Inspection on 31/01/06 for Pinewood

This inspection was carried out on 31st 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 but made no statutory requirements on the home.

Other inspections for this house

Pinewood 08/11/08

Pinewood 09/11/07

Pinewood 11/07/07

Pinewood 05/06/06

Pinewood 21/06/05

Pinewood 07/10/04

Pinewood 09/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Pinewood Pinewood Tringham Close Ottershaw Surrey KT16 0HL Lead Inspector Sandra Holland Unannounced Inspection 31st January 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pinewood Address Pinewood Tringham Close Ottershaw Surrey KT16 0HL 01932 872489 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) Welmede Housing Association Ltd Mr Suresh Bidessie Care Home 5 Category(ies) of Learning disability over 65 years of age (5) registration, with number of places Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: OVER 65 YEARS 21st June 2005 Date of last inspection Brief Description of the Service: Pinewood is small home accommodating up to five people who have learning disabilities, who are over 65 years of age. The home is a purpose built, single storey property, with five individual bedrooms and a spacious lounge / dining room. A garden is available to the rear of the property and there is a large driveway, with parking space for a number of vehicles. The service is managed by Welmede, a local organisation, which runs a network of homes in the area. Staff at the home are employed by the North Surrey Primary Care Trust (NSPCT). Pinewood is situated in a residential cul-de-sac in Ottershaw, which has a range of local facilities, including shops, post office, pubs and public transport. The larger town of Woking, with it’s greater range of shops and leisure facilities, is a short drive away. Pinewood is adjacent to Copse Lea, another home in the Welmede group, which is also managed by the registered manager of Pinewood. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. As the inspection was unannounced, no one at the service knew it was to be carried out. Mrs Sandra Holland, Lead Inspector for the service carried out the inspection over a period of four hours. Ms Beverley Hewton, Deputy Manager was present representing the service. A number of records and documents were examined, including medication administration record (MAR) sheets, resident contracts and resident financial records. All five residents and two members of staff were spoken with. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. To fully assess how the home is meeting the National Minimum Standards (NMS) for Care Homes for Adults, it will be necessary to read the reports of both inspections. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. What the service does well: Residents are actively encouraged to be as fully independent as possible and to make their own choices. The home is very well presented, in a homely style, with colourful decorations and comfortable furnishings. Residents are well supported to develop their skills, both in the home and out in the community. Residents expressed their appreciation of the changes being made in the home and for the increased selection of activities available. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Resident’s contracts with the care home must contain all the required information. The amount of medication held in the home must accurately match the record held. The complaints procedure should be reviewed and revised. The hospital style bed and worn armchair in a resident’s bedroom should be replaced. The management of the home must be reviewed. The flooring in the kitchen must be made level or replaced. An annual development plan must to be drawn up. A system to assess the quality of the service provided must be developed and must involve residents and others involved in their support. The manager should sign and date records to show that they have been monitored internally and that he has overseen them. An assessment of the fire risks in the home must be drawn up. Certificates to confirm the safety of the electrical service and that the water supply in the home has been tested for Legionella bacteria, must be obtained. The temperature probe used to test hot food served, must be in working order. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 7 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 DS0000013749.V277342.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Residents are provided with contracts. These contain most but not all of the required information. EVIDENCE: The deputy manager advised that residents are supplied with contracts which are known as Licence Agreements. These were seen to state the terms of the agreement between Welmede and the resident, the services to be provided and the responsibilities of the resident. These had been signed by the resident where able. The financial contribution to be made by the resident is stated, but the agreement does not state who pays the balance of the fees for the resident. If a local authority has made the arrangements for a resident to be accommodated or to receive personal care at the home, it is required that a copy of the agreement is supplied to the resident. As the original agreement form did not detail the room to be occupied by the resident, an additional letter has been sent by Welmede to each resident, giving this information. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 10 A requirement has been made. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. The stock of medication in the home must accurately match the record held. EVIDENCE: Medication administration at the home is currently recorded on Welmede organisational medication administration record (MAR) charts, although the deputy manager stated that the home is about to start using MAR charts supplied by the pharmacy. These were seen to have a photograph of the resident attached, to whom the record chart related and no gaps in the records were noted. The deputy manager advised that medication is supplied to the home by a local pharmacy in original packets and bottles. Receipt of medication into the home is recorded on the MAR chart on arrival. On examining the stock of medication in the home and the record held, it was not possible to check that these matched, because there was no indication as to when some supplies of medication had been started. This is not acceptable and systems must be put in place to enable an audit trail of the administration of medication to take place. An immediate requirement has been made. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 12 Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. A well-balanced and varied diet is offered to residents. EVIDENCE: Residents were seen enjoying their lunch time meal and stated that they enjoy their meals at the home. It is clear that residents are offered a nutritious and healthy diet. Staff advised that they take the residents’ needs and likes and dislikes into account when planning meals. Residents make their own choices for breakfast and lunch, with just the main evening meal planned in advance for practical reasons. Residents were observed to make their own choices and to be encouraged to be independent, with regard to helping themselves and clearing their things from the table. It was pleasing to see residents and staff sitting together family style for their meal, in a relaxed but appropriate manner. The dining room is comfortably furnished, with an attractively laid table. Residents were cheerful and chatty in their interactions with staff. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. A complaints procedure is available but needs to be updated. EVIDENCE: The home’s written complaints procedure was seen and was dated for revision in 2002, but this had not been done. The procedure referred to the National Care Standards Commission (NCSC) and had been amended by hand to refer to CSCI. The procedure needs to be reviewed and revised. Residents spoken to confirmed that they knew who they should speak to if they had any complaints or were worried in any way. Staff advised that any dissatisfaction that is made to them verbally, is usually dealt with immediately and informally. Staff confirmed that they would pass any serious concerns directly to the deputy manager or manager. A requirement has been made. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 25. A programme of improvement of the furnishings in the home is underway. EVIDENCE: It was pleasing to see that new furniture for the lounge/dining room was being delivered on the day of inspection. This included a dining table and chairs, china display cabinet, side tables and T.V. cabinet. Residents advised that the lounge sofas had also been obtained in recent months, following the redecoration of the home. The communal areas of the home were attractively decorated in cheerful colours. A requirement was made at the inspection carried out on 21st June 2005, that the flooring in the kitchen must be made level or replaced. This has not been done. The deputy manager stated that the whole kitchen is to be re-fitted in the next financial year, and the flooring will be replaced at the same time. A number of aids and adaptations have been provided around the home to assist the residents with their mobility and to support their independence. Hand rails have been fitted in toilets and bathrooms and a ramp provides Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 16 wheelchair access to the front door. One resident is currently using a walking frame to assist her mobility around the home, following an operation. A specialist, easy access bath and a wheelchair accessible shower are available for residents with limited mobility. One resident showed me his bedroom and it was noted that the bed was a hospital style bed, with a metal frame, which did not appear very homely. The armchair in the room was very worn, with a hole in the upholstered arm. The room was otherwise well presented and clean. Staff stated that the hospital style bed had been left in the room from the time of the previous resident, two or three years ago. It is recommended that a bed of a more domestic style is obtained. An additional extractor fan has been fitted to the main bathroom as required at the inspection carried out in June 2005. A requirement and a recommendation have been made. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28. Residents are supported by a small but stable and committed team of staff. EVIDENCE: The deputy manager stated that residents are supported by a small team of staff who carry out all roles within the home, including personal care, shopping, cooking, laundry, domestic tasks and activities. Residents are supported to assist with tasks as they are able and if they wish to. From observing the interaction between residents and staff, it was clear that staff are interested in the residents and enthusiastic about their roles. Staff were seen to include residents in lively conversations and to engage with them at all times, speaking to residents in a relaxed but appropriate manner. Residents were seen to be at ease with staff and to respond in a positive way. Staff were seen to respect resident’s private space, knocking on their bedroom or bathroom doors and waiting for a response, before entering. From speaking to staff, it was clear that they know and understand the resident’s needs and are committed to meeting these. A small number of staff have undertaken National Vocational Qualifications (NVQ’s). One member of staff has obtained NVQ level 3 in care and is now undertaking level 3 in management. One member of staff is undertaking NVQ level 2 in care and another is undertaking NVQ level 3 in care. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. It is recommended that the management arrangements at the home are reviewed. A system of reviewing the quality of the service provided must be established. EVIDENCE: At present the home is managed by the registered manager, who also manages Copse Lea, another Welmede service which is next door to Pinewood, whilst the deputy manager is in day to day control of Pinewood. It is apparent that this arrangement is not ideal. A requirement was made at the inspection carried out on 21st June 2005 that the manager must sign and date records, with a timescale for completion by 27th July 2005, but this has not been carried out. A number of the other requirements made at that inspection have not been met, including the drawing up of a fire risk assessment for the premises and of an annual development plan for the home. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 19 A further requirement was made at the inspection carried out on 21st June 2005, that a system of monitoring the quality of the service provided must be introduced, and a timescale of 20th August 2005 was given for this to be met. The deputy manager stated that she was not aware that any system of quality assurance is currently carried out. This requirement has not been met. The deputy manager has only been in post for a few months, but stated that she is already making changes within the home, to improve the lives of the residents and staff. A vehicle has been obtained solely for the use of the home, which now permits the residents and staff to arrange spontaneous activities and a number of new activities have been introduced to meet the resident’s individual interests. Staff advised that greater variety has been introduced to the menus planned and that the meals had improved as a result. Monies are held for safekeeping for residents and records relating to these were seen. The amounts held were found to accurately match the record held. Residents were observed withdrawing their monies and it was pleasing to see that they signed to record receipt of the amount drawn. A number of records relating to health and safety were seen (but not all). The temperatures of the fridge and freezer and that of hot food served, were seen to be within normal ranges. It was noted that the food probe was not working at the time of inspection and two items of food in the freezer were not properly wrapped, labelled or dated. A requirement was made at the last inspection, that the home’s water system must be tested for Legionella bacteria and a certificate was to be obtained to confirm the safety of the electrical services in the home. These have not been carried out and the requirement has not been met. Requirements have been made. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x 2 3 x 3 x 2 3 x STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(1)(b)& (3) Requirement Timescale for action 28/04/06 2 OP9 13 (2) 3 OP19 13 (4) Each resident must be provided with the terms and conditions in respect of accommodation to be provided, including as to the amount and method of payment of fees. Where a local authority has made arrangements for the provision of accommodation or personal care to a resident at the care home, the resident must be supplied with a copy of the agreement specifying the arrangements made. The registered person must 31/01/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Specifically, the quantity of stock of medication in the home must accurately match the records held. The registered person must 28/04/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from avoidable risks. The kitchen floor must be made level or replaced. DS0000013749.V277342.R01.S.doc Version 5.1 Pinewood Page 22 4 OP31 12 (1) (a) 5 OP33 24 (1-3) 6 OP33 25 (1) 6 OP38 13 (4) (c) UNMET FROM 21/06/05. The registered person must ensure that the home is conducted so as to promote and make provision for the health and welfare of residents. The management of the home must be reviewed. The rgistered person must establish and maintain a system for reviewing and improving the quality of the care provided at the care home. The system must provide for consultation with residents and their representatives. A copy of any report in respect of any review, must be made avilable to residents and provided to CSCI. UNMET FROM 21/06/05 An annual development plan must be drawn in respect of the care home. UNMET FROM 21/06/05 The registered person must ensure all parts of the home to which residents have access are free from hazards to their safety; certificates confirming the safety of the electrical supply and to confirm that the water supply has been tested for Legionella bacteria, must be obtained; a fire risk assessment for the premises must be drawn up. UNMET FROM 21/06/05 28/04/06 28/04/06 28/04/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 23 No. 1 2 Refer to Standard OP16 OP24 Good Practice Recommendations It is recommended that the complaints procedure is reviewed and revised. It is recommended that the hospital style bed and worn armchair in a resident’s bedroom are replaced. Pinewood DS0000013749.V277342.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Surrey Area Office 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 DS0000013749.V277342.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. 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!