Inspection on 09/11/07 for Pinewood

This inspection was carried out on 9th November 2007.

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 11/07/07

Pinewood 05/06/06

Pinewood 31/01/06

Pinewood 21/06/05

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 Pinewood Tringham Close Ottershaw Surrey KT16 0HL Lead Inspector Steve Webb Unannounced Inspection 9th November 2007 10:30 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.V347838.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 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.V347838.R01.S.doc Version 5.2 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) penny.lamb@surreypct.nhs.uk Welmede Housing Association Ltd Penelope Lamb Care Home 5 Category(ies) of Learning disability over 65 years of age (0) registration, with number of places Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability, over the age of 65 years - (LD(E)) The maximum number of service users to be accommodated is 5. Date of last inspection 11th July 2007 Brief Description of the Service: Pinewood is small home accommodating up to five people over 65 years of age, who also have a learning disability. 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. Pinewood is one of a number of homes operated by Welmede, a local housing association. The “North Surrey Primary Care Trust” currently employs the home’s staff, but the housing association is about to take over their employment from the PCT. 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 its greater range of shops and leisure facilities, is a short drive away. Pinewood is adjacent to Copse Lea, another home in the Welmede group, and the two homes have historically shared one manager. At the time of this inspection the fees were said to be £1039.00 per week. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.30 am until 7.15 pm on the 9th of November 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the home manager, some of the staff members on duty during the day, and some feedback from service users. Some time was also spent informally observing the interactions between service users and staff at various times during the inspection, including over lunch with some of the residents. Both verbally and by their body language, most residents appeared relaxed and happy within the home, and the interactions observed between the residents and staff members, were positive. The inspector also examined the premises, in detail, given the outstanding issues from previous inspections. It was evident that the service is well managed on a day-to-day basis by the new manager who had begun to address a number of the issues in the home. The morale of most of the staff seen, appeared to be good, though there was some anxiety about the provider’s upcoming takeover of responsibility for staff management from the Primary Care Trust. It is of concern that the provider has failed to demonstrate that they are running the home in the best interests of residents in a number of areas, and in some cases, over an extended period. A number of previous requirements still remained unresolved at this inspection. Ongoing failure to address these shortfalls will be likely to lead to enforcement action by the Commission. What the service does well: The needs of residents are assessed and regularly reviewed, for the most part. Prospective residents have access to a service user guide that is available in text and picture format, and also on cassette, to support them in making an informed decision about coming to the home. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 6 The needs and wishes of residents are described in some detail within personcentred care plans that include guidance for staff on how to provide individualised support. The staff make every effort to ensure the healthcare needs of the resident are met, and good records of the actions and outcomes for the residents are in place. Staff support the privacy and dignity of residents in the course of their work. Residents have access to activities and events in the community, though this can be limited by staffing levels at times. Spiritual and cultural needs are also provided for and family contact is supported. Residents are encouraged to make decisions and choices in their daily lives, and to be involved in aspects of their own care, though the outstanding health and safety issues in the kitchen and laundry impact upon these opportunities for some residents. Residents help to plan the menus and some are involved in shopping and cooking and related tasks. Residents have access to various forums to raise ay concerns or complaints they might have, and are provided with a copy of the complaints procedure. Systems are in place to protect residents from abuse, and staff members receive training on safeguarding. The majority of the home is homely and attractively decorated. Standards of hygiene were generally good, aside from the odour in the adapted bathroom. Staff receive a good induction and core training to equip them for their role and the manager identifies the outstanding training requirements to ensure that staff are put forward for regular refresher training. Appropriate quality assurance systems are in place and the home is subject to a range of internal auditing systems. What has improved since the last inspection? What they could do better: Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 7 The degree to which the privacy, dignity and confidentiality of residents is respected is potentially compromised by the ongoing absence of an office in the home, where confidential conversations and phone calls involving staff, could take place. Though most areas of the home are pleasantly decorated and furnished, the home fails to provide a safe, well-maintained environment, and fails to address the needs of residents in a number of areas. Although some adaptations have been provided to meet the changing needs of residents, a number of other adaptations are required. The laundry facilities do not provide the necessary support to the home’s infection control procedures. The manager identified a need for additional staffing in a “Statement of Need” produced in May 2007, in order to more fully meet residents’ needs, but to date no additional staffing has been agreed by the provider. NVQ attainment is beneath the required level at present, and additional staff should be enrolled to ensure that all staff are aware of current good practice. Staff CRB checks should be regularly updated to maximise the protection afforded to residents by the recruitment procedure. In a number of areas, the provider has failed to act in residents’ best interests, and is still failing to effectively promote the health, safety and welfare of residents. The Registered Individual with overall responsibility for the home needs to address the outstanding requirements from the last inspection that have still not been met. The expectation that residents’ funds are used to pay for staff entrance fees and entertainment costs on holidays, must be made explicit within the homes service user guide. 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 be made available in other formats on request. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 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.V347838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are assessed and kept under review, to ensure they are being met, and prospective residents have access to a service user guide that is available in text and picture format, and also on cassette, to support them in making an informed decision about coming to the home. Standard 6 is not applicable because the home does not offer an intermediate care service. EVIDENCE: All of the residents have been at the home for some time, and any assessments from the time of their admission had been archived. However, examination of a sample of two of the care plans indicated continued improvement, and a positive move towards person centred care plans, and a regular process of review to ensure they remain relevant to the changing Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 10 needs of the individual. It is evident that the service is meeting the needs of residents. The home now has a detailed service user guide and statement of aims and objectives, both of which are in a mixture of text and picture format to improve their accessibility. These documents are also available on cassette. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, and 10: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs and wishes of residents are described within person-centred care plans that include guidance for staff on how to provide individualised support. The healthcare needs of residents are met, and good records of healthcare are in place. The home has an appropriate system in place to manage the medication on residents’ behalf, since none of them are currently able to manage their own medication. Though in various ways the privacy and dignity of residents is supported by the staff, the degree to which this can be achieved effectively is severely compromised by the ongoing absence of an office and the limitations that this places on the confidentiality of face-to-face and telephone conversations, and email correspondence. EVIDENCE: Examination of a sample of the care plans indicated they have continued to develop within the “person-centred” model, and focus on the individual needs Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 12 and preferences of the individual based on a variety of assessment and enquiry tools, and risk assessments. All but one of the person-centred care plans had been done and one was still being completed, but had been set aside while a specific healthcare plan had been devised relating to supporting the resident, who has been diagnosed with a terminal illness. The various tools in use, identify the needs, preferences, likes and dislikes of individuals, and include individual guidance on how to support the resident around specific activities, events, daily routines or times of day. A range of appropriate risk assessments is included, to inform the social and healthcare aspects of the residents support. Healthcare needs are identified within a health needs assessment, which addresses aspects of both physical and emotional health, and relevant specific guidance is included on how to support these issues. Individual Healthcare Plans are completed for two residents and in process for the others. One resident who is especially hard of hearing, has a vibrating pillow pad to alert her, should the fire alarm be triggered at night, and other specialist equipment has been obtained where required. The home accesses appropriate support from external healthcare agencies, including speech and language therapists, psychologists and McMillan nursing services. Healthcare appointments records indicate recent appointments and regular routine checks where appropriate. However, it was reported that on occasion, health needs have not been picked up promptly, and some performance management issues have resulted. There are copies of any completed incident and accident records for the resident, on their file as required, as well as these being held centrally for monitoring. The care plans also include a weekly planner of the regular scheduled activities for the individual in pictorial format, and a range of photos of the resident engaged in various activities. Any spiritual/cultural needs are also identified, as well as interests in particular activities. A communication summary describes the communication repertoire of the resident and provides information to support staff to understand particularly the non-verbal elements of this. The speech and language therapist has also been involved with one resident whose first language is not English, in order to support improved communication. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 13 Where necessary, a behavioural summary also provides staff with information on probable triggers, and how to respond consistently to elements of inappropriate behaviour. ABC charts are also completed to record any incidents, to provide “intelligence” to enable future planning and assessment of the effectiveness of current management plans. However, some of these were undated, which reduces their usefulness. Staff should be reminded to sign and date all records. All of the individual guidance and information formats include a staff signature sheet, which staff are required to sign to confirm their awareness of the content. As already noted, there is evidence of a cycle or regular review of the various risk assessment systems and care plans on a monthly basis to ensure they remain relevant, as well as periodic formal review, to which residents are invited. Within each plan is also a very good summary of the financial situation of the resident in an accessible leaflet format, detailing their various income/benefits and contributions towards fees etc. The home manages medication on behalf of all residents at present, as none are felt to have the capacity to do so for themselves. The home has an appropriate procedure in place, which provides the required medication audit trail, and includes records of the quantities of medication received, administered and any returns to the pharmacy. A system of regular stock-checks has been introduced, which requires two staff signatories, but this had not been adhered to on one occasion recently, which the manager had addressed with the staff concerned. The medication file includes a specimen signature and initials sheet for the staff who administer/witness the process, and a copy of the medication procedure. Any homely remedies are approved by the GP in writing, and their administration is recorded on the back of the medication administration record sheets. A photo of each resident is also included, together with details of their GP and any allergies. All bar two of the staff have received medication training, and the two who have not done this, only act as witness and second signatory, though they should also receive appropriate accredited training to undertake this role. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 14 The level of consultation with residents about their care and lifestyle has improved, and the individual preferences of residents, with regard to their care are now better respected. They are involved in fortnightly residents meetings and encouraged to have a say in the day-to-day operation of the home. The meetings are minuted and the minutes produced in picture/text format and made available on cassette. The CSCI inspection process has been explained to them and the content of the last report fed back to them in a residents’ meeting. Two of the residents indicated that they were happy with how they were supported by the staff and at various points during the inspection, staff were observed to be attentive and alert to the needs of individual residents. The privacy and dignity of residents are supported in a variety of physical ways, including each having individual, lockable bedrooms, to which they all have a key, though only one currently uses it. Two residents also have a front door key. The toilets and bathrooms are also provided with appropriate locks, and staff knock on bedroom doors before entering. However, the ongoing lack of an office in the home is a major issue in terms of residents’ privacy since there is nowhere in the home where staff can discuss their needs or make phone calls about them, in private. Staff and management have to either stand in the laundry to talk or make phone calls, use the lounge, when it is unoccupied, or leave the building to go over to the next-door home to use the office there, which has implications for staff cover and safety. Residents’ reviews also have to take place in the resident’s bedroom. The home and resident records are kept in a locked cupboard, and the day-today administration base of the home is a small desk in the entrance hallway opposite the front door. The home’s computer, on which emails are sent and received about residents and other aspects of the home’s operation, is located in the communal lounge, which also presents a potential breach of confidentiality and privacy. The Responsible Individual needs to consider how best to overcome the issue of not having an office or room in the home that can be used for confidential matters. This issue has been raised in the last two inspection reports but no action has yet been taken by the provider to address it. This issue is also discussed in the premises section of this report. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 15 The issue of maintaining residents’ dignity and privacy was also a feature of one of the complaints, which had been received by the home. There is a further issue that potentially impacts on the privacy, dignity and safety of residents. The back garden still has no side gate with which to secure the garden, to prevent residents leaving without the staff being aware, or unauthorised outsiders gaining entry to the garden. This also means that residents always have to be accompanied by staff when using the garden, which would not always be necessary if it was appropriately secured. This issue has been outstanding since the inspection in June 2006. The front garden is also entirely unfenced, offering no privacy to the front/ side of the house and no deterrent to local youths playing on the front grass. This is reported to have been a problem that has previously necessitated the police being called, and the writing of a risk assessment for resident/staff safety. It is understood the provider is in discussions with the local council regarding possible planning restrictions on the provision of a hedge or fence to the front garden. However this should not impact on the installation of a gate to the rear garden. Residents have been consulted on this, in a residents’ meeting and thought that a fence or hedge would be a good idea. A requirement on this matter is made under Standard 19 and Regulation 23, later in this report. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. From the available evidence seen the lifestyle and activities experienced by residents meet their needs and provide them with opportunities for community access and involvement. Their spiritual and cultural needs are also addressed. Residents’ contact with family is supported where possible, and volunteer befrienders also support some individuals. The residents are supported to make decisions and choices in their daily lives, though the outstanding health and safety works in some areas impact upon their involvement in daily routines, self-care and autonomy. They receive a varied diet from a menu to which they contribute, and some take part in the shopping and preparation aspects. EVIDENCE: Aside from the regular scheduled activities in which each resident takes part, that are detailed in their activity planner, they are also offered a range of other opportunities for activities and community access and are encouraged to participate in the daily living tasks in the home in line with their preferences, Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 17 and within the limitations of current staffing levels, which can be a limiting factor at times. However, owing to the poor condition and unevenness of the flooring in both the kitchen and laundry, access to these areas by some residents has had to be curtailed on health and safety grounds. In the case of the kitchen, these repairs have been outstanding since June 2005. Both issues are also impacting on the ability of the residents to take an active part in their own daily living experience, potentially leading to a reduction in their self-care abilities. It is understood that these repairs may have gone out to “tender”, but the provider must now take steps to address these issues, as further failure to do so could lead to enforcement action by the Commission. This matter is made subject to a requirement under Standard 19, later in this report. Where possible, residents are still encouraged to be involved in the shopping, cooking and serving of meals and also help to lay and clear tables. Some also help with vacuuming and other cleaning. This was observed to be the case during the inspection. The photos in the care plans confirm some of the activities in which individuals have taken part, and some of the residents talked about these activities during the inspection. The care plans include a record of residents’ hobbies and interests, and one residents spoke about his great interest in railways and how this had been enabled by the staff, including train trips, opportunities to watch trains and to have some train models and a number of videos and DVD’s on the subject. Where necessary access to activities is supported by relevant risk assessments in order to minimise risks. Recent activities have included a visit to Leeds Castle, a pottery class, art and craft sessions three times a week, bowling, attending the Gateway Club, bingo, drama, board games and attending the Rainbow church club and other local clubs. Three of the residents have funding for external one-to-one support workers for two hours per week to provide additional community access. The home does not have its own dedicated vehicle, but has to share one with the home next door, which may have some impact on activity choice and availability, and may increase the use of dial-a-ride and sometimes taxis to enable community access. Consideration should be given to the unit having its own adapted vehicle. Residents spiritual needs are provided for via the rainbow church club, and local places of worship. One resident attends church with their 1:1 worker Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 18 sometimes, and another has just started to do this. Two of the residents like to watch programmes like Songs of Praise, but do not wish to go to church. The service makes appropriate arrangements to address any cultural and diversity needs, as well as for other identified individual needs. On the day of inspection, some of the residents went out in the morning with a resident from the home next door, and staff, to try to launch his radiocontrolled model aeroplane. One went out with a volunteer activity support worker to access the community, and several joined the residents of the home next door, in the afternoon for a music session with a visiting musician. The regular Friday morning art and craft session, facilitated by an external worker, had been cancelled owing to the worker being off sick. One resident is still able to access the community without staff support and this is enabled. Three of the residents went on holiday to the Isle of Wight and two to Devon (one went twice), and a further trip to Portsmouth is being planned. Residents are expected to pay towards certain additional activities, for example a trip to the theatre, but they also pay for the costs of staff entry fees for these events and for staff costs on holidays. The service should have a policy on these additional costs, and they should be made explicit in the Service User Guide. This matter is discussed further under Standard 35, later in this report. Family contact for the residents varied from regular weekly visits to family, to no contact, though two residents do have volunteer 1:1 friends. Contact is supported and encouraged wherever possible. As already noted, the current limitations on access to the kitchen and laundry for two residents limits their autonomy and choice, but in other aspects residents are consulted and have a good deal of freedom to determine their day-to-day lifestyle. Although none is able to fully manage their own money, all have access to their personal allowance and make decisions on how this is spent. They also sign for their money and receipts are retained for purchases. The residents plan the menus on a weekly basis with staff, using meal picture cards where necessary, and staff maintain an overview with regards to healthy eating issues. The residents appeared to enjoy their meals, and the lunch and teatime atmosphere was relaxed. The lounge-dining room provides a light, airy and pleasant environment for dining. From discussion the inspector felt that the home would be able to meet any specific dietary needs identified. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have various forums through which to raise ay concerns or complaints they might have, and are provided with a copy of the complaints procedure. Systems are in place to protect residents from abuse, and staff members receive training on safeguarding. EVIDENCE: The home has an appropriate complaints procedure, which is also available in an accessible format, a copy of which is posted in each bedroom. Examination of the complaints log showed it to be empty. It was also in a tearoff booklet format, which is not the most appropriate for such a record as pages could be removed without it being evident the record had been altered. The manager explained that she had copies of three recent complaints (which were evident from discussions recorded in the staff meeting minutes), and was in the process of establishing the separate complaints logs for Pinewood and the adjacent home, following recommendations from the recent inspection of the other home. (Previously the complaints record had been combined within the wider quality assurance system). Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 20 All three of these matters had been addressed appropriately, and discussed with staff in a recent team meeting. The manager agreed to set up a bound complaints log for the home, and to enter the three complaints therein. Two of the residents indicated that they would speak to the manager if they were unhappy about anything. Residents also have the opportunity to raise any issues in the fortnightly residents’ meetings, via quality assurance surveys, or with the visiting senior manager who undertakes monthly monitoring visits, and three of them also have contact with external volunteers. No complaints have been received by the Commission, for referral to the provider for investigation, since the last inspection. The home has a procedure on “Dealing With Abuse” and staff members had signed the signature sheet, confirming they have read it. The inspector asked one staff member about this policy and she was clear about her role, and had received training in safeguarding vulnerable adults. The training records indicate that all staff had received training in safeguarding vulnerable adults in either 2006 or 2007. No issues relating to the safeguarding of vulnerable adults have been reported to the Commission since the last inspection. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Though most areas are pleasantly decorated and furnished, the home fails to provide a safe, well-maintained environment, and fails to address the needs of residents in a number of areas. Although some adaptations have been provided to meet the changing needs of residents, a number of other adaptations are required. The home was clean and standards of hygiene were good, aside from the issues regarding the kitchen and laundry flooring. However, the laundry facilities do not address the changing needs of residents, in that the washing machine does not have a sluice facility, which is necessary to support the home’s infection control practice. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 22 EVIDENCE: The lounge-dining room is the main communal space in the home and it is attractively decorated and homely. The room is of a good size and has plenty of natural light. The resident’s individual private rooms are personalised with their own possessions and have a lockable door. None of the bedrooms has en suite facilities. There are two communal bathrooms, one of which has an adapted bath with an integral hoist seat and a level-entry shower. Each of the bathrooms has a toilet, and there is a further separate toilet. Handrails have been provided for residents’ safety. The home’s corridors are wide, though they lack natural light in some areas and require the lights to be on all day. Most of the doors in corridors and to communal areas have already been fitted with sound activated door closers in the event of the fire alarm sounding. These enable the residents to maximise their independent mobility about the home, apart from the kitchen door, which is addressed below. There is an unpleasant residual odour within the adapted bathroom owing to the lack of natural ventilation. An additional extractor fan has previously been fitted but has not addressed the problem. The responsible individual should ensure that this bathroom is free from unpleasant odours at all times. Where necessary, ramps have been provided at exits to enable residents to access to the garden. The works to address the potential health and safety hazard presented by the bubbling and uneven flooring in the kitchen and laundry are still outstanding, and, in the case of the kitchen, have been outstanding since June 2005. This also means that the flooring is no longer properly sealed at its edges, making it impossible to thoroughly clean these areas. The manager informed the inspector that these repairs have now gone “out to tender”, with a tender deadline of 8/11/07, but no firm deadlines have been notified to the manager for the completion of the work. The back garden is still without a side gate with which to secure the area, to prevent residents leaving without the staff being aware, or unauthorised outsiders gaining entry to the garden. This issue has been outstanding since first being made a requirement in the report of the June 2006 inspection. The front garden is also still entirely unfenced, offering no privacy to the front/ side of the house and no deterrent to local youths playing on the front garden, which has previously led to the police needing to be called to the home. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 23 The manager informed the inspector that discussions with the local council are under way regarding possible planning restrictions on the provision of a hedge or fence to the front garden, but no proposed date for resolution of this issue has been forthcoming within the home’s improvement plan. Residents have been consulted on this, in a residents’ meeting and they thought that a fence or hedge would be a good idea. Within the bedrooms, the emergency call system is of a type that is fixed to the wall. In the absence of extension cords this would be likely to render it unreachable by a resident in the event of a fall. An example of this scenario was reported verbally to the inspector, where it was the cries of the resident, which had summoned staff assistance, as they were unable to reach the alarm system to activate it. The Occupational Therapy service and the care manager were reportedly contacted at the time, but no changes were made. The absence of extension leads to emergency call bells was raised in a previous inspection report. Appropriate steps must be taken to enable residents to summon staff assistance in the event of emergency. Consideration should also be given to modern alternative systems to enable residents to summon assistance, wherever they may be within the home. As noted earlier, there is no office provided within the home, where staff can discuss residents in private or on the telephone, and where the home’s computer can be located. The provider must consider further how these issues can be addressed within this service. There was no alarm activated holdback device fitted to the kitchen door, which is a designated fire door, and requires such a device if it is to be held open. This door was inappropriately held open by means of a wedge at the time of inspection, in order to facilitate ease of access by residents and staff. The fire officer was reported to have previously highlighted this issue. Given the mobility issues for residents, who should have ready access to the kitchen, it is necessary for an appropriate holdback device, integrated with the fire alarm, to be fitted to the kitchen door, though this issue is currently linked to the required flooring repairs also being addressed. The residents, especially those with increasing mobility impairment, should also have appropriate holdback devices fitted to the bedroom doors for use during the daytime, since these doors were also seen to be wedged open, to facilitate residents’ freedom of movement in and out of their bedroom. The manager has obtained a quote for the required holdback devices, which Welmede have reportedly agreed to fund, and have indicated verbally to the manager that they will be installed by mid-December. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 24 The home was found to be clean and free of unpleasant odours, aside from the odour already referred to, within the adapted bathroom, and standards of hygiene throughout the building were otherwise seen to be good. However, the current laundry facilities do not address the needs of residents, in that the washing machine does not have a sluice facility. This facility is necessary to support the home’s infection control practice. The home does have an old open sluice, but this was reported not to be in use, and such devices do not now provide the best infection control solution. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager identified a requirement for additional staffing in a “Statement of Need” produced in May 2007, in order to more fully meet residents’ needs, but to date no additional staffing has been agreed by the provider. NVQ attainment is beneath the required level, and additional staff should be enrolled to improve this situation to ensure that all staff are aware of current good practice. The home’s recruitment procedures provide protection to residents though CRB checks should be regularly updated to maximise this protection. Staff receive a good induction and core training to equip them for their role and the manager identifies the outstanding training requirements to ensure that staff are put forward for regular refresher training. EVIDENCE: The current staffing levels limit the opportunity for residents to access the community on occasions, particularly on a one-to-one basis, since the aim is not to leave one staff member in the home with more than three residents. The manager has previously reviewed staffing levels and produced a thorough and detailed “Statement of Need”, identifying why additional staffing is Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 26 necessary for a variety of reasons, and how it would be utilised, but as yet no specific proposal regarding increased staffing has been made. This issue was also raised in the last inspection report, and needs be addressed. Discussion with staff indicated some anxiety about the upcoming takeover of management responsibility for the staff, by the housing association, from the local Primary Care Trust, (PCT), but in the long run this should simplify what is currently a very complex management structure, involving two housing associations and the PCT. The manager had asked staff to write down their questions and concerns ahead of a planned meeting with staff to discuss the upcoming changes. Staff were otherwise motivated and attentive to the needs of residents during the inspection, and demonstrated a good understanding of their role. It was commented that staffing was stretched at times. One staff member confirmed she had completed all of her core training apart from infection control, and received regular supervision. She also confirmed she was due to start her NVQ level 3 in April 2008. Two of the staff have NVQ level 3 and one is due to start as above. Two other staff have been asked to enrol but as yet have not done so. In order to maintain or exceed government NVQ targets, additional staff should undertake NVQ. It should be an expectation that any new full-time staff will undertake NVQ following on from their induction and foundation training to ensure that they are aware of current good practice. Examination of a sample of the staff recruitment records indicated an appropriate system, including photo ID and all staff receiving a copy of the General Social Care Council, Code of Conduct. The record for the most recent appointee provided confirmation of the CRB check number and confirmed that a POVA check had been undertaken, which is good practice. However, in one case the CRB check was older than three years, and took place prior to POVA checks being undertaken. This and other CRB’s should be renewed every three years together with a POVA check to maximise the protection of residents. Owing to the absence of an office in Pinewood, the provider has decided to continue to hold these records in the unit next door, for security. This is appropriate until an office is provided within Pinewood. The manager indicated that the majority of core training was up to date, and had designed the induction programme, which includes dates and signatures to confirm the process. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 27 The manager indicated that the induction process was also used where staff transferred from other units to ensure that everyone started from the same baseline. This is good practice. The manager has training records to enable her to monitor the ongoing training needs of staff within the team. Staff are put forward for refresher training when necessary. Some core training still needs to be caught up with, but the manager indicated this was in hand. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At manager level the home is currently being well managed, in the interests of residents, by an experienced and qualified manager. However, in a number of identified areas, the provider has failed to act in residents’ best interests. Appropriate quality assurance systems are in place and the home is subject to a range of internal auditing systems. Residents’ finances are safeguarded by the home’s financial systems. However the expectation that residents’ fund some additional activities expenses, needs to be explicit within the Service User Guide. In a number of significant ways, the provider is still failing to promote effectively, the health, safety and welfare of residents. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 29 EVIDENCE: The home’s registered manager has been in post for a year at Pinewood, having also had previous management experience. She has NVQ level 4 and the Registered Manager’s Award and is qualified as an internal NVQ assessor. Since coming to Pinewood the manager has begun to address a variety of issues including pursuing action on the various outstanding inspection requirements. She also manages the home next door though this is counter to Standard 31.3 of the National Minimum Standards, and this issue should remain under review, in terms of its effect on the management of the home. The manager has produced a detailed report to the provider identifying the need for additional staffing for a variety of reasons, though this has yet to be addressed by the provider. As has been noted throughout this report, the provider has failed to take timely action on requirements arising from successive inspection reports, some of which have been made two or three times. Requirements have been made under the relevant standard and Regulation. The provider must now address the requirements within this report, as failure to comply will be likely to lead to enforcement action by the Commission. The manager, for her part, has highlighted these outstanding issues to the provider, but in most instances the provider has given no indication of a date by which time they will be addressed. Each resident has their own individual building society account, and though none is able to fully manage their funds, all have access to their money in appropriate amounts when they need it, and sign for these amounts, and receipts are kept for all expenditure. The care plans contain a very good summary of the individual financial situation of the resident in an accessible leaflet format, detailing their various income/benefits and contributions at source, towards fees etc. However this leaflet does not clarify that residents are expected to contribute separately towards some specific activities, and also to pay for the entrance fees of accompanying staff and some staff costs when on escorted holidays. Any additional charges, over and above basic fees must be made explicit within the Service User Guide. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 30 A quality assurance survey was undertaken in October 2007, and at the point of inspection only two questionnaires had so far been returned. Surveys were provided to residents, relatives, external healthcare professionals, 1:1 friends and the Welmede Housing Association. It is good practice to seek feedback from a wide range of sources about the service in this way. The manager indicated she would produce a summary report of the findings and proposed actions to address any identified issues. The manager had also provided a copy of the complaints procedure to families in June 2007. It is good practice to do this periodically to encourage an open dialogue with families about any concerns they may have. The manager had also completed an in-house Management Quality Audit in September 2007, and the provider undertook a “Regularity Review” of financial matters in June 2007. The manager was in the process of compiling an annual development plan, but this had been delayed by a period of sickness absence, though some aspects had been addressed by the earlier production of the “Statement of Needs” with regards to the staffing issues, in May. The manager undertook to complete the annual development plan by the 12th of December, and intended to include issues identified during the staffing review, the quality assurance feedback, inspection issues, outstanding health and safety matters and feedback from staff and resident meetings. The provider also undertakes regular Regulation 26 monitoring visits though some of the major outstanding issues identified in this inspection, do not feature therein. The reports do, however, refer to consultation with residents, as required. A number of ongoing heath and safety-related issues have been identified in this report, which have resulted in the safety of residents not being promoted effectively by the provider. Examination of a sample of health and safety-related service certification indicated appropriate service intervals. Staff had received fire safety training in 2006 and 2007.The home has an up to date fire risk assessment, last reviewed in September 2007, and regular fire drills had taken place. However, one resident had failed to respond to the fire alarm during the last drill and had failed to evacuate. Their individual fire risk assessment, dated 5/06, made no mention of this incident and had not been updated to identify an appropriate evacuation plan or any other steps. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 31 Fire risk assessments must be reviewed and kept up to date to reflect individual needs. Accident recording is appropriate and both individual (within the case records), and collective, accident records are maintained as required. Where several incidents had been recorded regarding one individual, this led appropriately to the establishment of a behaviour management plan. Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 32 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 X X 1 Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 33 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 OP19 Regulation 13 Requirement The responsible person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from avoidable risks. The kitchen floor must be made level or replaced. Previous requirements with timescales of 21/06/05, 28/04/06, 25/08/06 and 25/08/07 were not met. The responsible person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from avoidable risks. The laundry floor must be made level or replaced. A previous requirement with a timescale of 06/08/07 was not met. The front garden needs to be provided with an appropriate boundary to deter trespassers, provide residents with privacy and provide them with greater safety when opening the patio door. The rear garden also DS0000013749.V347838.R01.S.doc Timescale for action 09/02/08 2. OP19 13 09/02/08 3. OP19 23 09/02/08 Pinewood Version 5.2 Page 34 requires a gate to make it a secure and safe enclosed area. Previous related requirements with timescales of 28/7/06 and 28/8/07 were not met. The responsible person must make proper provision for the maintenance of residents’ privacy and confidentiality in the course of the day-to-day conduct of the home. The responsible person must provide a more accessible emergency call system within residents’ bedrooms, to increase the chance of a resident raising the alarm, in the event of an emergency such as a fall. An approved fire door holdback device must be fitted to the kitchen door, to maintain fire safety requirements whilst enabling residents’ independent mobility around the home. The use of a wedge is not appropriate and must cease. In the event that residents require their bedroom doors to be held open during the day to maximise their independent mobility, approved holdback devices must be installed to enable this. The use of wedges is not appropriate and must cease. Appropriate equipment must be provided to enable soiled laundry to be handled safely by staff and provide effective infection control to protect residents. An annual development plan must be drawn up in respect of the care home. Previous requirements with timescale of 21/06/05, Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 35 4. OP19 12(4)(a) 09/02/08 5. OP19 23 09/02/08 6. OP19 23 09/01/08 7. OP19 23 09/01/08 8. OP26 13 09/01/08 9. OP33 25 12/12/07 10. OP35 13 28/04/06 and 28/7/06, were not met. The provider must ensure that 09/12/07 additional charges over and above the basic fees are made explicit within the Service User Guide. 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 OP7 OP9 Good Practice Recommendations Staff should be reminded of the need to date and sign behaviour and incident records such as ABC charts to enable their effective use in planning future support. All staff that take part in the medication administration process should receive appropriate accredited training on this, to ensure they understand their role and the importance of medication records. Consideration should be given the provision of a dedicated vehicle exclusively for use by the home. Consideration should be given to the installation of a modern emergency call system, which would enable residents to summon staff assistance wherever they were within the property. Further steps should be taken to address the unpleasant odour within the adapted bathroom. The additional staffing identified as necessary should be provided, in order to more fully meet residents’ needs. New staff should be enrolled onto NVQ in order to maintain and increase the proportion of NVQ qualified staff and maximise awareness of current good practice. Staff CRB checks should be updated every three years to maximise protection for residents. Individual fire evacuation risk assessments should be reviewed regularly, should reflect any identified concerns, and should provide practical steps for staff to address the identified issues. 4. 5. OP12 OP19 6. 7. 8. 9. 10. OP26 OP27 YA28 YA29 OP38 Pinewood DS0000013749.V347838.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Oxford Office 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 DS0000013749.V347838.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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