Inspection on 18/01/08 for Pinetree Place

This inspection was carried out on 18th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinetree Place 05/02/07

Pinetree Place 20/02/06

Pinetree Place 09/08/05

Pinetree Place 01/03/05

Pinetree Place 13/10/04

Pinetree Place 23/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Pinetree Place 36a-d Ashingdon Road Rochford Essex SS4 1NJ Lead Inspector Sarah Hannington Unannounced Inspection 18th January 2008 09:00 Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 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 Pinetree Place DS0000015556.V357667.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 Adults 18-65. 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 Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinetree Place Address 36a-d Ashingdon Road Rochford Essex SS4 1NJ 01702 540135 01702 543777 john.wyatt@estuary.co.uk 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) Estuary Housing Association Limited John Bruce Wyatt Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Excluding any person who is liable to be detained under the provision of the Mental Health Act 1983 5th February 2007 Date of last inspection Brief Description of the Service: Pinetree Place is a Care Home providing personal care for twelve residents with Learning Disabilities. The cost of care at this home is £1,724.96. per week. It is situated near to Rochford town centre, local shops and amenities. There are local bus and train routes nearby. Pinetree Place is divided into four houses, referred to as House A, B, C and D, with D also known as the bungalow, being on one level. There are three residents in each house. Two offices are situated in another building, which was used previously as a day centre. Each resident has a single bedroom with a shared lounge, bathroom, toilet and kitchen facilities. Each house has their own garden with a security gate. A car park is situated between houses A, B, C and the bungalow and offices. Pinetree Place DS0000015556.V357667.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 2 Star. This means the people who use this service experience good quality outcomes. The site visit inspection focused on the entire key standards and any requirements and recommendations from the last key inspection. The inspection took 8 hours to complete. Three of the team leaders were present throughout the inspection. Due to the communication needs of the residents living at the home the CSCI (Commission for Social Care Inspection) felt that it was not possible to use surveys for feedback. However it was possible during the site visit to speak to many of the residents living at the home. Additionally the manager was sent a (AQAA) Annual Quality Assurance Assessment form by CSCI prior to the inspection, that asked how well the home is meeting the needs of the people who live at Pinetree Place. We also looked at what else we already know about the home and compared it with what the manager had said in the information provided on the AQAA. Information collated from the AQAA and discussions during the site inspection are reflected within this report. What the service does well: What has improved since the last inspection? The manager and organisation have made every effort to include residents in decision-making and to seek their ideas by setting up new consultation tools. One being the ‘Quality Network System’, this is where residents can suggest new ideas, say how they feel or put in requests about varied subjects. Additionally all residents have had a recent 1-1 interview process, this was to enable the manager to gauge their views about the staff who work with them and the overall service they receive. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 6 A new service users guide in the form of a DVD has been produced and the staff are continuing to develop documentation in different forms of communication that will meet the residents’ needs. One of the houses has been completely redecorated with new furniture and practical homely materials and a new kitchen has been purchased and put into place. 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. The summary of this inspection report can be made available in other formats on request. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process means that the staff team in the home can meet all residents’ needs. EVIDENCE: The manager is good at involving residents in making an informed choice about the home in which they may wish to live. Since the last inspection the manager and provider have been innovative in developing a DVD, which gives clear information about what services are provided and gives a tour of the home. If an indivdual wishes to view the home then a number of visits can be arranged. This will and may include meeting the staff and residents on an informal basis, having dinner, spending a day or evening at the home, an overnight stay and maybe a weekend stay. Additionally there is a service users guide and statement of purpose available. To further back this up four residents’ individual files evidenced that all pre-assessments, care plans and consultation had gone ahead previous to any placement being agreed. The manager states on his AQAA that, ‘The Prospective resident is invited for a look round the Unit. The resident has a meet & greet with the Staff and other resident (s) already living in the property.If all is well then they are invited for an overnight stay. If that is successful then the prospective resident is invited Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 9 for a weekend Stay which if succesful in their eyes then is followed up by a week’s trial stay followed by a multiprofessional review to ensure that all parties are happy, then the placement would be confirmed.’ The majority of relatives expressed an opinion that they had received enough information from the home prior to being offered a placement. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Consultation is in place for the majority of residents and good care planning means that residents have their care needs met in full. However this needs further development by establishing a consistent approach for all residents. EVIDENCE: Care plans use a mixture of, symbols, pictorial aides and photographs. Overall the residents, relatives and advocates are involved in the care planning process and all care plans included residents’ signatures and dates. Looking at individuals’ risk assessments it is apparent that the manager has a good assessments procedure in place. This process explores why some risk taking is a positive thing, as well as being balanced enough to prevent highrisk situations developing. Additionally including infringements of rights documentation to evidence why it is necessary to restrict and individual’s rights could be implemented and evidence that risks have been discussed with individuals. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 11 Care plans have been based on person centred planning. Care plans included individuals, goals, wishes, needs, likes and dislikes. In some pieces of documentation, regular updates need to be implemented, such as the reviewing of risk assessments, new current care plans being added when necessary. Generally some care plans needed to be more reflective of a person’s changing needs, for example, making it clear what the goals are, have been and what they are now, what has been or what is to be achieved and recording the final results or outcomes. In one care plan inspected there was a shortfall in reflecting the ongoing changing needs. This individual’s care plan, the guidance given to staff and the present risk assessments did not reflect the current changes. There was no written evidence of consultation, over the present or future plans that needed to be in place. Therefore shortfalls and an inconsistent approach for this individual meant that their needs were not fully supported. Residents spoken with did inform us that they knew about their care plans, had regular access to them or held them in their bedrooms. A number of residents had additional documentation implemented to support them to understand what support had been agreed upon, such as rotas of daily events and calendars. In general when speaking with staff, they demonstrated that they knew well the needs of the individual and understood the need and importance for residents to be involved. Staff spoken with acknowledged that care plans in general could be developed further and that all documentation for all individuals needed to be consistent in approach. The manager states on his AQAA that, ‘We produce a Service User plan to identify how needs will be met and any changes required will be dealt with. Behavioural Aggression problems wil be approached through the thirteen step risk Assesssment Plan and any actions required to be taken will be in line with agreement reached with the Service User whilst formulating the Plan at a Multiprofessional meeting and by Staff members trained in the PRT ??? Techniques. We support the Services Users in Making their own choices by Pictorialising as far as possible and by assessment with the Service User. The right to make choices is now further enhanced by Mental Capavcity Act. We will now be incorporating Mental Capavcity Act assessments into the Service Users Careplans. Any potential restrictions on choice or freedom will be discussed with the service User at a multi professional meeting.’ The majority of relatives expressed an opinion that they were involved in the care planning process. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides opportunities for residents to explore and receive activities that are suited to their needs and wishes. Regular nutritious meals are being provided and are reflective of indivdual choice. EVIDENCE: There is a wide range of recreational and educational activities offered to the residents at Pinetree Place. All residents are engaged every day of the week, in acessing day services, college, in house activities or supported by staff to use their local community. This gives residents the chance to mix with their own peer group and to form and maintain friendships. Each individual has daily notes in which routines, leisure and day service are recorded. Each individual has a pictorial plan of these that they keep. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 13 The manager provides transport for residents, this includes a car and people carrier. Additionally one wheel chair user has their own mobility car which is specifically designed for the use of wheelchairs and staff use this to enable them to access a fair and equal amount of activities and other pursuits. Residents have regular monthly meetings. The minutes of these meetings are currently in the written form only and could be developed into a format, such as pictorial or photographs, to enable the indivdual to have a better understanding of what had been discussed. Additional meetings area arranged with an advocate, who can represent the resident’s views and put forward any issues they may have to the manager and staff team. Relatives and friends are encouarged to have contact with the home and there are no restrictions on visiting times. Residents who may not have family or friends as a support, are encourage to have an advocate or for them to have both options put into place, so that they have a good range of people to represent and support them. The manager states on his AQAA that, ‘With the help of Batias Advocacy Staff we have set up a self Advocacy group comprising of those Residents who reside at Pinetree Place and the Service users from the surrounding Community. They meet weekly in the Local Community College in Rochford and they discuss with the Advocate all the issues they wish to discuss. One of last weeks discussions was on personal relationships - Boyfriends & Girlfriends. Also present at this group is the Peoples Parliament Representative who was elected to the post following Elections last year where we helped by running an Election Booth at Pinetree Place to enable local Service Users to take part in the Peoples Parliament Election Campaign.’ The majority of relatives expressed an opinion that there were no restrictions on visiting their relatives at Pinetree Place. The residents at Pinetree Place are encouraged to be involved in the daily running of the home. A resident spoken with stated that they liked to do gardening and that in the summer months this took place. Speaking with staff it was apparent that individual residents partake in a number of daily tasks such as preparing the evening meal, cooking and shopping for foods. However this is largely dependent on each individual’s abilities and skills. Staff evidenced that they do try to encourage individuals not only to maintain but also learn new skills. Menus looked at are varied, nutritious, and healthy. Residents’ spoken with said that meals reflected their choices and that they enjoyed the food provided. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s care documentation overall provided good information to enable consistent care to be provided and the residents’ are safeguarded by relevant risk assessments. EVIDENCE: Overall the manager and team evidenced that they work well in partnership with other professionals. Assessments and recommendations carried out by the local health care team are taken on board and forms part of the individuals’ care package. Five of the six care packages inspected evidenced that they were up-to-date and relevant to that individual. Information in general was to a good standard, a few files needed the risk assessments and care plans to have current dates and staff signatures in place, to evidence that they had been reviewed on a regular basis and updated. Overall information around the details in the care plans, risk assessments, consultation, daily notes and relevant general information is to a good standard. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 15 Out of six care files, one inspected lacked the relevant key information; it was not concise or well organised. There was a difficulty in being able to crossreference different pieces of information. A multi-disciplinary team is in place to provide support to this individual, but it was unclear what actions are to be taken and by whom. The care plan and risk assessments did not reflect current changes in this individuals health. There was a lack of updated guidance or protocols for staff and lack of information around any management strategies. Additionally shortfalls in the updating of the basic information provided made it look that the support and care was poorly planned out and did not reflect the current health needs of this individual. The manager states on his AQAA that, ‘We are currently working on a Healthcare Information Folder for the Clients to take with them to the Gps or Hospital visits, or any Professional practitioner appointments. These will contain all the Clients past medical history, the Clients like and dislikes, how to communicate with the Service User and the particular behaviours of the Service User and how to manage them.’ ‘We have reviewed our evidencing of specialist visits Hospital visits, Follow up appointments etc. and instructed the Staff to ensure that they write and file the approprite evidence in the Healthcare File section of the Care Plan.’ The medication administration systems in the home were inspected. Mar sheets in general are pre-printed and those that were hand written contained two signatures as required. No omissions were present on MAR sheets and medication in general was kept in accordance with required legislation. Staff who administer medication have received training. Staff discussion around medication and individual need showed that they knew individual need well and were competent around the medication policy and procedures. The manager states on his AQAA that, ‘The Team leaders/ Senior Care Staff seek information from our local pharmacist who supplies the medications prescribed for the residents in the Home in line with the medicine policies. The majority of relatives expressed an opinion that they are informed of any important issues and involved in the health care of their relatives. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good management of complaints evidences that residents and relatives receive satisfactory outcomes to any issues raised. Staff training in safeguarding of vulnerable adults maintains individuals safety and protects all residents. EVIDENCE: The complaints procedure is displayed in each of the houses in a pictorial format. On the last key Inspection the dedicated complaints folder was inspected and complaints are dealt with effectively. On this key inspection discussion with staff regarding concerns and complaints evidenced that issues are dealt with appropriately and within the/inserted times scales expected. The manager is robust in involving the safeguarding team if need be and staff spoken with evidenced that they were clear around these procedures. All staff has been trained in safeguarding and this/inserted forms part of the induction process for newly appointed staff. The manager states on his AQAA that, ‘Estuary has a complaints policy and procedure document present in every House in the Policies and Procedures File. We also have a simplified Pictorialised version wall mounted in every House and in the Admin Block for the Residents to see. This Pictorialised Document is explained to Residents in their House meetings.The Residents complaints/issues are discussed at House Meeting as documented by the Minutes of these Meetings. Also the Residents have their Self Advocacy meetings where they can discuss their issues with the Advocate and she would Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 17 then feedback to us. There is an official reply to any complaints within 28 days.’ The majority of relatives expressed an opinion that they knew who to make a complaint to and felt that it would be dealt with appropriately. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager provides a safe and clean environment for the residents of Pinetree Place. EVIDENCE: Pinetree Place has a high number of residents who have complex needs and as a result they need specialised materials to be in place. This is to enable them to maintain acceptable safety levels. In one residents bedroom there are highimpact metals rails in place. These need replacing, as some of the metal has become rough and may catch the resident if they were to touch them forcibly. In three of the house’s Kitchen surfaces and kitchen unit doors need replacing. Kitchen work surfaces need to be of impermeable materials so that they stop the spread of infection and are easily cleanable. Many of the communal areas in three of the houses need replacement of furniture, flooring, redecoration of wall and paintwork both communally and in some residents’ bedrooms. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 19 Additionally fencing in the garden of the bungalow needs replacing or repairing. In the bungalow, the staff at the home need to ensure that where required occupational therapy assessments are carried out in order for residents to use the facilities in the home with minimal risk. This is related specifically to the toilet facilities. Each home inspected, is odour free, clean and the staff are making every effect to make each place homely, as well as practical and safe to meet the needs of the individual residents’. One houses displayed artwork produced by the residents’ and in general all the houses are gradually being personalised with furnishings that are homely. Management are proactive in listening to individuals around improvements to the environment. Bedrooms are personalised and individuals have chosen colours and materials. In one of the houses they have installed a specialised bath for one individual with mobility issues. Maintenance and checks on specialised equipment is to a good standard. In another of the houses, the whole kitchen has been replaced and communal areas have been redecorated. Additionally new modern flooring and carpets are in place, new furniture has been purchased, including dining room chairs, a dining table, plus communal areas and individuals rooms have been redecorated in the colours they have chosen. The manager states on his AQAA that, ‘The Residents live in a homely, clean, comfortable and safe environment with their bedrooms decorated to match their own personal tastes and interest. the shared lounge /Dining rooms in each house are decorated in line with the genders of people living in the House. The Residents at House meetings actively take part in the choice of planned changes to the Décor.The ground floor accommodation in the bungalow is wheelchair adapted for our current resident who is wheelchair dependent.The Houses blend in with local community and thus we are indistinguishable from any other property in this road.’ Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill is able to meet the needs of residents. Recruitment procedures good and that protects the health, safety and welfare of the residents’. EVIDENCE: Staff spoken with during the inspection showed that the staff team in place are competent and know the residents’ needs well. Staff rotas’ looked at established that the home was covered by a good number of staff on duty at any one time. There are some staffing vacancies, which are in the process of being recruited to. However these are covered by long term use of agency staff that residents know and work with well. Interaction observed between staff and residents was good. Staff training and induction in general is to a good standard and covers the core areas expected. NVQ training is encouraged and given priority. The manager states on his AQAA that, ‘The vast majority of EHA Care Staff either have or are working towards NVQ 2/3.The four Team leaders are currently completing their NVQ4 in social care.’ Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 21 Staff files were reviewed and recruitment records evidenced that application forms were completed, interviews were held, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. The manager states on his AQAA that, ‘All EHA recruitment is through a procedure based on equal opputunites and ensuring the protection of service users. All prospective staff are CRB and POVA checked prior to any commencement of duty. Staff have clearly defined Job descriptions and understand both their own and other peoples roles within the organisation. These job descriptions are linked to the to achieving the service users’ individual goals. Key workers have identified areas of training and instruction required to enable them to work with the service users’ Regular supervision and team meetings are in place and covered on relevant current issues,such as, regular duties expected and the standards to which these should be achieved, budgets, inspections, documentation and recording of information, summaries of individual residents and generally discussing the need to improve the outcomes for all residents. It was appreciated by CSCI that the three-team leaders stayed long after duty hours to aide with the site inspection process. This showed that they had gelled well as a team and evidenced that they are professional in their approach when working with other professionals. Additionally, these staff were dedicated in ensuring that the residents that they work with, who have complex needs, had a chance to voice opinions during the site inspection about the staff team and the service that they received. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 41,and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems in general are improving and are starting to ensure that the home is run in the best interests of the residents. EVIDENCE: The four different houses have a team leader each. The team leaders have raised staff awareness by regular supervising and monitoring of individual practice. Additionally regular meetings, training sessions, supervision are now in place. The manager and team leaders have efficiently organised the day to day running of the homes and the outcome is that it benefit the residents. The manager has made progress in ensuring that good practices amongst the staff team are implemented. Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 23 Through discussion with the three-team leaders, they evidenced that a good philosophy of care is present and that good management strategies are being implemented, monitored and improved upon. The manager and team leaders have created a transparent and good ethos throughout’. Team leaders demonstrated that they are good at acknowledging the shortfalls discussed during this inspection, but were able to evidence that they still ensure that the residents are well looked after and safe. The manager states on his AQAA that, ‘There is an annual development plan for the Home. My 4 team Leaders and my self attended a 2 Day workshop on Team Building Skills. Our Line Manager at that time received excellent feedback from the Trainers on how well we were already operating as a Team. Our new level of Management structure has raised the profiles of all 4 Houses who now compete with each other to achieve objectives.This has been noted by our Psychiatric consultant and Registrar who state there is a change of atmosphere to a can do society structure at Pinetree Place. This has been backed up buy other Visiting Health Care Professionals who have noted a change of Ethos in Pinetree Place as a Unit.’ All certificates, policy and procedures are satisfactory. Resident’ ‘finances are available and accounted for. Regular fire checks and monitoring of equipment is now in place. However there are still no regulation 26 visits put into place by the organisation to ensure that quality of service is monitored, this needs to be implemented and for the results of these visits to establish what the outcomes are for the residents’. The manager does ensure that there is a good Quality monitoring system in place, however results of this need to be made available to CSCI, relevant interested parties and in a format the residents can access. The manager states on his AQAA that, ‘‘We have just commenced the next round of Service User interviews with 75 of my Service Users being interviewed today the 19th of October with regards to their likes and dislikes about their Homes and the Care Staff who support them also the choice of venues for next years outings. The remaining 25 were interviewed interviewed on the 21st November regarding their feelings about their Care, The Home, Staff and the Outings they want to be considered for next year.’ Pinetree Place DS0000015556.V357667.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 Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X 2 3 X Pinetree Place DS0000015556.V357667.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 YA6 Regulation Sch 3 (p)(q) Requirement Any restrictions on choice, freedom or being able to be included in health care decisions, (consultation) is clearly recorded onto a format (infringements of rights) to evidence that this is clearly thought out and why it is necessary. To promote and protect residents’ health, risk assessments must clearly detail the preventative care that staff are expected to provide. Care plans must reflect all resident’s current health needs and how they are to be met. Care plans must provide evidence that the home understands what support each person needs, and ensure that staff have clear guidance on how to meet each person’s individual need. This is a repeat requirement timescale 02/04/07 That individual equipment is appropriate for the purpose it is being used for and that it promotes independence as much as possible and protects an DS0000015556.V357667.R01.S.doc Timescale for action 03/03/08 2. YA9 Reg 14 (2)(a)(b) 03/03/08 3. YA19 Reg 17 (3) Reg 15 (2)(b)( c) 03/03/08 4. YA24 Reg 13 (4)(a)(b) (c) (d) 03/03/08 Pinetree Place Version 5.2 Page 26 5. YA24 Reg23 (1) (2)(a)(b) (c)(d) Reg 26 (1) 6. YA41 individual’s dignity and respect. This specifically relates to the toilet facilities. The home needs to be kept in a good state of regular repair. This is a repeat requirement timescale 02/04/07 To ensure that Regulation 26 visits take place and a copy of the resulting documentation is kept on the premises and is made available for inspection. 05/05/08 03/03/08 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 YA24 Good Practice Recommendations Each house needs a clearly laid out maintenance plan. This should outline time scales, furnishings to be purchased and redecoration needed. For a copy to be kept on the premises and is made available for inspection. Quality-monitoring information need to be collated and actions plan with outcomes are kept on the premises and made available for inspection and to all other interested parties. 2. YA39 Pinetree Place DS0000015556.V357667.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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