Inspection on 18/01/06 for Pinewood

This inspection was carried out on 18th January 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinewood 21/06/07

Pinewood 22/01/07

Pinewood 02/08/05

Pinewood 23/11/04

Pinewood 20/05/04

Pinewood 08/12/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Pinewood 101 Pinewood Avenue Crowthorne Berks RG45 6RQ Lead Inspector Jill Chapman Announced Inspection 18th January 2006 10:00 DS0000050231.V267162.R01.S.doc Version 5.1 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 DS0000050231.V267162.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 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. DS0000050231.V267162.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pinewood Address 101 Pinewood Avenue Crowthorne Berks RG45 6RQ 01344 773139 01344 752833 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) New Support Options Limited Mrs Lucy Muriel Dexter-Elisha Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000050231.V267162.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: The home is a detached 2-storey house situated in a residential area close to the Crowthorne village centre. The village has shops, pubs and local community resources. There is an accessible garden that has been equipped for wheelchairs. The house has a large lounge diner, kitchen and laundry. The service users bedrooms are all single and on the ground floor. There are assisted bathing facilities to help service users with restricted mobility. DS0000050231.V267162.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection carried out on a weekday morning to afternoon, over a period of six hours. The focus of the visit was to follow up the requirements and recommendation from the previous inspection and to inspect the outstanding key standards. There are three service users living in the home at present and they were all at home during the course of the inspection. Two were able to give some verbal feedback about life in the home and discussion with staff, observation of practice and looking at records gave further information about how needs are met. Care, staff and health and safety records were sampled and the premises were seen. Discussion took place with the manager and two staff on duty. Feedback was given to the Service Manager who telephoned at the end of the inspection. What the service does well: What has improved since the last inspection? Care plans and risk assessments have been updated and service users records are more organised and accessible now. Health and safety records are well organised and those sampled were up to date. DS0000050231.V267162.R01.S.doc Version 5.1 Page 6 Senior managers at New Support Options have supported the manager to improve her management skills and the running of the home has improved. Additional funding has been obtained from the Health Authority to provide extra staffing hours for one service user. The Local Authority is also reassessing the other two service users because their needs have changed. 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. DS0000050231.V267162.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000050231.V267162.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 There is an admissions procedure in place to help find out if the home can meet the needs of prospective service users. EVIDENCE: There have been no new admissions to the home since the last inspection. New Support Options has an admissions procedure, which meets the standard. The home has previously had an unplanned admission that helped them see how difficult it can be to meet previously un-assessed needs. DS0000050231.V267162.R01.S.doc Version 5.1 Page 9 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 & 9 Care plans help staff know how to meet needs and risk assessments help them keep service users safe. Care plans and risk assessments have been up dated and further improved. EVIDENCE: Care plans were sampled for all three service users. These have been updated and further improved since the last inspection. They provide clear information to help staff know how to meet needs. Service users preferred routines are reflected in care plans. There are care plans in place to show when choice has to be overridden due to safety or other reasons. For example a care plan is in place to help a service user use his radio so that it does not disturb others. Risk assessments have also been updated and a requirement to give more information in bathing risk assessments has been met. Risk assessments give good information on how to reduce risks. DS0000050231.V267162.R01.S.doc Version 5.1 Page 10 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): 12, 13, 14, 15, 16 & 17. Staff support service users to attend a programme of day service activities. Community and in house activities would benefit from further development and planning. Individual activity programmes need to be developed and the way they are recorded needs review. Staff support service users to keep in contact with families and friends. The routines of the home help encourage service users to become more independent and their privacy is respected. Service users help choose and shop for food. They have a varied diet and are given assistance when needed. EVIDENCE: Two service users talked about their interests and contact with family and friends. Although none of the service users are able to take up employment they do attend day services sessions during the week. One told about his regular swimming sessions, music group and art and craft group. Another attends a computer group and the art and craft group. Another service user DS0000050231.V267162.R01.S.doc Version 5.1 Page 11 enjoys music and communication sessions. The home has arranged for a ‘Music Man’ to visit every fortnight and this activity is enjoyed by all. Service users have enjoyed a busy December attending pantomimes and parties. There is still a need to further develop community access now that the Christmas festivities are over. Records show that outings to the shops, pub and recycling take place but they still seem to be on a spontaneous basis. These could be developed further to help service users experience a more planned programme, which could take into account new venues or activities. At present additional staff hours have not been recruited to so staffing levels can limit opportunities for outings. The manger anticipates that this situation will improve. The requirement to develop individual activity programmes has not yet been carried out. Community access and activities are recorded in the handover book and daily diaries and it is difficult for the manager and others to see exactly what each service user is doing over a period of time. Recording is often basic and daily diaries show regular entries, which show service users ‘relaxing in lounge’ or ‘relaxing on their bed’. It is recommended that the recording format be reviewed. Service users told how they keep in contact with their families. This includes regular visits from relatives, phone calls and home visits. Staff and service users were able to confirm how the routine of the home promotes independence, choice and freedom of movement. Service users all have keys to their rooms and the front door and staff prompt them to use them. Service users are offered the opportunity to participate in their personal cleaning and laundry. Staff were seen to respect service users privacy and they routinely knock on their bedroom doors before entering. Two male service users now have their own en-suite toilets for privacy and ease of access. Each service user is registered on the electoral role but they do not currently participate in the voting process. One service user told how he helps do the food shopping and how they help chose the menus at service users meetings. Menus show that a healthy diet is provided. One service user is PEG fed with a liquid diet and staff have been trained to carry out this process. DS0000050231.V267162.R01.S.doc Version 5.1 Page 12 DS0000050231.V267162.R01.S.doc Version 5.1 Page 13 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 & 20 Care is carried out taking service users preferences into account. Service users healthcare needs are well met. Staff are trained to deal with specific healthcare needs and they liaise well with health professionals. There is a safe system for storing and giving service users medication. EVIDENCE: Care plans give detailed information about how to carry out personal care tasks. Advice is sought from other professionals to help meet mobility needs or manage challenging behaviour. Health care needs and appointments are well documented. Monitoring charts are in place for specific health needs. Staff have been trained to know how to deal with these. It was observed that staff responded quickly and sensitively when two service users had a seizure. Staff contact relevant health professionals for advice and guidance and this information is recorded. The medication system was seen and is generally well looked after. Regular checks are carried out to make sure the right medication is given. Staff are trained to give medication and their competency is reviewed. The stock control of a PRN medication was not accurate and needs review. DS0000050231.V267162.R01.S.doc Version 5.1 Page 14 As required from the last inspection, guidelines for the administration of PRN medication have been reviewed with the consultant and have been re written. DS0000050231.V267162.R01.S.doc Version 5.1 Page 15 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 & 23 There are systems in place to enable service users to make complaints and to protect them from abuse. Staff need additional training in both of these areas. EVIDENCE: There is a complaints system in place and no complaints about the home have been received since 2004. Advice was given to provide an index for complaints forms to show the continuous record. In speaking to staff on duty there was a lack of clarity about the process and how to deal with complaints. There is a service user-friendly version of the complaints procedure, however they would not be able to access this without staff support. Further staff training is needed so they can help them do this. The organisation has a Vulnerable Adults procedure and a Whistle Blowing policy so that staff can report any suspected abuse. Staff on duty lacked clarity about the whereabouts of these policies and what to do other than to report information to Senior Staff. Further staff training is needed in this area. DS0000050231.V267162.R01.S.doc Version 5.1 Page 16 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 & 30 There are outstanding maintenance requirements, which need to be addressed to maintain a suitable environment for the service users. Timescales should be set to carry out work to meet additional health and safety or maintenance issues which the Landlords Audit identified. The home is kept clean and hygienic but some staff would benefit from training on hygiene issues. EVIDENCE: There are outstanding requirements to redecorate the hallways and finish the lounge. A chipped bath has not been repaired. The kitchen cupboards and flooring have not been replaced. The manager said that redecoration was due to start on the 9th January but the workmen did not turn up. This work is now scheduled for 23rd January. The manager showed the report of an audit that has been commissioned by the Landlords and has identified further work that needs to be carried out to ensure safety. This includes the provision of overhead tracking for a hoist in a service users bedroom and the making safe of the main fuse box and electrical wiring which is sited near to a sink in a service users bedroom. Timescales should be set to carry out these works. DS0000050231.V267162.R01.S.doc Version 5.1 Page 17 Since the last inspection a resident’s en-suite assisted bath has been re-sited to make it easier to access. The home is kept clean and hygienic. The infection control policy could not be found and staff on duty were inconsistent about safe laundering procedures. This highlights a need for refresher training. The home has a sluice sink and the manager is trying to replace this with a washing machine with a sluice facility to improve hygiene. The manager said there are problems in getting this installed. DS0000050231.V267162.R01.S.doc Version 5.1 Page 18 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): 33, 34 & 35. Steps are being taken to increase staffing to meet service users needs. Staff recruitment checks are carried out to make sure that staff are suitable to work with vulnerable people. EVIDENCE: A requirement has been outstanding since July 2004 to provide adequate trained staff on duty to meet service users needs. The requirement is not yet fully met but progress is being made. One service user has been reassessed and extra funding has been obtained to meet her needs. New staff will be recruited and the manager said that in the meantime, bank staff would cover these hours. The other two service users are in the process of being reassessed and it is hoped that additional funding will be allocated. There are 1.5 vacancies at present and staff are covering vacant shifts to ensure consistency for service users. Current staff deployment is three staff on an early shift and two on a late shift. On occasions an extra staff is deployed on a late shift to cover an outing or activity. There is a recruitment procedure in place to make sure suitable staff are employed. Sampling recruitment records and speaking to staff confirmed this. DS0000050231.V267162.R01.S.doc Version 5.1 Page 19 Advice was given to the manager develop a checklist for staff files so that she can make sure records required to be kept by regulation are in place. In discussion with staff and from looking at training certificates it was seen that staff receive training to meet the needs of the service users. This includes induction, core training and training related to health needs. It is recommended that the manager to develop a team training plan which would make it easier to have an overview of training needs. The manager is aware that medication refresher training and some core refresher training is due. DS0000050231.V267162.R01.S.doc Version 5.1 Page 20 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 The running of the home has improved. There are good systems in place to seek the views of the service users and others to see if the service is meeting the needs of the residents. EVIDENCE: The manager has just started her NVQ4/Registered Managers Award. Senior managers at New Support Options have supported the manager to improve her management skills and the running of the home has improved. There are a number of ways that the home involves service users in planning the service. There is an annual development plan for the home (PATH) and each service user has their own developmental plan (PATH). An annual survey is carried out involving service users, relatives and other stakeholders. DS0000050231.V267162.R01.S.doc Version 5.1 Page 21 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 x 12 3 13 1 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x x x DS0000050231.V267162.R01.S.doc Version 5.1 Page 22 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 Requirement The registered persons need to ensure that there are adequate, trained staff on duty to meet the needs of the service users. This has been outstanding from the last three inspections. . Outstanding timescale 20-0704. Internal redecoration needs to be carried out to the hallways and to finish the lounge. A chipped bath needs repair. Outstanding timescale 23-0205. Develop residents access to the local community. Outstanding timescale 2/10/05 Develop individual activity programmes. Outstanding timescale 2/10/05 The kitchen cupboards and flooring are in need of replacement. Outstanding timescale 2/11/05 Provide refresher training for staff on how to deal with DS0000050231.V267162.R01.S.doc Timescale for action 02/09/05 2 YA24 23 18/04/06 3. YA13 16(m) 18/04/06 4 YA14 16(n) 18/04/06 5 YA24 23 18/04/06 6 YA22 22 18/04/06 Version 5.1 Page 23 complaints. 7 8 YA23 YA24 13(6) 13(4)a 23(2)b 23(2)n Provide staff with Vulnerable 18/04/06 Adults training. Timescales should be set to carry 18/04/06 out the works identified in the Landlords Audit, particularly the overhead tracking for the hoist and the work to the electrical fuse box and wiring. Send written confirmation by Refresher training on infection control should be provided 18/04/06 9 YA30 16(2)j 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 YA13 YA20 YA35 Good Practice Recommendations It is recommended that the recording format of community activities be reviewed. The stock control of a PRN medication was not accurate and needs review. That the manager develop a team training plan which would make it easier to have an overview of training needs. DS0000050231.V267162.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000050231.V267162.R01.S.doc Version 5.1 Page 25 - 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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