Inspection on 06/01/06 for Pinetum Nursing Home

This inspection was carried out on 6th January 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Pinetum Nursing Home 12/02/07

Pinetum Nursing Home 03/08/05

Pinetum Nursing Home 16/12/04

Pinetum Nursing Home 08/06/04

Pinetum Nursing Home 11/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Pinetum Nursing Home Valley Drive Countess Of Chester Health Park Liverpool Road Chester Cheshire CH2 1UA Lead Inspector A Gillian Matthewson Unannounced Inspection 6th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pinetum Nursing Home Address Valley Drive Countess Of Chester Health Park Liverpool Road Chester Cheshire CH2 1UA 01244 380731 01244 380789 manager.pinetum@careuk.com 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) Community Health Services Limited Ms Anne Hughes Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (5) of places Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 48 service users including: * Up to 48 service users in the category OP (Old age, not falling within any other category) * Up to 5 service users in the category PD (Physical disability aged over 48 years) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of service users at all times and shall comply with any guidance which may be issued through the Commission for Social Care Inspection 3rd August 2005 2. 3. Date of last inspection Brief Description of the Service: The Pinetum Care Home provides nursing care and accommodation for up to 48 older people and up to 5 people over 48 years of age with a physical disability.The Pinetum Nursing Home is a detached, purpose built property situated within the grounds of the Countess of Chester Health Park near to the centre of the city of Chester and local shops and amenities. There is good access to public transport.The home was first opened in 1991. Bedroom accommodation is provided in single rooms that have hand washbasins. There are no en-suite facilities. Bedrooms are on two floors with a passenger lift and staircases to both levels. There are two main communal lounge areas with two additional sitting areas. There is a dining room on each floor. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector spent two hours planning the inspection by reviewing previous inspection reports and the service history over the last twelve months. The inspection took place over six hours and included a tour of the building, inspection of records and discussion with six residents, four relatives and five staff. Comments were positive in the main. One resident said “it’s very nice here, I enjoyed Christmas very much, particularly the Christmas party”. A relative said “ on the whole it’s very good”. Feedback was given to the Deputy Manager immediately following the inspection. What the service does well: Prospective residents are assessed prior to admission to ensure that the home can meet their needs. The home has a full complement of appropriately skilled staff. Residents like the staff and feel they work hard to meet their needs. They feel they are treated with respect, their privacy is maintained and they can exercise choice and control over their lives. There are good systems in place to protect residents from harm. The home is comfortable, clean and well maintained. There are good quality assurance systems in place to measure the home’s success in meeting its aims and objectives. There are adequate systems in place to safeguard residents’ financial interests and records are well maintained in accordance with the Data Protection Act. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prospective residents are assessed prior to being offered a place, to ensure that the home can meet their needs. EVIDENCE: All residents were assessed by either the manager or her deputy prior to their admission to the home. The pre-admission assessment documentation contained all the details required by this standard. The pre-admission assessments examined during the inspection had been completed in full. The deputy manager said that one prospective resident had recently been assessed. This person needed regular treatment that staff did not have the skills to provide. The manager had arranged for all the registered nurses to undergo training in this technique and receive ongoing support from a specialist nurse. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 10. The staff have a good understanding of the residents’ support needs. This is evident from the positive relationships that have been formed between the staff and residents. EVIDENCE: Each resident case tracked had plans of care, which were based on a full needs assessment. Care plans set out the actions needed to meet the nursing and personal needs of the resident. These were comprehensive and had been regularly evaluated to ensure that the nursing actions were achieving the desired outcome. Residents and relatives confirmed that they had been consulted and were involved in the care planning process. One relative said “the staff are wonderful, they are very cooperative and keep us well informed, anything you ask for is done straightaway”. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 10 Observations of staff during the inspection and discussions with residents confirmed that staff were careful to maintain residents’ privacy and dignity and treated them well. The staff induction programme included instruction on how to treat residents with respect. Residents had access to a telephone for use in private and some residents had a private line in their own room. They received their mail unopened. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home is conducted so as to help residents exercise choice and control over their lives. EVIDENCE: Residents confirmed that they were able to exercise choice in relation to their activities of daily living. For example, they could choose what to eat, where to spend their time and when to get up or go to bed. However, some of the residents spoken with said they sometimes had to wait a long time for a call bell to be answered. See Recommendation 1. They could handle their own financial affairs and were enabled to access the services of an advocate through Age Concern if they wished. One resident in a transitional bed was using an advocate to help them find another home. Residents’ rooms were personalised with their own belongings such as small items of furniture, pictures, ornaments and soft toys. The Service Users’ Guide advised residents of their rights in accordance with the Data Protection Act. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff have knowledge and understanding of adult protection issues, which protects residents from abuse. EVIDENCE: There were appropriate policies and procedures in place in relation to adult protection and whistle blowing. Staff training on induction included abuse awareness and this was followed up with more in depth training. The last training session was held in September 2005. All staff had undergone Criminal Records Bureau (CRB) checks. An appropriate referral had been made to social services under the locally agreed adult protection procedures since the last inspection. The member of staff concerned no longer worked at the home. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. The home provides a safe, comfortable and clean environment for residents. Systems are in place to control the spread of infection, in accordance with professional guidance. EVIDENCE: The home was purpose built and all areas were accessible to residents, including wheelchair users, apart from the kitchen and laundry. There were also accessible outdoor sitting areas. A programme of routine maintenance and renewal of the fabric and decoration of the premises was in place. The home was clean and tidy at the time of the inspection. The laundry, hand washing and sluicing facilities were satisfactory. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 14 There were policies and procedures in place to assist with the prevention of cross-infection and staff received training in infection control. The company that owned the home employed an infection control nurse specialist and monthly audits of infections were carried out that identified whether the resident had been admitted with the infection or acquired it in the home. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staffing levels are sufficient to ensure that residents needs can be met. EVIDENCE: On the day of inspection there were 41 people in residence. Seven of the residents required continuing health care, nine required transitional care, two required respite care and 23 were permanent residents funded either privately or by the local authority. Staffing consisted of four registered nurses and seven care assistants in the morning, three registered nurses and six care assistants in the afternoon and evening, and two registered nurses and three care assistants at night. In addition, there were also two student nurses on duty. There were no vacancies and the home had not used any agency staff for a few months. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. This is a well managed home. EVIDENCE: The manager is a first level registered nurse with considerable management experience. At the time of the inspection she had just completed the Registered Managers’ Award (NVQ Level 4) and was awaiting her certificate. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 17 Clinical governance audits were carried out by the provider’s clinical governance officer. Monthly figures were sent to the clinical governance department in relation to staff turnover, training, bed occupancy, financial performance, accidents and incidents, infections and pressure sores. The manager and deputy carried out monthly audits on medication, care plans and health and safety. Regulation 26 visits were carried out on a monthly basis and reports submitted to CSCI. Policies and procedures were reviewed annually in October and updated as required. Customer satisfaction surveys were left out for residents and relatives to complete. On the day of the inspection the staff had received a commendation as a result of a survey completed by a relative who was very appreciative of ‘the wonderful care that was given to my father and all the family’. The administrator was appointee for one resident. This had been agreed in consultation with the resident, his family and the Benefits Agency. His money was held in an interest bearing account and statements were provided monthly. The home held small amounts of spending money (up to a maximum of £100) for may of the other residents. A balance sheet was maintained for each resident, which documented all deposits and withdrawals and a running balance. Receipts were given for all deposits and signatures obtained from the resident or their representative for all withdrawals. A new safe had been purchased since the last inspection. The home had satisfactory policies on record keeping and access to records. The home maintained all of the records required by the Care Homes Regulations, including a record of furniture brought by a service user into the home for all service users. Since the last inspection, a new computer system had been installed that included computerised care records. All staff had received training in how to use the system and how to maintain security. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 18 All staff received training in safe working practices during their induction. In 2005 updates for existing staff had been provided in first aid, moving and handling, health and safety (including control of substances hazardous to health), food hygiene and fire safety. The home provided a qualified first aider on every shift. Five fire drills had been carried out in 2005 but the time of these was not recorded. This number of drills was likely to be insufficient to ensure that all day staff attended two fire drills a year and all night staff attended four. See Recommendation 2. All lifting equipment had been serviced in December 2005. The service engineer had recommended that two of the eleven hoists be replaced. See Recommendation 3. On the day of inspection a ceiling hoist was being fitted into one of the resident’s rooms to make it easier for staff to assist him. All other equipment was inspected and serviced at the required intervals. A Landlord’s Gas Safety Check had been carried out in April 2005. Portable electrical appliances had been tested in May 2005. The electrical wiring installation check was due in February 2006. Water temperatures were recorded monthly and were within acceptable limits. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 4 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP14 OP38 OP38 Good Practice Recommendations Call bells should be answered as quickly as possible. A record of the times of fire drills should be maintained to ensure that both day and night staff have attended the required number. Replace the two hoists identified as requiring replacement by the service engineer. Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Pinetum Nursing Home DS0000018814.V276596.R01.S.doc Version 5.1 Page 22 - 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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