Inspection on 03/10/06 for Pinetrees

This inspection was carried out on 3rd October 2006.

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. 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

Pinetrees 11/09/07

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 Unannounced Inspection 3rd October 2006 10:00 Pinetrees DS0000064232.V315091.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.V315091.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.V315091.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.V315091.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. 1st March 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. This is Pinetrees third inspection since separation. 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 £940 to £1030, items such as toiletries and taxi fares are extra. Visitors to the home can see a copy of CSCI reports, these are located in the entrance hall. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a completed pre – inspection questionnaire. One inspector carried out the unannounced fieldwork visit over seven and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. The staff on duty and the Manager were spoken to. The inspector met with all of the service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. Following the fieldwork visit CSCI surveys were received from four service users and four relatives. What the service does well: Service users 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. Individual care plans included input from the service user about their personal goals. Service users 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 service users what they think about the home and if anything can be done better. Service users are provided with opportunities to participate in appropriate activities. 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. Service users have a choice of meals. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 6 Each service user 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 persons room contains the things that are important to them. Autism. westmidlands has regular Sexuality and Protection Meetings where current practice issues are discussed and good practice ideas explored. 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: Care plans need to be reviewed and evaluated appropriately. However it is recognised that this is work in progress. The flooring in the second lounge requires attention so that this room is a pleasant area for service users to use. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 7 Staffing levels need to be reviewed to ensure there are enough staff at the weekends to support service users 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. Quality assurance systems need further development to ensure service users views underpin the development of the home. Some areas of health and safety need improvement to ensure the safety of service users. 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. Pinetrees DS0000064232.V315091.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.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The 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. Satisfactory assessment and admission procedures are in place. EVIDENCE: The Service User Guide and Statement of Purpose have been updated since the last inspection to reflect recent staff changes. The Manager needs to ensure these documents are dated so that the reader can see the documents are current. Copies of these documents are available in the hallway and people who live at the home have a copy of the guide. No new service users have been admitted to the home since the last inspection. Sampled files showed that assessments had been carried out before current service users moved into the home. The assessment covers areas of independent living skills, personal care skills and social and personal relationships. The Manager was able to talk through the assessment and admission process. An admission policy is available but this was not sampled. CSCI surveys received from all four service users record they were consulted about moving to the home and received enough information. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 10 Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so that they know how to support service users to meet their individual needs and goals, but information is not always up to date. Service users are supported to make decisions about their day-to-day lives and are consulted on all aspects of life in the home. Service users are supported to take risks within a risk assessment framework. EVIDENCE: Two service user care records were sampled. Care plans detailed how staff should support the individual and covered all necessary areas to include religious and cultural needs. One care plan had been recently reviewed but the other one was overdue for review. Person centred planning review meetings are held and service users have the opportunity to attend and contribute to the meeting if they want to. A new system of recording the agreed goals from these meetings has been Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 12 introduced, this indicates who is responsible for ensuring the goals are met and by when. Where needed, behaviour management guidelines were available for service users. One sampled was quite basic in content but a second was in a much more detailed format that was also very easy to understand. The Manager said this was a new format that was intended to be completed for all future guidelines. As at the last inspection, one file was in need of a general “tidy up”: material that is old or has been superseded should be removed and disposed of, or archived, as appropriate. Service users 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 a service user. One of these meetings took place during the visit, topics discussed were led by service users and staff valued everyone’s opinion. One service user said he was going to type up the minutes from the meeting. Service user satisfaction questionnaires have also been introduced as a way of getting service user views. Other ways in which service users participate in the running of the home include shopping for food, participating in staff recruitment and assisting staff in testing of the fire alarms. Records sampled included individual risk assessments. They detailed what action staff are to take to minimise the risks to service users of going out alone, medication and self- medication, cutting own toe nails, fire evacuation, use of sharp knives, riding bikes and trips and holidays. Risk assessments are regularly reviewed and agreed with the individual and updated if there are any changes. It was difficult to see at a glance what risk assessments each individual had as there was not an index of assessments in place. To speed up the process of location assessments it is recommended an index is completed. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The 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. EVIDENCE: Sampling of records and discussion with service users show that service users 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 service users are even learning foreign languages. Service users have opportunities to attend a variety of activities in the community, this includes swimming, drama and Greek lessons. One service user said he is learning German, which he enjoyed. Activities that service users wanted to do were discussed at the weekly ‘people’s meeting’, plans were Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 14 made for Halloween and Bonfire Night celebrations, social clubs and a trip to grey hound racing. One service user continues to undertaken administrative work at the Providers headquarters for which he is paid. Records and observation of practice showed that service users are involved in household tasks including washing up, preparing meals, cleaning, setting the table and doing their laundry, with staff support where required. When at home service users spend time watching TV, writing letters, listening to music, sitting in the garden, spending time alone in their bedroom and surfing the Internet. Staff at the home are very good in supporting service users to maintain and develop relationships with friends and family. The Manager said that a summer barbecue had been held, friends, relatives and neighbours had been invited. Some service users visit members of their family at their home, occasionally staying overnight. The home is commended for the work it has done in helping service users visit family away from the West Midlands in Kent and Blackpool. Staff have taken one individual to visit a relative who was ill in hospital. The Manager also helped in the birthday arrangements for one service users relative who was 100, undertaking the catering for the event. Staff also support service users to telephone or write letters. CSCI surveys received from four relatives recorded they were more than satisfied with the overall care provided, one described it as ‘an excellent home’. Lunch time practice was observed. Service users had a choice of different meals eg soup, sandwiches or beans on toast. One service user chose to eat in the garden, another in the lounge. One service user cooked his own meal. Staff ate with service users and there was friendly chat at the dining table. Service users and staff spoken with confirmed choice of food was available. Minutes of ‘peoples meetings’ show menu’s are discussed. Food records show a nutritious and varied diet. Fruit was observed on the dining table to include a variety of apples, bananas, pears, grapes and oranges. Service users were observed helping themselves to what they wanted without having to seek permission from staff. Pinetrees DS0000064232.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The 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 service users receive personal support in the way they prefer and require and their health needs are met. The arrangements for the management of the medication protect the service users. EVIDENCE: Care plans sampled detailed how staff are to support individuals with their personal care. Service users were well dressed and their clothes were appropriate to their age, gender and the weather. A sample inspection of service users’ health records indicates that service users 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. For example, one individual has had a recent review of his health needs with the Asthma Nurse. Each service user 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 understand document. It is good that they are written by service users themselves- with staff assistance. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 16 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 service users are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. Each service user is assessed as to whether they are able to administer their own medication. Where it is assessed as being safe for the individual to do this staff support them as much as necessary until they are sure that they can do it without support. Medication Administration Records (MAR) were signed appropriately. Pinetrees DS0000064232.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints ensure that service users views are listened to and acted on. Arrangements for protecting service users from abuse are very good. EVIDENCE: The CSCI has not received any complaints regarding this service in the last twelve months. One service user spoken with said the he did not have any complaints but that if he did he would bring them to the attention of staff. Records showed that service users are asked if they are unhappy about anything or have any concerns. CSCI surveys received from all four service users record they are aware of the complaints procedure. It is good that a new comment book has been placed in the hallway, this gives visitors to the home the opportunity to make comments about the home, positive or negative depending on their view. All surveys returned by relatives recorded that they were aware of the home’s complain procedure. One relative commented that they had made a complaint once and it had been dealt with immediately. 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. The Manager of Pinetrees is part of this group. It is impressive that service users are working with the West Midlands Police (WMP) in training officers in interviewing techniques for vulnerable Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 18 adults. The participation of the service users not only has benefits for WMP but has 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 service users. Two of the service user’s financial records were looked at. These showed that the individual spent their money on personal items that they wished to buy. Receipts were available for expenditure. One service user said that his keyworker was going to help him update his inventory of personal belongings that afternoon. This shows that staff at the home assist individuals in looking after their possessions and have a system to monitor if anything goes missing. Pinetrees DS0000064232.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The condition of the decoration and furnishings generally enables service users to live in a homely and comfortable environment. 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. Service users spoken with said they were happy with their bedrooms. Rooms were personalised and reflected individual’s personalities, gender and culture. The kitchen is quite worn in appearance and the Provider will need to consider allocating funding to replace or refurbish the units in the near future. As required at the last inspection the kitchen has been repainted, this makes this room look cleaner and nicer than before. The kitchen had areas that required Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 20 attention where the washing machine and dryer had been removed leaving an unsightly gap in the units. The Manager said this gap would soon be filled as a new dishwasher was on order. Since the last inspection the hallway and landing have been repainted, this makes these areas look nice but it is unfortunate that some small areas of carpet have been marked with gloss paint. The Manager said it was hoped that some new carpets would be obtained for the home. The home benefits from having two lounges. The back lounge is used more as an activity area. The laminate flooring in this room requires attention as many of the boards have chips. This makes this room look quite worn. Infection control procedures were satisfactory. Records were available to evidence that food in the fridge is stored at safe temperatures. This ensures infection control and reduces the risk of services users getting food poisoning. Liquid soap and paper towels were available for staff and service users to hygienically wash and dry their hands. CSCI surveys received from all four service users record that the home is always fresh and clean. Pinetrees DS0000064232.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally sufficient arrangements are in place to ensure that service users benefit from a staff team that is competent, qualified and well supported to meet their individual needs but recent events have impacted on the staffing levels needed at weekends. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. Discussion with the Manager indicates that 50 of staff have not yet completed an NVQ. However progress towards meeting this standard is being made with two staff being close to completing their NVQ, this will then bring the percentage of staff with an NVQ to 66 . The home benefits from having a core group of permanent staff but in recent months the home has had some staff vacancies which have meant some use of agency staff to cover the deficits. Discussion with the Manager and observation of the rota shows that the same agency staff was used so that consistency of care to service users was maintained as far as possible. Discussion with the Manager and observation of the rota shows that new staff have now been Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 22 recruited to the vacant posts. It is good that the staff recruited have transferred from other autism.westmidlands homes, this means that these staff are already experienced in working with individuals who have autism. One of the new staff knows the service users well, having worked at the home previously. Staffing levels at the time of the inspection were satisfactory to meet service user needs. The numbers of staff on duty each day are variable depending on what is planned for that day and if service users are staying with relatives. There have been some recent changes in the frequency in which some service users spend time with relatives. This has had implications on the staffing levels needed. Staff said it had meant service users were not always able to go out on a Saturday, or alternatively everyone had to go out as a group. The Manager and staff said that due to this change staffing levels had now increased on a Saturday with an extra staff being provided from 10am to 2pm. Examination of the rota shows that the extra staffing levels are being provided most Saturdays but not all. It was also unclear what would happen if an individual wished to go out after 2pm when the staffing level dropped. Two staff records were sampled. These included all the required recruitment checks had been completed to ensure that staff are suitable to work with the service users. The Manager had also obtained evidence that the agency member of staff used had a satisfactory Criminal Record Bureau check undertaken. Records sampled and discussion with staff show that staff had done mandatory training to include adult protection, Studio III, health and safety, first aid, ‘Safe Handling of Medicines’ and food hygiene. Staff spoken with were happy with the training on offer. One staff said they had recently completed lone working and supervision and appraisal training. One new staff confirmed they had commenced an induction to the home. Staff spoken with confirmed they received very regular formal supervision, staff also said that the Manager was available for informal chats at any time. One new staff said that they had felt very supported since working at the home. Pinetrees DS0000064232.V315091.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager has ensured that service users’ benefit from a well run home. Arrangements are in place to seek the views of service users but quality assurance systems need development. The health, safety and welfare of service users’ is generally promoted and protected with minor improvements required. 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. On the day of this visit, despite it being her day off the Manager was at the home to induct a new member of staff. Discussion with the Manager shows other tasks done in her Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 24 own time include taking work home to complete such as staff supervision records. 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. 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. The visitors book shows that these visits are happening monthly but there were no reports of these visits in the home since February. To fully fulfil their purpose the Manager must have a copy of these reports so that she has a clear record of any actions she needs to complete as a result of the visit. It was identified at the last inspection that the home does not have a full quality assurance system. Since the last inspection the Manager has developed some service user and visitors comment cards, these were observed to be in use. Fire records showed that an engineer regularly services the fire equipment. Staff test the fire alarms regularly to make sure it is working but attention is needed to the frequency of testing of the emergency lighting. Regular fire drills are held with service users and staff so that they all know what to do if there is a fire. A Corgi registered engineer has completed the annual test of gas equipment to make sure it is safe. 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 users. Additionally several staff have attended lone working training, provided by the Susie Lamplugh Trust. An external company have recently completed a health and safety audit of the home, the report had been received by the Manager on the day of the inspection visit. Scores had been given to areas, this Emergency procedures 100 , Fire 96.8 , Risk Assessment 27.8 , Training 71.4 , Welfare 100 , Equipment 100 , Manual Handling 100 , Food 100 . Sampling of risk assessments evidenced that the Manager had already taken action to ensure environmental risk assessments were satisfactory. A specialist water company has a contract to regularly monitor the water to ensure it is safe but records of water temperatures were quite difficult to track due to the technical contents of the report. It is recommended that the recording system is reviewed to enable the reader to clearly see that temperatures are maintained around 43°C and are protecting service users from the risk of scalding. Hand testing of the water at the visit showed that it was at a safe temperature for service users. Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 25 Pinetrees DS0000064232.V315091.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 CONCERNS AND COMPLAINTS 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 Standard No 22 23 Score 3 4 2 3 4 3 X ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000064232.V315091.R01.S.doc LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pinetrees Score 3 3 3 X 3 X 2 X X 2 X 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 YA6 Regulation 15 Requirement Care plans need to evidence that they have been reviewed at least six monthly. Outstanding from 30/11/05. Timescale for action 30/11/06 2. 3. YA24 YA33 23(2)(a) 18(1)(a) 4. YA39 24(1-3) The laminate flooring in the 30/12/06 second lounge requires repair or replacement. Review staffing arrangements at 30/11/06 the weekends to ensure adequate numbers of staff are on duty to meet the needs of service users. A formal quality assurance 30/12/06 system needs to be developed that includes the views of service users. Outstanding from 30/06/06 but progress made on seeking views of service users. Ensure copies of the reports of 30/11/06 monthly visits by the Provider’s representative are available in the home. Ensure that the emergency 30/10/06 lights are tested monthly, with a record maintained. 5. YA39 26 6. YA42 13(4) 23(2) Pinetrees DS0000064232.V315091.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA1 YA6 YA9 YA24 YA37 Good Practice Recommendations The Service User Guide and Statement of Purpose should be dated to show they are current documents. Some files are in need of a general “tidy up”: material that is old or has been superseded should be removed and disposed of, or archived, as appropriate. Introduce an index of risk assessments so that assessments are easier to locate. The kitchen is quite worn in appearance and the Provider will need to consider allocating funding to replace or refurbish the units in the near future. 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. It is strongly recommended that the current recording system for monitoring water temperatures is reviewed to enable the reader to clearly see that temperatures are maintained around 43°C. 6. YA42 Pinetrees DS0000064232.V315091.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: 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 Pinetrees DS0000064232.V315091.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. 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. 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