Inspection on 21/06/05 for Pinewood

This inspection was carried out on 21st June 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 08/11/08

Pinewood 09/11/07

Pinewood 11/07/07

Pinewood 05/06/06

Pinewood 31/01/06

Pinewood 07/10/04

Pinewood 09/06/04

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

CARE HOMES FOR OLDER PEOPLE Pinewood Tringham Close Ottershaw Surrey KT16 0HL Lead Inspector John Chivers Unannounced 21 June 2005 @ 12.30. st 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 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. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pinewood Address Tringham Close Ottershaw Surrey KT16 0HL 01932 872489 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) Welmede Housing Association Limited Mr Suresh Bidessie CRH - Care Home 5 Category(ies) of LD(E) - Learning Disability, over 65 (5) registration, with number of places Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of the persons to be accommodated will be 65 years and over. Date of last inspection 7th October 2004 Brief Description of the Service: Pinewood is managed by Welmede Housing Association and is one of many homes registered to the organisation in the county. The home is registered for a maximum of five residents of either gender over the age of sixty five years. All of the residents have learning disabilities. The home is situated in a residential area about a mile from a large town centre. The home provides a comfortable, homely and supportive environment. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 12.15 pm. The duration of the inspection was four hours. As part of the inspection process one member of staff was interviewed and discussion was held with three residents and the home’s management. The process included inspecting the home’s policies, procedures, records, staff personnel files and utility test certificates. The premises were also inspected on this occasion. The findings of the inspection evidenced that the home is managed in a satisfactory manner and afforded a good standard of care to the residents. Residents were open, friendly and some were eager to talk to the inspector. Others with limited communication skills communicated by facial expressions and gestures. The home provides a warm, accepting and homely environment. Staff interviewed were supportive of the home’s management. Whilst the findings of the inspection were mainly positive, some requirements are made. What the service does well: The home has created a homely and caring service where residents feel safe and supported. Comprehensive care plans are in place and these are monitored and reviewed by staff. The home enables and encourages residents to participate in a range of activities within the home and in the local community. Resident’s health care is monitored and clear records are kept. The home’ recruitment procedures are satisfactory and staff have substantial experience of working with people with learning disabilities. Relationships between staff and residents were positive and resident’s spoke/indicated favourably about staff and the service received. The home has a regard for maintaining a safe environment, although some utility tests need to be undertaken and certified as safe. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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 standard(s) 3 and 6. The home ensures that written needs assessments are undertaken prior to admission. EVIDENCE: Written needs assessments were available in the sample of residents files inspected. The assessments covered all areas as required by Standard 3.3 of the National Minimum Standards (Care Home’s for Older People.) The home does not provide intermediate care; therefore Standard 6 was not applicable at this inspection. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10. The home ensures that residents care plans are in place and are monitored and reviewed. The home has a positive regard for health and medical matters concerning the residents and demonstrates diligence and consistency regarding recording in these areas. EVIDENCE: Written care plans were available in the sample of residents files inspected. The care plans covered a wide range of areas including written risk assessments. There was evidence of care plans being monitored and reviewed on a regular basis. Health care and medical needs are detailed in the initial assessments and care plans. There was evidence of such areas being reviewed and updated as appropriate. Visits to the doctor and other health care professionals are recorded. There was evidence of consistency of recording in these areas. One resident stated in discussion that the staff “look after” his health and another confirmed that she had recently attended a dental appointment. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 10 The home has a policy regarding privacy and dignity. One resident stated that staff afford him privacy and treat him with respect. Other residents indicated by ‘head nods and smiles’ and gestures that their health needs are catered for. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14. The home has a clear commitment to engaging and enabling residents to participate in activities within the home and in the community. The residents have an opportunity for consultation and are afforded choice, though this could be evidenced more formally by keeping minutes of residents meetings up to date and on file. EVIDENCE: Weekly activity sheets were held in the sample of residents files inspected. Activities include both sedentary and active pursuits and excursions away from the home. One resident in particular had a keen interest in railways and trains and talked about how the staff encourage him to maintain his interest in the subject. The resident also stated that he had a large collection of model trains, which was evidenced during a visit to his bedroom. This resident also stated that he enjoys odd jobs and tasks around the house. Residents also stated/indicated that they had involvement in the local community and engaged in shopping expeditions, church attendance, visits to the community centre, cinema and visits and outings to family and relatives. Residents have autonomy consistent with their individual risk assessments and one resident in particular stated that he often visits the main line railway station to engage in ‘train spotting’. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 12 The manager stated that residents contribute to the running of the home and make individual choices and that this is usually conveyed via discussion with key workers or residents meetings, which occur once or twice per month. Written minutes were available regarding the meetings; however it was noted that the minutes presented occurred some time ago and none were available for meetings held recently. The manager stated that recent meetings have occurred though the minutes may be with a member of staff ready for typing. It would be important for the minutes to be typed and held on file in order to evidence occurrence, though staff confirmed that meetings do occur. A requirement will be made regarding this. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 17 and 18. The home has regard for treating complaints seriously and takes active steps to protect its residents from abuse and harm. EVIDENCE: The home has a written complaint procedure and copies of the procedure were available in the sample of residents files inspected. One resident stated clearly that he had no complaints about the service provided and those with limited communication skills also indicated that they were satisfied with the service and the way staff treat them. Staff that were interviewed were aware of the complaint procedure and were clear that they had no concerns about the service provided to the residents. Complaints forms were available. The manager stated that no complaints had been received. The home has an internal policy and procedure regarding the protection of ‘Vulnerable Adults’. In addition the home holds the Surrey County Council Multi-Agency Adult Protection procedures. There was recorded evidence that some staff had recently attended training in the protection of vulnerable adults and other staff were due to attend courses in the near future. A sample of the resident’s personal finances was inspected. Cash held in the residents individual cash tins were consistent with the balance in their cashbooks. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,21,23,24,25 and 26. The location and layout of the home is suitable for its stated purpose, is accessible, safe and meets the resident’s individual and collective needs. The home is generally well maintained; though redecoration is due to commence in the near future and some new furniture needs to be obtained. Additional ventilation is necessary in one of the bathrooms and floor covering in the kitchen and laundry needs to be levelled or replaced. EVIDENCE: The home is a single story detached building situated in a residential area. The home is a short distance from the town centre and is close to bus routes. The exterior of the home is maintained in good order and the garden areas were free from safety hazards. Whilst the communal areas present to a good standard and are homely, the home is scheduled for redecoration in July 2005. It was noted that whilst the settees and armchairs were comfortable, they were beginning to show signs of Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 15 wear and tear around the arm rest areas. It would be important for the home to replace these items and a requirement will be made regarding this. A sample of resident’s bedrooms were inspected. The bedrooms have a good standard of furnishing and are personalised; however the wallpaper in a number of bedrooms is peeling or torn. The manager stated that these shortfalls along with the peeling wallpaper in the corridor areas would be addressed when redecoration takes place. As this is in progress a requirement will not be made. It was noted that the floor covering in the kitchen and laundry had risen in certain areas. It is important that the covering is levelled or new floor covering fitted. Toilets and bathing facilities are of a good standard and afford privacy. It was noted that fungal marks were evident on areas of one of the bathroom walls and ceiling. It is important that this is investigated and additional extractors fitted if necessary. The manager reported that the home’s heating and lighting was satisfactory. Hot water temperatures are taken and recorded. Resident’s stated/indicated in discussion that they were satisfied with the standard of accommodation and furnishing in their individual bedrooms. The home has an infection control policy. Standards of cleanliness and hygiene were satisfactory throughout the home and no safety hazards were evident during the inspection. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30. The home’s recruitment and vetting procedures are satisfactory and the home has regard for staff training. EVIDENCE: The home has a recruitment policy and procedure. A sample of staff personnel files was inspected. The files varied in content but in the main included: application form, 2 references, contract, copy of job description, objective setting, supervision notes, interview notes, copies of certificates, health declaration, training record/programme and identification. Criminal Record Bureau checks were in evidence in the sample of files inspected. There was evidence of staff training and of training courses planned for the future. The member of staff interviewed confirmed attendance on training courses. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38. Whilst internal monitoring is basically sound the quality assurance systems could be enhanced by introducing residents and relative’s questionnaires and the drawing up of an annual development plan. The home has regard for health & safety matters; however a written fire risk assessment and certain utility tests must be undertaken. EVIDENCE: Regulation 26 visits occur and are, according to the manager unannounced. Copies of Regulation 26 visit reports were available in the home and copies of the reports are also forwarded to the CSCI Surrey Local Office. The home does not have a current annual development plan. It is important the organisation draws up such a plan in consultation with the manager. Whilst the Regulation 26 visits evidence monitoring and scrutiny, there are no other formal internal monitoring systems or aids in place. It is important that the manager inspect and sign records etc on a regular basis and introduce Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 18 resident’s and relative’s questionnaires in order to assist with the home’s internal quality audits. The home has a health & safety policy. The home’s health & safety ‘law’ poster was prominently displayed. The fire officer visited the home on 11th November 04 and assessed the home’s fire precautionary arrangements as satisfactory. It was noted at this inspection however that a written fire risk assessment was not in place. It is important that a fire risk assessment in drawn up. There was evidence of weekly fire alarm tests and fire evacuation drills occur on a quarterly basis. A current fire equipment test certificate was held. A range of written risk assessments and a COSHH assessment was also held. The Environmental Health Department (food hygiene) inspected the home’s catering arrangements on 20th August 04. The report regarding this was satisfactory. The home had a current gas test certificate, however the electrical systems and Legionella testing had not been carried out. It is important that such tests are arranged and the systems evidenced as safe. The home’s accident book was available. Three accidents, (not serious) had occurred since the last inspection. Recording was clear and detailed. No safety hazards were evident during the inspection. Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 2 2 x 3 2 3 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x x x 2 Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 20 No 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. 2. 3. Standard 19.2 25.1 33.2 Regulation 13, 4 (a) 23,2 (p) 25, 1 Requirement That the floor covering in the kitchen and laundry is levelled or replaced. That additional ventilation/extractor is fitted in the bathroom. That the organisation draws up an annual development plan for the home in consultation with the manager. That the home introduce questionnairs for residents and relatives in order to assist with quality assurance monitoring (This was a requirement at the last inspection and must now be addressed.), That a written fire risk assessment is drawn up. That the homes water systems are tested for Legionella and that the homes electricity systems are tested and certified as safe. That the home replace the settee and arm chairs in the lounge. That the manager sign and date records etc as part of internal monitoring system That minutes of recent residents meetings are held on file Timescale for action 20 / 8 /05 20 / 8 / 05 20 / 9 / 05 4. 33. 6&7 24, 1 (a) & (b) 20 / 8 / 05 5. 6. 38.2 38. 3 23, 4 (a) 13, 4 (c) 25 / 7 / 05 20 / 8 / 05 7. 8. 9. 20.7 33.3 14.1 23, 2 (g) 24 17 20 / 9 / 05 20 /7 / 05 25 / 7 / 05 Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 21 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 Good Practice Recommendations Pinewood H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 H58 H09 S13749 Pinewood V224325 240505 Stage 4.doc Version 1.30 Page 23 - 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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