Inspection on 21/06/07 for Pinewood

This inspection was carried out on 21st June 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinewood 22/01/07

Pinewood 18/01/06

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 Julie Willis Unannounced Inspection 18 & 21st June 2007 09:15 th Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood Address 101 Pinewood Avenue Crowthorne Berks RG45 6RQ 01344 773139 01344 752833 info@new-support.org.uk www.new-support.org.uk New Support Options Limited 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) Mrs Lucy Muriel Dexter-Elisha Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 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. The current fees for the home are between £1,447.31 and £1461.49 per week. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service on 18th June at 9am but was only in the service for about an hour due to difficulties that the newly appointed manager was having accessing information from the homes computer system. The inspector returned at 9:15 am on 21st June and was in the service for about 7 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people who responded to questionnaires that the Commission had sent out. The inspector had the opportunity to meet 2 of the 4 people that use the service and to talk to one resident. The residents thoughts, opinions and comments are reflected throughout this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals with various religious, racial or cultural needs. This service is good at meeting the needs of residents with a range of diverse needs. There were 12 requirements made at the previous inspection visit in January 2007. All but one of the requirements had been fully met. The time scale for completion of the one remaining requirement, which concerned refurbishment of the kitchen, has been extended to enable the work to be completed. The CSCI are not aware of any complaints about the home since the last inspection. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 6 What the service does well: 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. The summary of this inspection report can Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. All service users are fully assessed prior to their admission to ensure the home will be able to effectively meet their need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the file of the most recently admitted resident indicated that they were fully assessed prior to their placement in the home. The tool used for the purpose of assessment was comprehensive and holistic in content and involved the resident, their family and a multi-disciplinary team of professionals. There was evidence that the management of the resident’s transition from one home to another had been carried out professionally and with sensitivity. The resident had been introduced to their new home in staged manner which gave the resident time to adjust and familiarise themselves with the routines of the home, the staff team and other residents. A trial period followed to allow time for the resident to fully settle into their new surroundings after which a full review was carried out which involved the Care Manager, health professionals, staff, family members and the resident themselves. At the meeting the residents continued residence in the home was confirmed. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 9 Quality in this outcome area is adequate. The care plans require review to ensure that they are sufficiently detailed and up-to-date to enable staff to effectively meet the resident’s need. Residents are encouraged and supported to make decisions in relation to their everyday lives. All risks to service users safety are fully assessed and guidelines are in place to reduce the risk identified. This judgement has been made using available evidence including a visit to this service. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 11 EVIDENCE: Examination and case tracking of 3 peoples care files indicated a need for some of the information to be archived. The files were confusing as several files contained information, which dated back at least 7 years and did not appear directly relevant to the resident as they present now. One file contained information concerning a residents’ dislocated shoulder but there was no crossreferencing to indicate how this may impact on the resident’s current health or how it may be relevant to their care. There is a need to ensure that the files in daily use reflect the current needs of the residents so as not to confuse new or agency staff that may be on duty in the home for the first time. It would be helpful if important older information could be added to the pen picture of each resident or in a chronology so that staff can be signposted to where to find further detailed information if they need it. The staff have the skills necessary to involve residents in the on-going development of their care plan. A key worker system is in operation which enables staff to establish an effective relationship with individuals and work on a one-to-one basis with each resident. There is evidence that individuals are involved and consulted about decisions about the home such as activities of daily living and social activities. Each care plan includes comprehensive risk assessments. Management of risks takes into account the age and specialist needs of individuals, balanced with their personal aspirations for independence and choice. Where there are limitations in place, discussions have taken place with the resident. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16, 17 Quality in this outcome area is good. People that use the service take part in activities that provide opportunity for personal, practical and emotional development and are encouraged to be part of the local community. People are provided with a menu that is nourishing, varied and meets their individual and cultural need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents are provided with the opportunity to engage in activities that are stimulating and worthwhile. There was evidence in the daily records that people make good use of communal facilities including local restaurants, cinemas, sports facilities and public houses. Each resident has an activity plan produced in user-friendly format, which is kept in the resident’s own room and on the house notice board. All of the residents are supported to take part in a structured day services programme. This is usually group activity at the day centre such as music Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 13 therapy or dance, drama or games. The home is responsible for ensuring residents are transported to the different venues in order to take part and have a house vehicle which is wheelchair accessible. One resident told the inspector that they work at a local supermarket, which they particularly enjoy. The resident also told the inspector of their involvement with Mencap board meetings and ‘Be Heard’ committee. The resident has an active social life and attends the ‘Friday Night Project’ and ‘Challenge Club’ The home provides a nourishing menu, which meets the needs of the residents. The residents confirmed that they are provided with choice and variety and are regularly consulted about the menus. Residents that require a special diet are provided with the necessary foodstuffs. Care plans indicated that users weight is monitored routinely and a dietician is involved when needed. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18, 19, 20 Quality in this outcome area is adequate. Residents physical and personal support needs are satisfactorily met and medication is dealt with safely and appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examination and case tracking of 3 residents care records it is evident that service users physical and personal care needs are satisfactorily met by the home. Some of the information in care plans needs archiving as information on file refers to previous health problems and injuries but it is not clear how this impacts on the resident’s current health or everyday life. Observation of staff and residents interaction demonstrated that care was provided in a manner, which maintained the users right to dignity, privacy, independence and choice. One resident confirmed that they have complete freedom to choose what they do and any restrictions have been agreed between themselves and staff as part of their on-going care plan. A resident told the inspector they had caring doctors and nurses at their local surgery and were provided with routine treatments and health checks as a matter of course. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 15 Residents do not self medicate at the home. The system adopted for the administration of medication is the monitored dosage system. This system reduces the likelihood of medication error and provides an accurate record of administration. All staff have been fully trained in safe administration and have been assessed by the Organisation as part of their formal training. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 & 23 Quality in this outcome area is good. The home has a complaints procedure, which is clear and accessible. Resident’s views and comments are listened to and acted upon. Residents are protected from abuse and exploitation by well-trained and competent staff that demonstrates knowledge of the homes abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examination of the complaint record it is evident that there have been no complaints made to the home since the15th September 2006 and no information concerning complaints have been reported to the CSCI. All complaints are fully investigated and the outcomes to complainants are fully recorded. Residents have access to the complaint procedure, which is explicit in their copy of the Service User Guide and readily available on the homes notice boards. Discussion with the Manager and staff indicated that feedback is actively sought from residents and their families on an on-going basis. One resident told the inspector that they were confident that if they had a complaint it would be dealt with effectively and in a timely fashion by management. The resident confirmed that the residents are provided with the opportunity to express their views in residents meetings and at other times. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 17 There was evidence in staff files that all staff receive training in the abuse of vulnerable adults as part of their formal induction and NVQ training in which it is a core module. Refresher training courses are also offered at regular intervals. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 Quality in this outcome area is adequate. Some areas of the home need refurbishment to provide a more accessible and comfortable environment for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was generally clean and hygienic throughout. Communal areas were spacious and comfortably furnished. All bedrooms were personalised to the choice of each resident. The garden was well kept and is well used by residents. A gazebo had been erected in the back garden for residents to enjoy during hot weather. A number of double glazed windows at the home have become fogged which impedes resident’s views from their bedroom windows. There is a need to repair or replace these. The kitchen is in need of refurbishment to ensure that it is more accessible to residents in wheelchairs and to provide residents with a more comfortable Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 19 environment. This requirement has been outstanding since 2005 and is now being addressed by the Organisation. Details of the refurbishment and the schedule of works were shared with the inspector during the inspection. The time scale for completion of this requirement has been adjusted to take into account the work schedule and its possible impact on residents. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35, 36 Quality in this outcome area is adequate. Staff are caring and kind but lack support and supervision in their job role This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the staff recruitment and training files for 5 workers at the home evidenced that staff were appropriately recruited, inducted and trained. Selection and recruitment procedures at this home involve residents and are robust. All necessary checks are carried out on staff to ensure that they possess the necessary attributes to care effectively for the residents. Records were well kept and met the required standard. One resident said that they thought that the staff were “kind” and observation of practice confirmed that staff had built a rapport with the residents. Staff appeared to have a good understanding of how their individual role benefits the work of the team and a thorough knowledge of the key values that underpin their work with residents. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 21 The staff handover was observed and was found to be resident focused. New policies and procedures are discussed in detail at each meeting and resident’s cash accounts are checked at each staff handover to ensure that resident’s monies are accurately kept. In recent months there has been slippage in the frequency of formal supervision sessions and in several cases lengthy gaps of 4 to 5 months between sessions. Likewise there has been limited opportunity for staff to have a say in how the home functions as there have been few staff meetings. Access to training has significantly improved since the last inspection. All staff including bank workers have had the opportunity to undertake safeguarding adults ‘Our approach’ training. Refresher training in core skills has been provided along with more focused training such as certificated infection control and stoma care training. All staff have received a refresher course in the safe administration of medication. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37, 39, 42 Quality in this outcome area is good. The home is safe and well managed by a competent manager and professional staff team. The home seeks and focuses on the views of its residents on an on-going basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been a change in management since the last inspection. A temporary manager that is experienced and competent is currently managing the home whilst another permanent manager is recruited. The Service Manager is providing support to the temporary Manager during regular visits to the home and in frequent one-to-one meetings. Quality assurance is being monitored during the monthly Proprietors visits and from regular surveys distributed to parents and carers. These are collated at head office and an annual customer satisfaction survey sheet is produced Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 23 which identifies areas of satisfaction and improvement. Surveys provided to the CSCI evidence satisfaction with the service provided. Comments by carers and parents such as “excellent service”, “the staff keeps me informed” and “I trust the staff” were made on survey forms. Examination of a number of health & safety records indicated that all necessary checks and servicing of equipment is routinely undertaken to safeguard the health and welfare of users. Unnecessary risks to users are identified using a comprehensive risk assessment. So far as possible the risks are reduced or eliminated by putting in place effective guidelines, policies and procedures. Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 24 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23 Requirement The kitchen cupboards and flooring are in need of replacement. Outstanding timescale 2/11/05 Repair or replace fogged double glazed windows to improve the environment for the residents Timescale for action 22/12/07 2 YA24 23 22/12/07 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 Refer to Standard YA36 YA24 Good Practice Recommendations Ensure that all staff are offered regular one-to-one supervision sessions and have the opportunity to participate in regular staff meetings There is a need to redecorate some areas where paintwork appears worn Pinewood DS0000050231.V340565.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000050231.V340565.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!