Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 28/07/05 for Pinetree Lodge Nursing Home

Also see our care home review for Pinetree Lodge Nursing Home for more information

This inspection was carried out on 28th July 2005.

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

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

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

The manager and staff have consistently shown a caring attitude towards the people who use the service. They work with people to find the best outcome that will keep people at ease. Relatives said that the staff were exceptionally good at what they did and although most people were at the later stages of the dementia illness they cared a great deal about the people. On the whole residents retained memory is related to the earliest part of their life and therefore they need assistance with all aspects of their personal care needs. Staff continue to value individuals and try to engage people in conversation and making decisions when staff are working with them to complete all of the personal care tasks. Mental Health Concern`s staff training department is extremely active and all of the staff have access to a wide range of training. The type of training offered includes access to degree and masters level courses as well as secondments onto nurse training. Mental Health Concern is not only the owner of Pinetree lodge but also a charity. Headquarters staff actively promote the recognition of people with mental health needs as full citizens. They run service user boards and provide opportunities for people with mental health needs to access employment. One of the relatives discussed their role on this board and how their views were valued both by the service user board and the staff at Pinetree Lodge.

What has improved since the last inspection?

Mental Health Concern has been running a comprehensive recruitment programme for all of the services they run. Two nurses have been recruited to fill vacancies at Pinetree Lodge. Five care staff vacancies still need to be filled but interviews were taking place in the following week. The recruitment of nurse has reduced the strain staff were experiencing covering shifts. With the continued vacancies staff are still needing to work extra shifts but felt less stressed and often found that one of the nurses would step in to cover for a missing care staff member. Since the last inspection Mental Health Concern has decided to employ staff in kitchen. They are now actively recruiting people to fill this role. Also they have reviewed the suggestion that laundry staff were employed. The service manager has started to complete some in depth life histories of people with very complex needs. The ones produced have given staff a whole new insight into why people might display certain behaviours. Staff were very keen to gather more of this type of information about all of the residents. The manager has ensured alarms have been fitted to some people who remain in bed bedroom doors so that if other resident`s inadvertently walk it staff will be made aware. Also two high/low beds have been purchased and plans are in place to purchase more so that bed rails can be phased out.

What the care home could do better:

The staff need to continue developing their record keeping skills and ensure the different good practices they use whilst working with people are fully recorded. All of the assessment records need to be up-to-date and accurate and life histories are completed. However this is not achievable until the staffing levels have been resolved. The continued lack of support staff such as activities co-ordinators and laundry staff places additional pressure on the existing team. At present staff have great difficulty organising appropriate activities for people. Staff not only need to provide personal care but also complete catering and laundry tasks. The group of residents have extremely high dependency needs and this needs to be reflected in the staffing mix.

CARE HOMES FOR OLDER PEOPLE Pinetree Lodge Nursing Home Dryden Road Gateshead Tyne and Wear NE9 5BY Lead Inspector Katie Tucker Unannounced 28 July 2005 1:00pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pinetree Lodge Nursing Home Address Dryden Road Gateshead Tyne and Wear NE9 5BY 0191 4774242 0191 4774264 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mental Health Concern Mrs Kathleen Bailey Care Home with Nursing 34 Category(ies) of DE(E) Dementia - over 65 (34) registration, with number MD Mental Disorder (5) of places DE Dementia (5) Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/03/05 Brief Description of the Service: Pinetree Lodge Nursing Home is owned by Mental Health Concern and opened in 1984. It is designed to accommodate the needs of older people with dementia care and nursing needs. The home is a purpose built bungalow style facility. It is divided into three units and provides nursing care for people with mental health needs, predominantly those needs associated with dementia-type illnesses, in each unit. There are a variety of lounges and dining rooms throughout the building as well as a sensory room. One lounge provides access to an internal courtyard and a sensory garden has been created. The home is situated in a residential area just off Durham Road in Gateshead. Other healthcare facilities are located in the same grounds. Public transport is within easy walking distance and this gives access to local shops and social amenities. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Pinetree Lodge Nursing Home, which was conducted as part of the routine yearly programme. An inspector spent half a day at the home and spoke to 11 service users and visiting relatives. A sample of assessments, care plans and risk assessments and the complaints procedures were examined. The staff were asked about the service user plans, staffing levels, access to training and any changes to working practices, as were the service users. The general maintenance of the building was checked. Pinetree Lodge provides a service for people with a dementia-type illness (memory loss) as well as for people with mental health needs. The majority of the people have difficulty making their views known. Therefore staff practice, attitude and approach were observed and judgements were made on how well the approaches that were used were working. This type of observation formed a part of the inspection process as well as what people said and was backed up through the examination of records, comments made by residents, staff and relatives. During this inspection key standards were focused on but not all were checked. What the service does well: The manager and staff have consistently shown a caring attitude towards the people who use the service. They work with people to find the best outcome that will keep people at ease. Relatives said that the staff were exceptionally good at what they did and although most people were at the later stages of the dementia illness they cared a great deal about the people. On the whole residents retained memory is related to the earliest part of their life and therefore they need assistance with all aspects of their personal care needs. Staff continue to value individuals and try to engage people in conversation and making decisions when staff are working with them to complete all of the personal care tasks. Mental Health Concern’s staff training department is extremely active and all of the staff have access to a wide range of training. The type of training offered includes access to degree and masters level courses as well as secondments onto nurse training. Mental Health Concern is not only the owner of Pinetree lodge but also a charity. Headquarters staff actively promote the recognition of people with mental health needs as full citizens. They run service user boards and provide opportunities for people with mental health needs to access employment. One Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 6 of the relatives discussed their role on this board and how their views were valued both by the service user board and the staff at Pinetree Lodge. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 A wide range of records are available but staff are in the process of completing them. Therefore shortfalls will continue to exist until these are completed. EVIDENCE: A new assessment document has been introduced in the home. This has been specifically designed to provide information on the needs and experiences of those people with a dementia- type illness. This is a very comprehensive tool, which is starting to generate comprehensive information about all aspects of people’s lives and needs. At present staff are in the process of filling these in but because of staffing constraints are finding this a slow process. Staff are aware that the life histories need to cover people’s personality traits when they were younger, events that occurred and their feelings at that time, routines and jobs or roles. People with dementia tend to revert to previous routines and patterns of behaviour and having this information allows staff to work more effectively with people and reduce the challenges that may be presented. Once the staffing issues have been resolved they are intending to concentrate on this aspect of the service. An intermediate care service is not provided at Pinetree Lodge. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 Although the staff in practice demonstrate that they help service users to make decisions about their lives, are aware of associated risks and plan people’s care, this is not reflected within the care plan. EVIDENCE: The staff have a very in depth knowledge of the people using the service and their needs. Full assessment information and care plans are being put in place. Evidence is now being provided to show that service users or their representatives can contribute directly to the compilation of the service user plan. Staff and CSCI acknowledge that over the last year staffing levels have precluded the work people wanted to complete on developing these records and this aspect of practice will be looked at during the next inspection. The deputy manager has been involved in a working group who have been developing a falls prevention assessment tool. This tool is in its final stages prior to being piloted and a great deal of consideration has been given to how this should be developed. The risk assessment for manual handling are being revisited with the health and safety representative to ensure they are compliant with good practice. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 10 Risk-taking assessments are to be developed. These types of plans identify the strengths people have and the common day risk that would be still acceptable for someone to take. Staff need to be confident that people can continue to safely use their skills. It is vital that the level of risk presented to resident’s from continuing an activity would be outweighed by the service users level of skill and the quality of life it would lead too, is recorded. The assessment tool for bedrails is incomplete and the health and safety representative is in the process of redesigning them. Bedrails are also classified as mechanical restraints and appropriate care plans around this type of physical intervention have to be in place. Some of the residents because of the nature of there needs have limitations imposed upon them by the service such as needing someone to accompany them when they leave the building. Staff have started to record limitations in place for individuals. The manager is also aware that should generic limitations be in place because of Pinetree Lodge’s rules this would be recorded in a standard contract. Relatives and some of the residents discussed the care and how staff involved them in planning what they did. Relatives were extremely complimentary about the level of care provided at Pinetree Lodge. Staff worked with people in a discreet and sensitive manner. The staff ensured that they knocked on bedroom doors prior to entering and any personal care task was undertaken in an unobtrusive manner. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15 The employment of an activities co-ordinator would enhance the service offered at Pinetree Lodge. EVIDENCE: It remains very evident that Pinetree Lodge would benefit from the employment of an activity co-ordinator. Throughout the day staff tried very hard to spend time with people but the high dependency needs of people meant that this engagement was sporadic. One of the relatives works as a volunteer and said he assisted staff to clean up, chat to people and made floral displays for the front of the building. Also a person on an employment scheme works at Pinetree Lodge and she is not allowed to complete personal care tasks but does sit and chat to people. Although all are well meaning someone with a range of activity skills would assist people to be engaged in meaningful occupation during the day. Pinetree Lodge is unitised and each unit has a keypad system, which means that people cannot independently walk throughout the building. Also bathrooms, bedrooms and at times toilets are locked throughout the day. Alternative means for monitoring service users has been put in place. This needs to be recorded in the standard contract. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 12 Also the manager has previously stated that service users are unable to have a key to their rooms because they would be unable to use the key due to their mental health condition or people could inadvertently open other people’s doors. Also the locks are universal therefore people do not have individual keys and can open all of the door s if they have a copy of the master key. One person could manage to keep a key but because all of the locks are the same they could inadvertently leave the building. Mental Health Concern intends to change all of the locks during the next refurbishment programme. Where individuals do not retain the capacity to use a key this must be recorded in their service user plan. At present Pinetree Lodge does not have kitchen staff and care staff undertake this task as part of their daily routine. Also a large number of people require one-to-one assistance during the meals or need alternatives to be offered at various times during the day. The current demands on staff will reduce their ability to monitor the overall intake. Staff are consistently needed to prepare additional meals and snacks throughout the day as well as assist people to eat these meals. Staff are very stretched at Pinetree Lodge because the people who live here have very complex needs and are totally reliant on staff. Mental Health Concern is in the process of recruiting staff dedicated kitchen staff for Pinetree Lodge. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints procedure is available and has been proved to work effectively. EVIDENCE: Mental Health Concern developed a complaints procedure, which complies with the requirements of both the national minimum standards and Care Home Regulations 2001. This is reproduced in the service user guide and made available to residents or their representative. The manager recognises the importance of dealing with minor concerns in a proactive manner. Where people have raised concerns she has dealt with these to the satisfaction of all concerned and ensured the actions have been sustained. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Once the refurbishment programme of Pinetree Lodge has been completed the environment will more readily meet the needs of the residents. EVIDENCE: Pinetree Lodge is located within a residential area of Gateshead. It is a purpose built property and is a single storey building. Thus it can meet the needs of someone with a physical disability. The home is decorated and furnished to a satisfactory standard and on the whole is kept well maintained. Plans are in place to complete a full refurbishment of the home. This will include the provision of individual locks for bedrooms and appropriate nurse call alarm systems within all the bedrooms. Currently the available system has the call alarms located up a height so they cannot be easily reached also much of the falls prevention equipment cannot be used because they need to be plugged into a call alarm. Pinetree Lodge has been specifically set up to provide dementia care but environmental adaptations that assist people with memory loss have not been put in place. The manager is very aware of small environmental changes that Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 15 could be made to make the environment more user friendly such as using different colour schemes in different areas s. A number of publications outline how to make units less confusing and stressful for people with dementia-type illnesses. Also the J Rowntree Foundation and Stirling University provide information and guidance about environments plus how poorly planned living areas created challenging behaviour. In order to meet the requirements of the Disability Discrimination Act 1995 reasonable adjustments have to be made to accommodate the needs of people with a disability and this includes dementiatype illnesses. Willowdene under the Care Home Regulations 2001 must be fit for it’s purpose thus when re-decorating using techniques advised in the vast body of research on how to make the environment service user friendly for people with a dementia would ensure it met that requirement. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The recent difficulty in recruiting staff is starting to be resolved but insufficient staff are still in post to guarantee that the needs of residents can be fully meet. The lack of dedicated laundry, kitchen and activities staff compounds the difficulties staff face trying to maintain a good service. The staff team are extremely dedicated and constantly work overtime to meet the needs of people. EVIDENCE: The manager ensures that 2 first level nurses (RMN) and four care staff are on duty and during the night a 1st level nurse (RMN) and three care staff are on duty. The manager works supernumerary. Up until recently two nurses were required to fill vacancies but five care staff vacancies remain. Mental Health Concern have also reviewed the dependency levels of people at the Pinetree Lodge and decided to increase the number of hours provided. People are being actively recruited to these posts. The existing staff have been covering gaps for the last year and were finding that this could not be sustained. Since the nursing staff vacancies have been filled staff did not feel that they were as stressed and can see an end to the recent staffing difficulties. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 17 Domestic staff are employed but not laundry or kitchen staff, as the home set up to follow ordinary life principles so it was expected that care staff would complete the latter two tasks. The service users are extremely dependent on care staff to meet all of their needs. Mental Health Concern are going to employ dedicated kitchen staff and this will allow staff to concentrate more of their time on the needs of residents. Mental Health Concern has completed a baseline assessment of the actual number of hours taken up by staff to complete laundry tasks. Staff feedback that overall when day and night time hours spent on this task were added up about ¾ hours were spent per day on this task. Larger items are sent to a local laundry but staff wash all of the residents clothes. This level of work would fulfil a part-time post and a dedicated laundry person would reduce the number of clothes inadvertently spoilt. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 38 The management and administration of the home ensures the safety and well being of service users. EVIDENCE: The manager is extremely dedicated to meeting the needs of people with a dementia-type illness and actively tries to operate a service that will provide quality for people at the latter stage of this disease. Recently Mental Health Concern presented her with the Tom Carpenter Award for tireless work promoting the values of the organisation and the highest standard of care and practices at Pinetree Lodge. Personal allowances are held at the head quarters and they maintain all of the records. Mental health Concern adopts the policy of not being appointee for individuals and either social service or families undertake this role, which is good practice. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 19 The manager purchases items on behalf of service users from the petty cash and then informs the finance department who make the appropriate adjustments to people’s accounts. Service users or their representatives can have access to the information on these accounts at any time via the organisations intranet. Thus it is the finance department that handles all of the monies and ensures robust procedures are in place. At the last inspection an inspector from the Health and safety executive visited and found that on the whole Pinetree Lodge had a good risk management system in place but he made a number of recommendations. These included increasing the frequency of refresher mandatory training, moving heavy items from high shelves, determining how the prevention of Legionnaire disease measures were complied with, improving risk management for moving and handling and bedrails plus monitoring stress management for staff at Pinetree Lodge. The staff and Mental Health Concern are ensuring that all of his recommendations are complied with and a good number have now been addressed. When reviewing the fire log it was identified that all staff rotate onto night shift and the requirement is that night staff receive three monthly fire drills and instruction. These do not have to be the formal video sessions that staff receive but refresher sessions. The manager has been putting in place systems to ensure this is being completed. Maintenance checks are being made regularly by the home and as planned by contracting engineers. The manager was advised to monitor all outstanding maintenance issues and it was recommended that Mental Health Concern employ a dedicated handy person to complete minor maintenance works. The hot water in bathing areas was running at between 40˚c to 42˚c, which is a little low. However, service users are noted to have bath at 36˚c to 39˚c, which staff said is stated the service users’ wish. It is advised that this should be recorded in the service user plan. The staff training co-ordinator and manager are ensuring all staff receive the outstanding training as a matter of priority. High/low beds have been purchased and the number of bed rails being used is reducing. One person continues to sleep on a mattress on the floor but the staff have considered every alternative and found that none will be as safe as this practice. However they have said that this will continue to be reviewed and if the person’s behaviour changes so alternatives measures can be taken this will be acted upon. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x 3 x x 2 Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Care plans and risk assessments must be in place around how to work with people who are distressed. (required at the last inspection - timescale 12.08.05) Risk-taking assessments must be developed. (required at the last inspection - 12.08.05) Moving and handling risk assessments must be accurate, reflect recognised good practice and be reviewed regularly.(required at the last inspection - 12.08.05) The staff must compile information on all areas of service users lives where are limitations occurs because of their mental or physical health needs. (Requirement made at previous inspections –timescale for action 25.03.05) Activities co-ordinators must be employed to ensure personcentred approaches are used so culturally and individually appropriate activities are provided in the home. Staff must demonstrate that Timescale for action 12. 07.06 2. 7 12 (2) 17 (1) (a) Schedule 3 (3) (q) 12.07.06 3. 12 16 (2) (n) 2.12.05 4. 14 23 (2) (j) 3.11.05 Page 22 Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 5. 22 13 (4) (a) and (b) 6. 24 12 (2) 7. 30 38 18 (1) (c) 23 (4) (c) (v) service users choose to have baths at temperatures markedly below the recommended 43°c. The alarm call cord system must 25.08.06 be replaced during the planned redecoration and alternative means for summoning assistance must be in place in the interim. (Requirement made at previous inspections -timescale 25.08.06) The alarm call cord system must 25.08.06 be replaced during the planned redecoration and alternative means for summoning assistance must be in place in the interim. (Requirement made at previous inspections - timescale 25.08.06) Refresher mandatory training 3.11.05 must be completed in the required timescales. (required at the last inspection -timescale 12.08.05) All staff must have the appropriate number of fire drills per year and this must be recorded in the fire logbook. (required at the last inspection timescale 17.06.05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 27 38 Good Practice Recommendations The owners should consider employing dedicated laundry staff. (Recommended at the previous inspection.) Mental Health Concern should employ a dedicated handy person. Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pinetree Lodge Nursing Home B52 B02 S18176 Pinetree Lodge V219565 280705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!