Inspection on 02/08/05 for Pinewood

This inspection was carried out on 2nd August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pinewood 21/06/07

Pinewood 22/01/07

Pinewood 18/01/06

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 AVENUE 101 Pinewood Avenue Crowthorne Berkshire RG45 6RQ Lead Inspector Jill Chapman Unannounced 2 August 2005 @ 10.45 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 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 Stationary 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. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pinewood Avenue Address 101 Pinewood Avenue Crowthorne Berkshire RG45 6RQ 0118 9297918 Telephone number Fax number Email 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 LD registration, with number of places PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/11/04 Brief Description of the Service: The home is a detached 2-storey house situated in a residential area close to the town centre. The town 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. The residents bedrooms are all single and on the ground floor. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out on a weekday over a period of five hours. There were a number of other visitors in the home during the inspection, an auditor, builders, an electrician, Care Manager and the Area Manager who oversees the home. The inspector spoke with the Manager, two Senior Support Workers and the Area Manager. Three residents were in the house at the time; one went out with day services and another went out with relatives. Care and health and safety records were sampled. Due to the disruption in the home because of the many visitors the scope of the inspection was limited. The requirements were followed up and some of the standards were inspected. It was not possible on this visit to spend significant time with residents on this occasion. There were fourteen requirements from the last inspection, eleven of these have been carried out and three are still outstanding. These will be referred to in this report. What the service does well: What has improved since the last inspection? The care planning process is being reviewed to make this more person centred. Work has started to improve bathing facilities and there are plans to redecorate some areas of the home. New lounge furniture and a new washing machine have been purchased. A management support programme has helped the Manager improve her management skills. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 6 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. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 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 standard(s) Not inspected on this visit. EVIDENCE: PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 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 standard(s) 6 & 9 There is written information to help staff know how to meet residents care needs but some care plans need to be updated. Risk assessments show staff how to keep residents safe but some need updating. Bathing risk assessments need to clearly show staff how to prevent scalding or drowning. EVIDENCE: The care plans for all three residents were seen. Two files have been reviewed as part of a person centred care plan system and the other is due to be updated. One of the reviewed file had detailed up to date and detailed plans in the new format. The other had mostly updated care plans but some dated 2003 were still in place and had not been updated. Some new plans in this file also needed to be dated and signed. Risk assessments were seen for the three residents. These have been updated in two files, but in one file needs to be dated and signed. A third file is due to be updated. A requirement to make sure that bathing risk assessments include the risk of scalding and drowning has not been met. One file had a risk assessment that PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 10 covered scalding but not drowning and on the other two files, bathing risk assessments were not found. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 11 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 standard(s) 13 & 14 Residents do not get enough planned access to the local community. The development of a meaningful in house generated activity programme is needed to give them a better quality of life. EVIDENCE: Activity records in residents’ files and the communication book were seen and a discussion took place with staff and managers. The inspector was told that current staff deployment does not allow sufficient cover to enable regular planned access to the local community. Records sampled showed that one resident has only been out twice in June and July. For the other two residents there were some records of spontaneous outings to the shops or the local tip. These outings appeared to be motivated by the task rather than the residents’ choice of activity, for example, the need to get food shopping or to coincide with going out for a GP appointment. Two residents have day services activity sessions every week. A third does not have this service at present due to her health needs and staff are trying to get this reinstated. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 12 There was not enough evidence of a meaningful house generated activity programme. Daily records mostly showed residents as ‘relaxing in the lounge, their bedrooms or the garden’. In discussion with managers they said that they are looking at ways of helping staff work in a more flexible way. An alternative way of planning and recording activities has been developed and is to be put in place. They said that all residents attended a barbeque at the weekend and there is a planned trip to Longleat in August. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 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 standard(s) 19 Staff help residents by monitoring their health needs and support them to attend health care appointments EVIDENCE: Residents files were seen and show that their health care needs are well met. Specific needs are regularly monitored and there are risk assessments for some medical conditions. Guidelines regarding PRN medication need to be signed and dated and to be regularly reviewed with the relevant health professional. One resident has significant healthcare needs and these are well documented with evidence of consultation with health professionals. Staff have received training to manage her feeding regime. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 14 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 standard(s) Not inspected on this visit. EVIDENCE: PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24 A number of improvements to the home are being carried out, to make the home more suitable for the residents needs. Some further improvements are needed. EVIDENCE: There were a number of requirements regarding the premises from previous inspections. New lounge furniture and a new washing machine have been purchased since the last visit. At the time of this inspection builders were in the home carrying out alterations to an en-suite bathroom and to provide two en-suite toilets. A soiled bedroom carpet has been replaced. There is an outstanding requirement to carry out redecoration in the hallway and the lounge. A chipped bath has not yet been repaired. The manager said that the landlords have carried out a survey of required maintenance. It was seen that the kitchen cupboards and flooring are in need of replacement and a timescale needs to be set for this work to be carried out. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 There are insufficient staff on daytime shifts to fully meet the residents needs. EVIDENCE: A requirement to provide sufficient trained staff on duty to meet the needs of the residents and for the health and safety of staff and service users has not been fully met. A resident who was causing considerable disruption and risk to other residents has now moved to another placement. He had been funded for one to one staffing. The area manager said that staff deployment has been reduced from three staff per daytime shift to two, because of the vacant bed and the loss of extra funding for the third staff member. Evidence from this inspection shows that two staff per shift has significantly affected the opportunities for the other three residents to be taken out of the home. All three residents need a staff member to help them with their mobility needs and so two staff cannot take all three out at once. The gender care needs of one resident can also affect the opportunity for outings for all three residents. The Area Manager confirmed that they are actively seeking to fill the vacant beds. Because the care needs of the three residents have increased since the current staffing levels were agreed with the purchasing authorities, New Support Options are referring them for reassessment. One assessment has already taken place and extra funding is anticipated soon. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 17 Evidence from this inspection is that two staff on shift is insufficient to fully meet the current needs of the residents. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 42 The registered manager has benefited from a management support programme to improve her management skills. Regular health and safety checks help keep residents safe. EVIDENCE: The registered manager has started NVQ 4, the Registered Managers Award, however there is no assessor at present and this is delaying the process. She has been supported By New Support Options to develop her management skills and has received management related training. The Area Manager said that she has benefited from this management support programme. Rotas sampled show that the managers time off shift varies and the Area manager said that New Support Options do not have a set formula for this. This matter should be kept under review to make sure that current staff deployment is not detrimental to the management task. The health and safety file was sampled and showed that routine health and safety checks are carried out. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 19 PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x 1 1 x x x Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 PINEWOOD AVENUE Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 3 x H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 21 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 33(2) 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. Evidence from this inspection is that two staff on shift is insufficient to meet the current needs of the residents.Outstanding timescale 20-07-04. Some bathing risk assessments need further development to specify that the risks of drowning and scalding have been considered .Outstanding timescale 23-12-04. Internal redecoration needs to be carried out to the hallways and to finish the lounge. A chipped bath needs repair. Outstanding timescale 23-02-05 . Develop residents access to the local community. Develop individual activity programmes. Guidelines regarding PRN medication need to be signed Timescale for action 2-09-05 2. 42 13© 2-09-05 3. 24 23 2-10-05 4. 5. 6. 13 14 13(2) 16(m) 16(n) 19 2-10-05 2-10-05 2-10-05 Page 22 PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 7. 24 23 and dated and to be regularly reviewed with the relevant health professional. The kitchen cupboards and flooring are in need of replacement, The day and night time staffing needs of the residents should be reasssed 2-11-05 8. 33(3) 2-11-05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 37(3) Good Practice Recommendations The managers hours off shift should be kept under review to make sure that the current staff deployment is not detrimental to the management task. PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Berkshire, 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 PINEWOOD AVENUE H51-H01 101 Pinewood Avenue V234534 020805 Stage 4.doc Version 1.30 Page 24 - 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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