Inspection on 11/09/07 for Pinetrees

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinetrees 03/10/06

Pinetrees 01/03/06

Pinetrees 21/09/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Pinetrees 36 Kensington Road Selly Park Birmingham B29 7LW Lead Inspector Kerry Coulter Key Unannounced Inspection 11th September 2007 09:00 Pinetrees DS0000064232.V342259.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 Pinetrees DS0000064232.V342259.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. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinetrees Address 36 Kensington Road Selly Park Birmingham B29 7LW 0121 471 4399 0121 472 4639 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) autism. west midlands Mrs Jacqueline Thronicker Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care and accommodation to four persons under 65 with a learning disability. 3rd October 2006 Date of last inspection Brief Description of the Service: Pinetrees was previously registered jointly with another of autism.west midlands homes but separated into a single registration in 2005. The home offers accommodation to 4 people with autism spectrum disorder. The home is situated in a pleasant tree lined road; it has modern internal features and a large rear garden. All bedrooms are single rooms. There is sufficient off road parking for three vehicles. The home is not equipped to provide services for people with physical disabilities. Current fees for living at the home range from £800 to £900 (2005 to 2006) as recorded in the statement of purpose for the home. Visitors to the home can see a copy of CSCI reports, these are located in the entrance hall. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Surveys were received from everyone who lives at the home, two relatives and five staff, their views are included in this report. Three people who live at the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. What the service does well: People spoken with said they were happy living at this home. The staff are friendly and helpful. The staff team is stable, and people are supported by staff they know, and who are familiar with their needs. People are involved in writing their own care plans. People are encouraged to be independent. They clean their own bedrooms, go shopping for food and go out on their own if it is safe for them to do so. Staff ask people what they think about the home and if anything can be done better. People who live a the home have a weekly meeting with staff. People are provided with opportunities to participate in appropriate activities and have a holiday if they want. The staff help people to stay in touch with family and friends. This is in person, by phone and by letter. The commitment of staff to helping people with this is commendable. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 6 People have a choice of meals that are healthy and that they enjoy. Each person has a Health action plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. All the people living at Pinetrees have a single bedroom. These are all very different, and each person’s room contains the things that are important to them. The style of management in the home is relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living there. What has improved since the last inspection? What they could do better: Systems in place to look after people’s monies could be improved so that the risk of money going missing is reduced. Staffing levels need to be reviewed to ensure there are enough staff at the weekends and evenings to support people to do what they want to do. The home is well managed but the Manager often works in her own time to ensure management tasks are completed. It is therefore strongly recommended that a review of the time allocated to the Manager for Management tasks is undertaken. The home should be visited monthly by the representative of the provider and a report made of the visit to ensure the provider is overseeing that the home is being well managed. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 7 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. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 8 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 Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 9 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): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provide prospective service users with relevant information about the home to enable them to make a choice about if they want to live there. Individual’s needs are assessed before they move in and they can visit so they know whether their needs can be met there. EVIDENCE: The Service User Guide and Statement of Purpose were clearly on display in the hallway of the home. These are in a format that is appropriate for people who live at the home to understand. They included most of the relevant and required information so that prospective service users would know what the home provided and could make a decision as to whether or not they would want to live there. Information on fees needs to be updated within the statement of purpose as the fee levels recorded were for 2005 to 2006. No new people have been admitted to the home since the last inspection. Sampled files at previous inspections showed that assessments had been carried out before current people moved into the home. Admission procedures remain unchanged, a pre-admission assessment would be carried out before a person was admitted to the home. There would also be preparation before the person moved in which would include visits to the home. Pinetrees DS0000064232.V342259.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, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have the information they need in care plans and risk assessments so they know how to support people safely to meet their needs and achieve their goals. The people living there are supported to make choices about their dayto-day lives. EVIDENCE: Records sampled included an individual care plan. These stated how staff are to support the individual with their personal care included promoting their independence, communication, behaviour, day activities, leisure and social needs, sexuality, independence, sleep, eating and drinking and their health needs. All plans sampled were up to date. Each person has behaviour management guidelines in place, these have been further improved since the last inspection. The format was very easy to understand and included triggers to behaviours, warning signs and how staff should respond to ensure behaviour is managed consistently and safely. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 11 Person centred planning review meetings are held and people have the opportunity to attend and contribute to the meeting if they want to. At the meeting goals are agreed and a list of action points completed. These were sampled for one person and most of the actions agreed had been completed. Since the last inspection the home has improved how people are involved in care planning. Each person now has their own person centred plan that they have completed themselves, this includes their likes, dislikes and personal preferences so that staff know how to support the person in the way they want. Monthly key worker meetings are held with each person to monitor their well being and discuss any problems the person may have that they need additional support with. Staff were observed empowering people as much as possible to make choices about what they wanted to eat, drink or where they wanted to spend their time. People who live at the home make decisions about their lives and participate in the running of the home. In addition to the person centred planning meetings this is done via weekly ‘peoples meetings’ chaired by someone who lives at the home. One of these meetings took place during the visit, topics discussed were led by people and staff valued everyone’s opinion. One person said he was going to type up the minutes from the meeting. Service user satisfaction questionnaires are also used as a way of getting people’s views. Other ways in which people participate in the running of the home include shopping for food, assisting staff in testing of the fire alarms and assisting in audits of the premises. The Manager said that even though people can read they are currently developing a picture board as people said they would like this format. Records sampled included individual risk assessments. These stated how staff are to support the person to minimise risks such as taking their medication, fire evacuation, accessing the community without staff, domestic tasks and holidays. Where new risks had been identified a new risk assessment had been completed, for example the risk of one person smoking in their bedroom. The majority of risk assessments had been reviewed six monthly and updated where there had been changes to the person’s needs or goals. The Manager was aware that a minority of assessments were overdue a review and planned to do this soon. Pinetrees DS0000064232.V342259.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Excellent arrangements are in place so that people living at the home experience a meaningful lifestyle. People are offered a healthy diet and are encouraged to choose what they want to eat and drink. EVIDENCE: Sampling of records and discussions show that people who live at the home have opportunities to participate in a wide variety of activities. These include opportunities for personal development. One member of staff spoke enthusiastically about the work being done to develop one individuals skills when greeting people. Some people are even learning foreign languages. One person has written his ‘memoirs’ and staff are approaching publishers in an attempt to get them published. Records and observation of practice showed that people are involved in household tasks including washing up, preparing meals, cleaning, setting the table and doing their laundry, with staff support where required. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 13 The Manager stated in the AQAA ‘Wherever possible we access facilities open to the general public and avoid classes which cater for those with special needs’. The home does not have adequate staffing levels most weekends and evenings and it is a credit to the hard work and commitment of staff that they manage to maintain good activity opportunities for people. People have opportunities to attend a variety of activities in the community throughout the week, this includes swimming, drama, shopping, meals out, visits to museums, horse racing and Greek and German lessons. One person continues to undertaken administrative work at the Providers headquarters for which he is paid. Two people went out swimming with staff during the inspection visit, on return they said they had a good time. When at home people spend time watching TV, writing letters, listening to music, sitting in the garden, playing board games, spending time alone in their bedroom and surfing the Internet. Staff support people to embrace their cultural backgrounds for example by learning languages, celebrations such as Easter, Christmas and ‘Name Day’ and having culturally appropriate foods. People have the opportunity to have a holiday if they want to. One person was supported by staff to visit his Mother in Kent and his Brother in Blackpool. He has also been to Greece this year to visit his Father. Two people went on a joint break with staff to Skegness. Staff at the home are very good in supporting service users to maintain and develop relationships with friends and family. As already stated staff have taken one person on short breaks to visit his family. Staff also support people to telephone or write letters. One person has had their 40th birthday and so staff helped them to organise a big party at the home. The person designed and sent out invitations to the party to family and friends. CSCI surveys received from two relatives recorded they were satisfied with the overall care provided, one said ‘staff go out of their way to bring him home for us’, another said ‘happy, successful and lovely place’. Some people who live at the home have had recent family bereavements. Records and discussions show that staff have supported people well during this difficult time. Staff are currently helping people design a memorial garden. Lunch time practice was observed. Staff sat and ate with people, there was a very relaxed atmosphere at the table making it a pleasant social occasion. One person chose not to eat at the table and ate elsewhere. One person who lives at the home commented that the lunch was ‘nice’. People had a choice of different meals, soup and / or sandwiches. The vegetable soup was homemade and was delicious. The Manager said they frequently have homemade vegetable soup as a way of getting people to have more fresh vegetables in Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 14 their diet. Fruit was observed in the dining room and the fridge was well stocked with fresh foods, people were observed helping themselves to what they wanted without having to seek permission from staff. Most of the meals are freshly prepared, staff were later observed cooking a homemade fish pie with fresh vegetable for the evening meal. People who live at the home choose the menu and participate in doing the shopping list for food. Food records show menus are nutritious, fruit is part of the daily diet, for example people often have fruit or fruit juices at breakfast. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 15 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. Arrangements ensure that the personal care and health needs of the people living there are met. The management of the medication protects people and ensures their well-being. EVIDENCE: Care plans sampled detailed how staff are to support individuals with their personal care. People who live at the home were well dressed and their clothes were appropriate to their age, gender and the weather. Discussion with staff and observation of finance records shows that people have their own personal toiletries and are supported to go to the barbers if they want to. A sample inspection of health records indicates that people are receiving routine access to general health services, such as well person’s checks, dentist, eye tests and chiropodist. Referrals are made to other health professionals as required such as the mental health nurse. Each person has a Health action plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The format includes photos and pictures making it an easy to Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 16 understand document. These are excellent documents as they are comprehensive and are written by people themselves- with staff assistance and show people are involved in decisions about their healthcare. Records show that staff assist people to monitor their weight on a monthly basis to ensure they are healthy. One person is currently trying to give up smoking and the Manager has recently accompanied him to smoking clinics to give extra support in his attempts to stop. There is very little medication in use at the home, it good that staff are able to usually manage peoples behaviour by their approach rather than using medication. One person said he was going with staff the following week to have his medication reviewed. Staff have received medication training. Medication is stored in a locked cabinet. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Where people are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. Medication Administration Records (MAR) were signed appropriately. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 17 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. Arrangements are in place to ensure that the views of the people living there are listened to and acted on. Arrangements generally ensure that the people living there are protected from abuse, neglect and self-harm. EVIDENCE: The CSCI has not received any complaints regarding this service in the last twelve months. One person who lives at the home spoken with said that he did not have any complaints but that if he did he would bring them to the attention of staff. Surveys completed by people who live at the home, staff and relatives indicate they are all aware of the complaints procedure. It is good that a comment book has been placed in the hallway, this gives visitors to the home the opportunity to make comments, positive or negative depending on their view. However all comments in the book were observed to be positive about the home. The home has satisfactory policies and procedures for adult protection. Staff have received prevention of abuse training. Autism West Midlands has regular Sexuality and Protection Meetings where current practice issues are discussed and good practice ideas explored. One member of staff is part of this group and feeds back important issues to the staff team. It is impressive that people who live at the home are working with the West Midlands Police (WMP) in training officers in interviewing techniques for vulnerable adults. Their participation not only has benefits for WMP but has Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 18 the additional benefit of the home forging closer links with Vulnerable Persons Police Officers. Sampled staff records show that robust recruitment procedures are followed for the protection of people who live at the home. Two people’s financial records were looked at. These showed that the individual spent their money on personal items that they wished to buy. Monies are often handed directly to the individual and staff sign the records. It would increase the financial safeguards in place if the person signed the record to say they had received the money or two staff signed the record. Discussion with the Manager shows that a check of people’s monies is not done at the staff handover. This should be done so that if money went missing staff would quickly be able to identify on what day this happened and hopefully track what might have happened to it. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 19 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, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure the home is homely, comfortable, safe and clean for the people living there. EVIDENCE: The home is situated close to the Pershore Road and a number of shops, pubs and places of worship. Public transport is within walking distance and it was reported that some service users access public transport as part of their daily routines. The home was clean, warm and free from unpleasant odour. People spoken with said they were happy with their bedrooms. Rooms were personalised and reflected individual’s personalities, gender and culture. Improvements have been made to the kitchen since the last inspection with new drawer fronts and cupboard doors fitted. A new dishwasher has been fitted which has filled a gap that previously looked unsightly. This makes this room look cleaner and nicer than before. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 20 New carpets have been laid on the stairs, hall and landing, the front lounge and also in the back lounge where previously laminate flooring was laid. This has improved the acoustics in the back lounge and helped with noise levels. One bedroom has also had new carpeting covering the area around the wash hand basin therefore removing the institutional feel to the bedroom. The two lounges have recently been repainted and new curtains and blinds have been fitted in all rooms bar one. The AQAA records that one person said he did not want new curtains as he liked the ones he had. A new settee has been purchased for the lounge, this makes the room look more homely. Infection control procedures were satisfactory. Records were available to evidence that food in the fridge is stored at safe temperatures. The home is now using the Environmental Health Safer food better business recording pack, this shows good standards of food safety. CSCI surveys received from people who live at the home record that the home is always fresh and clean. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvement is needed to ensure that staff are supported to do their job so that they can support the people living there to meet their needs and achieve their goals. The recruitment practices protect the people living there. EVIDENCE: Staff were observed to give support with warmth, friendliness, patience and treat people respectfully. Discussion with the Manager and the AQAA indicates that three of the five staff have completed an NVQ, three staff are working towards level 3 and one is working towards level 2. The numbers of staff on duty each day are variable depending on what is planned for that day and if people are staying with relatives. There have been some recent changes in the frequency in which some people spend time with relatives. This has had implications on the staffing levels needed, particularly at weekends. Staff said it had meant people were not always able to go out at weekends unless extra staffing had been planned in advance, or alternatively everyone had to go out as a group. This is also the case at evenings. Surveys from staff and relatives were very positive about the home but staffing was an issue for people. Comments included ‘benefit from more Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 22 staff during the day and weekends’, ‘need more staff’, ‘hard with annual leave and illness’, ‘if bigger staff team could do more 1:1’ and ‘hampered by inadequate staffing resources’. Whilst inadequate staffing levels have had minimal impact on outcomes for people at the home this is only due to the good will and hard work of the Manager and staff at the home and has resulted in them feeling they do not get the support they need from the provider. Staff will often work extra hours or change their shifts so that people can go out. The small staff team is inadequate to cover for people’s annual leave and any sickness. Discussion with the Manager indicates that she has written to funding authorities in an attempt to get more funds for staffing and is awaiting their response. There have been no new staff recruited since the last inspection. Two staff records were looked at. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been done before the person started working there to ensure they are ‘suitable’ to work with the people living there. Staff get the training they need. Staff said that ‘training is relevant’ and ‘in house (training) is very good’. Training records showed that staff had done training in fire, autism, food hygiene, first aid, adult protection, lone working, manual handling and Studio III (physical intervention). The AQAA completed by the Manager records that it is proposed to run training on the Mental Capacity Act and Infection Control in the near future. Staff records did not show that staff had regular formal, recorded supervision sessions with their line manager. Staff should have at least six supervisions every year to ensure they know how to support the people living there, their performance is monitored and their training needs are identified. The Manager said that in addition to the supervision records available she also did a lot of informal supervision with staff that she often did not get time to record. Records did show that staff had an annual appraisal where areas of personal development were identified and objectives were set for the forthcoming year. These objectives now need to be monitored through regular supervision. Discussion with the Manager indicates that she does not have any formal supervision with her line manager but does have mentoring sessions from another home manager. It is recommended a system of supervision with a line manager is introduced to ensure the Manager gets the right support she needs to do her job. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well run home. The people living there can be confident that their views underpin all self-monitoring, review and development by the home. Generally the health, safety and welfare of the people living there is promoted and protected. EVIDENCE: The style of management in the home is relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living there. The Manager has a significant amount of experience in care and has completed the Registered Managers Award as well as having a NVQ 4 care qualification. The home is well managed but the Manager often works in her own time to ensure management tasks are completed. The Manager generally works day shifts and tries to be extra to the staff on duty so that she can carry out management tasks but on the day of the inspection was part of the shift due to staff sickness at short notice. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 24 As identified at the last inspection the home is well run but through the good will of the Manager in working extra hours. It is therefore strongly recommended that a review of the time allocated to the Manager for Management tasks is undertaken, consideration could be given to providing management support via the appointment of a Deputy or Senior staff to share the burden of some management tasks. This was recommended at the last inspection and it is very disappointing that appropriate support systems are still not in place. One staff commented ‘if it wasn’t for the managers organisation, flexibility and hard work I would have looked for another job’. It is the responsibility of the organisation to ensure that their representative visits the home on a monthly basis to ensure it is being well managed. Reports available in the home show this is not being done on a monthly basis. The current system relies on home managers visiting other homes to do the visits, this impacts on the time they have to manage their own homes. Discussion with the Manager indicates that the Provider has recently appointed a new senior manager, this is a new role within the organisation. It is recommended that part of this role should include the responsibility for visiting the home monthly and also to undertake supervision with the home manager. Systems are in place to seek the views of people living at the home at people’s meetings, key worker meetings, reviews and quality assurance questionnaires. Quality assurance forms are also freely available in the hallway for visitors to complete if they want to. A sample of recently completed surveys included comments such as ‘staff helpful’, ‘cannot speak highly enough of the quality of life at pinetrees’. Fire records showed that an engineer regularly services the fire equipment. Staff test the fire alarms and emergency lights regularly to make sure they are working. Regular fire drills are held with people who live at the home and staff so that they all know what to do if there is a fire. The West Midlands Fire service visited the home in October 2006 and said that the fire precautions were satisfactory. A Corgi registered engineer has completed the annual test of gas equipment to make sure it is safe Staff test the fridge and freezer temperatures daily to ensure food is stored safely and reduce the risk of people having food poisoning. A specialist water company has a contract to regularly monitor the water to ensure it is safe but at the last inspection the records of water temperatures were quite difficult to track due to the technical contents of the report. These have now been amended and clearly show the tap temperatures. Records showed that water temperatures were safe and protect people from the risk of scalding. Often staff work alone in the home. The Manager has completed a risk assessment for this practice to ensure it is safe for both staff and service Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 25 users. Additionally several staff have attended lone working training, provided by the Susie Lamplugh Trust. Since the last inspection the Manager has introduced a new building safety audit, this is done weekly by someone who lives at the home with the support of a member of staff. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 2 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 3 2 X X 3 X Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 27 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 YA33 Regulation 18(1)(a) Requirement Review staffing arrangements at the weekends and evenings to ensure adequate numbers of staff are on duty to meet the needs of people at the home. Previous requirement from 30/11/06. Timescale for action 30/11/07 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 YA1 Good Practice Recommendations The Service User Guide and Statement of Purpose need to be updated with the current fee information for the home so that people have all the information they need about the home. Risk assessments should be reviewed six monthly to ensure the information is up to date and people are not at unnecessary risk of accidents or injuries. Improve the financial safeguards in place for people’s monies so that the risk of money going missing is reduced. Increase the frequency of formal supervision for staff to ensure they know how to support the people living there, DS0000064232.V342259.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA9 YA23 YA36 Pinetrees 5. YA37 6. YA39 their performance is monitored and their training needs are identified. It is strongly recommended that a review of the time allocated to the Manager for Management tasks is undertaken, consideration could be given to providing management support via the appointment of a Deputy or Senior staff to share the burden of some management tasks. The home should be visited monthly by the representative of the provider and a report made of the visit to ensure the provider is overseeing that the home is being well managed. Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pinetrees DS0000064232.V342259.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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