and provide advice to prevent a further occurrence. The quality assurance systems in place would be improved if the responsible individual produced a written report of their findings following their required visits to the home. A written report must be made available as this provides evidence that the operation of the home is being overseen by the organisation that has the ultimate responsibility for it.Residents would benefit from new staff receiving induction training that meets the Skills for Care workforce training targets. Residents would benefit from 50% of staff having an appropriate qualification in Care of Older People. The home`s recruitment practices safeguards residents, however, improvements are needed to provide further safeguards.

CARE HOMES FOR OLDER PEOPLE Pines Residential Home (The) 106 Vyner Road South Birkenhead Wirral CH43 7PT Lead Inspector Beate Roth Key Unannounced Inspection 11:00 20 February and 5th March 2007 th 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.V321807.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.V321807.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 0151 653 7258 Hodge & Wilson Ltd Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: The Pines is registered to accommodate 20 elderly people. Residents are accommodated in single bedrooms, most of which have en-suite facilities. Bedrooms are available on the ground and first floors. Residents have access to a lift. There are two comfortably furnished living rooms and a dining room available for residents. There is a bathroom on the ground and 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. Parking is available at the rear of the building. There is access to a bus service from the home. Upton and Claughton Village provide a selection of shops and amenities and are a short bus ride away. At the time of this inspection, the weekly fees for the home ranged from £425.00 to £550.00. Additional charges are made for hairdressing, chiropody, toiletries and newspapers. A service user guide and a statement of purpose, which describe the services offered at The Pines is made available to new residents, their relatives and professionals before a resident comes to live at the home. A copy of the most recent inspection report can be obtained from the manager. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours and is based on two visits to the home. The inspection is also informed by information received about the service since the last inspection and by questionnaires completed by the residents, their relatives and health professionals who visit the home. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager, service manager and responsible individual. A tour of the home was undertaken. The inspector spoke with residents, relatives and staff. What the service does well: Residents have their needs appropriately assessed before moving to the home, which, ensures that a service is only offered to people whose needs can be met. Residents’ benefit from being able to make trial visits. This assists residents to make a decision about whether the home is right for them. Staff are aware of the needs of residents and how to meet them. Residents spoken with reported that a good standard of care is provided. Relatives and health professionals reported that staff are caring and have a good understanding of the care needs of residents. Observations and discussions with residents indicated they consider they are treated with respect. The wellbeing of residents is promoted by the flexibility of the daily routines, visitors being made welcome to the home and the provision of well balanced, appealing meals. Activities are available for residents to take part in should they so wish. The home has a satisfactory complaints system which residents know how to access. The procedures at the home and training provided to staff around adult protection safeguard residents. The home is clean and well presented and provides a comfortable and pleasant atmosphere. A number of staff have worked at the home for several years and know the needs of the residents well. This promotes continuity of care. The friendliness and kindness of the staff was commented on by residents at this visit. When asked about the care they receive from staff, residents said “the care is very Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 6 good” and “we are well cared for.” Questionnaires returned by relatives indicated that the “staff are really caring and helpful.” What has improved since the last inspection? What they could do better: The home does not have a manager who is registered with CSCI. There has been a delay in a complete application being made to CSCI, which has resulted in a delay in assessing the competence of the manager to run the home. A complete application to register the manager needs to be submitted to CSCI so that this application can be assessed without any further delay. Contracts between the home and the residents need to be made available at the home so that an assessment can be made as to whether the wellbeing of residents is supported by the contracts. Information from fact sheets on specific health conditions should be written in to care plans to provide easier reference for staff. This should identify how symptoms present themselves and the action to be taken by staff. It continues to be recommended that the competence of staff to administer medication be recorded in staff training records. A safe environment needs to be provided at the home at all times. Fire doors are not to be wedged open as this makes them ineffective in the event of a fire. Portable appliances need to be regularly checked by a person who is qualified to do so, so as to ensure that these appliances are safe for use. The Health and Safety Executive must be notified of significant injuries that occur at the home in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. This is to ensure that this legal requirement is met and enable the Health and Safety Executive to assess that appropriate action has been taken and provide advice to prevent a further occurrence. The quality assurance systems in place would be improved if the responsible individual produced a written report of their findings following their required visits to the home. A written report must be made available as this provides evidence that the operation of the home is being overseen by the organisation that has the ultimate responsibility for it. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 7 Residents would benefit from new staff receiving induction training that meets the Skills for Care workforce training targets. Residents would benefit from 50 of staff having an appropriate qualification in Care of Older People. The home’s recruitment practices safeguards residents, however, improvements are needed to provide further safeguards. 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.V321807.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.V321807.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): 2, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New residents are fully assessed before they are admitted to the home in order to ensure their needs can be met. It was not possible to assess if the wellbeing of residents is supported by the contracts they have with the home, as this documentation was not available. EVIDENCE: A sample of new resident’s files were seen. There was evidence of appropriate assessments being carried out before new residents move to the home. There was also evidence that information is gathered from social workers and health professionals to inform the assessment. During the assessment the manager visits the new residents at hospital or at home. During this visit the services that can be offered are discussed and whether The Pines is suitable for the resident is assessed. New residents spoken with said they had been asked about their needs during the assessment. The initial assessments cover the Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 10 religious, cultural and linguistic needs of residents. Since the last inspection further information is being recorded in the initial assessment and care plans around the social history of residents where this is possible. Before residents decide to move to the home they are invited to make visits to see if the home is suitable for them. A new resident spoken with confirmed this. During these visits they can meet staff and current residents and view the home. Contracts between the home and the residents were not available at the home and so it was not possible to assess if residents have up to date written information around the fees payable and what this covers. The manager said that the residents are provided with a contract and a copy is kept at another office base. One resident spoken with said that they had a contract whilst the other residents spoken with were not sure. A record of the care home’s charges to residents, including any extra amounts payable for additional services must be kept at the home. A sample contract was available that covers the rights of the resident, services provided and terms and conditions of residence. Pines Residential Home (The) DS0000060687.V321807.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 residents are well met. Residents are treated with respect. The management of medication supports the well being of residents. EVIDENCE: 4 care plans were seen. The care plans identify the current needs of the residents and provide sufficient information for staff around the action to be taken to meet these needs. The staff spoken to were aware of the needs of the residents whose records were inspected, and how to meet these needs. Fact sheets around health conditions were available on resident’s files. This information should be written in to the care plan to provide easier reference for staff. This should identify how symptoms present themselves and the action to be taken by staff. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 12 The residents spoken to said that they are well cared for at the home. When asked about the care they receive from staff, residents said “the care is very good” and “we are well cared for.” Questionnaires returned by relatives indicated that the “staff are really caring and helpful,” the home gives the support that has been agreed and that they are kept informed about important issues affecting their relative. The records at the home indicated that referrals are made to health professionals in accordance with the needs of residents. A record is made of visits by health professionals and the outcome is documented. Residents spoken with said that their health needs are well met. Questionnaires were returned by 3 GP’s who indicated that the staff have a good understanding of the care needs of residents, medication is appropriately managed and that they are satisfied with the overall quality of care provided at the home. A sample of medications and the corresponding records were examined and found to be in order. Any changes to medication are being counter-signed by a second member of staff where it has not been possible to obtain this confirmation in writing from a GP. All staff who administer medication have completed an intermediate certificate in the safe handling of medications. In addition, the pharmacist for the home has trained all staff that administer medication. It continues to be recommended that the competence of staff to administer medication be recorded in staff training records. The pharmacist who supplies medication to the home visits to audit the medication and ensure that the home is complying with legal requirements. A risk assessment was available for a resident who administers their medication. These measures put in place help safeguard the residents from the possibility of maladministration of medication. A sample of records of accidents were seen, these indicated that in general appropriate action had been taken. An accident that had resulted in a fracture to a resident had not been reported to the Health and Safety Executive in accordance with RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.) The risk assessment for this resident was updated following this accident in order to safeguard against a further incident. At induction training staff are provided with guidance on how to meet a residents needs in a dignified manner and how to respect their privacy. A policy is also available to provide guidance to staff entitled “maintaining dignity, respect and polite behaviour.” Staff were observed to treat residents with respect. Staff were observed to speak to residents in a respectful manner and were sensitive when responding to the residents needs. The residents interviewed said that the staff are “polite,” “friendly,” “helpful” and “kind.” Pines Residential Home (The) DS0000060687.V321807.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 visiting the service. The wellbeing of residents is promoted by the flexibility of the daily routines, visitors being made welcome to the home and the provision of well balanced, appealing meals. EVIDENCE: Observations and a discussion with staff and residents indicated that the routines of daily living are flexible. Residents said they choose what time they get up and go to bed, whether to socialise or stay in their rooms and what to do each day. There is a list of weekly activities that has been drawn up following consultation with residents. The activities include flower arranging, armchair aerobics, singing with an entertainer, bingo, coffee mornings to which relatives are invited and board games. A resident organises a quiz on a monthly basis. Residents spoken with said that they enjoy the activities provided and that enough activities are available. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 14 The residents spoken with said that their friends and relatives are able to visit them whenever they wish and that they are always made to feel very welcome by the staff. Representatives from local churches visit the home, religious services are provided at the home, a mobile library and clothes shop also visits the home. A number of residents regularly go out with their families and friends. Observations of the dining area indicated that a pleasant environment is provided for residents to have their meals. The food being prepared looked appetising. Lunchtime menus are displayed in a book in the main reception for residents and their visitors to view. Visitors may eat with the person they are visiting as long as sufficient notice is provided. Breakfasts are provided following consultation with each resident and are served in the bedrooms on request. A choice of evening meals is provided. The records of menus indicated that a variety of meals that would provide a balanced diet are available. Any special dietary needs are written in to a residents care plan. The cook reported that she is informed about any dietary needs and ensures these are taken into account when meal planning. When asked about the food provided, residents described the food as “excellent” and said it is of a “good quality” and that fresh ingredients are used. Pines Residential Home (The) DS0000060687.V321807.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 visiting the service. Residents are safeguarded. Residents know how to make a complaint. Staff know how to manage complaints and adult protection matters. EVIDENCE: The home has a complaint procedure. A leaflet advising residents and their visitors about how to make comments and complaints about the home is prominently displayed in the reception area. Staff spoken to were aware of the complaint procedure and what to do if a resident or visitor wished to make a complaint. Residents spoken with only had positive comments to make about the home but said that if they needed to complain they would speak to the manager or service manager. There has been one complaint made to the home since the last inspection and appropriate action has been taken to investigate this. Information about advocacy services is available for residents in the complaints procedure. The induction for staff covers the adult protection procedure. The majority of staff have attended adult protection training provided by Wirral Borough Council. Two members of staff were interviewed and were very well aware of Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 16 the procedure to follow should they suspect abuse. A copy of Wirral Borough Council’s adult protection procedures is available at the home. Pines Residential Home (The) DS0000060687.V321807.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 home is well maintained and there is a good standard of cleanliness and hygiene, providing residents with a pleasant environment to live in. EVIDENCE: A tour of the home showed that the home is well maintained and decorated to a high standard. The decoration in the upstairs bathroom is showing some signs of wear. Records of maintenance and redecoration together with observations of the home showed that work is ongoing to maintain standards. Communal space is provided in two lounges and a dining room. These rooms are well presented and well furnished. Sufficient communal space is provided. The residents spoken with said that they are very happy with the physical Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 18 standards provided to them at the home. The private garden area of the home is well tended and provides a patio area and patio furniture. An extension has been built at the home. An application has been made to CSCI to increase the number of older people that the home is registered for. The extension is being decorated at present. At the time of the inspection this was being managed so as not to cause an inconvenience to the residents or present any hazards to safety. On the day of this inspection the premises were found to be very clean and malodour free. Residents spoken with said that the home is kept very clean. Relatives who returned questionnaires described the home as “very clean” and “well appointed.” Pines Residential Home (The) DS0000060687.V321807.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 adequate. This judgement has been made using available evidence including visiting the service. There are sufficient numbers of staff to meet the needs of residents. Residents would benefit from staff receiving induction training that meets the Skills for Care workforce training targets and from 50 of staff having an appropriate qualification in care of older people. The home’s recruitment practices safeguard residents, however, improvements need to be made to provide further safeguards. EVIDENCE: The rotas and a discussion with staff indicated that there are sufficient numbers of care staff to meet the needs of the residents. The rotas indicate that there are at least three care staff on duty in the morning and two on the afternoon and evening shifts. At night there is one sleeping in and one waking member of staff on duty. A sufficient number of domestic and catering hours are provided. Residents spoken to said that staff are available when they are needed. The recruitment records for the two new members of staff were seen. The required information was in general, available. An application form is not used by the home and so a record of the applicant’s work history and relevant experience was not recorded. This information is significant in operating a robust recruitment procedure as it assists in assessing the suitability of a Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 20 candidate. For example, it helps to assess if reasons for leaving previous employment are relevant for the current position applied for. Gaps in work history need to be explored with an applicant and the lack of a recorded work history does not allow for this. Records of staff training indicated that a brief induction is provided which is supplemented by training days around particular aspects of care of the elderly. There was evidence that training around first aid, infection control, safe handling, medication management, food hygiene and protection of adults from abuse had been undertaken by staff in the last 12 months. The training programme for 2007 has been drawn up to reflect the current training needs of staff. 4 out of 19 care staff hold an NVQ in Care of Older People. The National Minimum Standards for Care Homes for Older People recommends that at least 50 of staff hold this qualification. Work is taking place to encourage staff to undertake this qualification. At previous inspections there has been evidence that there is an induction programme that meets the Skills for Care workforce training targets however this induction was not being provided to new staff. At this inspection this training is still not being provided to new staff. Residents would benefit from staff completing this training as it provides a complete introduction to working in a care setting. Pines Residential Home (The) DS0000060687.V321807.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 management arrangements at the home do not fully support the wellbeing of residents. The arrangements for quality assurance and supervision of staff need further improvement. The safety of residents is in general well promoted. Improvements are needed to the practices around fire safety. EVIDENCE: Following the last inspection, an application to register a manager for the service was made to CSCI. The application was returned to the manager by CSCI on 14th December 2006 as the application was not complete. At the time of this visit this information has not been made available to CSCI. Without a complete application CSCI is unable to assess the competence of the manager. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 22 The manager has undertaken an NVQ Level 2 in Care of Older People and is in the process of enrolling on an NVQ Level 4 in Care and Management. There are quality assurance systems in place. There are arrangements for obtaining the views of residents and their relatives. A member of staff said that their views are taken into account in relation to the operation of the home. Staff meetings are held. The residents were informed of this inspection and were encouraged to meet with the inspector. At previous inspections it has been reported that the quality assurance systems in place would be improved if the responsible individual produced a written report of his findings following his statutory visits to the home. The responsible individual continues to make weekly visits to the service and provides verbal feedback to the manager. Some written reports have been made available to CSCI, but not on a consistent basis. A written report must be made available as this provides evidence that the operation of the home is being overseen by the organisation that has the ultimate responsibility for it. Consideration should be given to using a professionally recognised quality assurance system to monitor the service. The manager reported that the home does not look after any money for residents. The financial affairs of residents are managed by the residents themselves, or by their family or a solicitor. Residents are able to bring personal possessions to the home. The manager and staff reported that supervision is provided to staff on a regular basis. The practices of staff are observed and the duties of staff and their training needs are discussed. A record is being made around training provided to staff. In order to fully meet the National Minimum Standards for Care Homes for Older People, it is strongly recommended that a record be made of the other issues covered within staff supervision. Steps have been taken to ensure that a safe environment is provided. Water is regulated throughout the home to ensure that the temperature does not exceed 43 degrees centigrade. Regular checks of the water temperature are undertaken. Radiators have radiator covers in accordance with a risk assessment. There are appropriate storage facilities. A sample of safety check records were seen for the electricity, gas, and servicing of the fire safety systems and nurse calls and were appropriately maintained. Records of in-house checks of the fire alarm and emergency lighting were seen and were in order. There was no evidence of portable appliance tests being carried out at the home. The manager reported that this had recently been identified and is in the process of being attended to. During a tour of the home some bedroom doors were wedged open. Fire doors must not be wedged open as they would be ineffective in the event of a fire. Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 23 Fire doors may only be held open if an appropriate device that is approved by the fire service is made available. Pines Residential Home (The) DS0000060687.V321807.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 X 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 2 29 2 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.V321807.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 OP2 Regulation 17 Requirement The registered persons must ensure that a record of the care home’s charges to residents, including any extra amounts payable for additional services not covered by those charges and the amounts paid by or in respect of each resident be kept at the home. The registered persons must ensure that the Health and Safety Executive is notified of significant injuries that occur at the home in accordance with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. The registered persons must ensure that a record of an applicant’s employment history and work experience is recorded in order to ensure robust recruitment practices. The registered persons must ensure that the induction training meets the Sector Skills DS0000060687.V321807.R01.S.doc Timescale for action 05/03/07 2. OP8 13 05/03/07 3. OP29 19 05/03/07 4. OP30 18 05/06/07 Pines Residential Home (The) Version 5.2 Page 26 Workforce training targets. 5. OP31 8 The registered person must ensure that a complete application to register the manager is submitted to CSCI with the correct information so that this application can be assessed without any further delay. The registered person must prepare a monthly written report on the conduct of the care home (previous timescale of 07/06/05 not met). The registered persons must ensure that fire doors are not wedged open. Fire doors may only be held open if an appropriate device that is approved by the fire service is made available. The registered persons must provide evidence to CSCI that an individual who is qualified to do so has tested the portable appliances at the home and that these appliances are safe for use. 05/04/07 6. OP33 26 05/03/07 7. OP38 23 05/03/07 8. OP38 23 05/04/07 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 OP8 Good Practice Recommendations Information from fact sheets on specific health conditions should be written in to the care plan to provide easier reference for staff. This should identify how symptoms DS0000060687.V321807.R01.S.doc Version 5.2 Page 27 Pines Residential Home (The) present themselves and the action to be taken by staff. 2. OP9 It is recommended that the competence of staff to administer medication be recorded in staff training records. A minimum of 50 of staff are to hold an NVQ 2, or equivalent qualification. Consideration should be given to using a professionally recognised quality assurance system to monitor the service. It is recommended that a record be made of all issues covered within staff supervision in accordance with the National Minimum Standards. 3. 4. OP28 OP33 5. OP36 Pines Residential Home (The) DS0000060687.V321807.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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