Inspection on 15/05/07 for Pinewood Care

This inspection was carried out on 15th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pinewood Care 23/06/09

Pinewood Care 01/07/08

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Pinewood Care 34 Telegraph Road West End Southampton Hampshire SO30 3EX Lead Inspector Michael Gough Unannounced Inspection 15th May 2007 10:00 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 Care DS0000069022.V336156.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 Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood Care Address 34 Telegraph Road West End Southampton Hampshire SO30 3EX 02380 472722 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) G & A Investments Projects Ltd Stoika Radeva Care Home 16 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Pinewood is a care home situated in West End on the outskirts of Southampton. The Registered providers are G & A Investments Projects Ltd and own another care home in Southampton. The home provides accommodation for sixteen service users within the categories of older persons and older persons with dementia. The home offers accommodation in a range of single and double rooms over two floors. The home has a stair lift to the first floor of the home enabling service users access to the entire home. The home has a central lounge and dining room and also a smaller lounge area; there is also a conservatory. To the front of the home is a car parking area and to the rear of the property is a large well maintained and pleasant garden, which is accessible to service users. The home is situated close to local facilities and is a short journey away from Southampton. Fees at the home are £480 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Pinewood Care Home and takes into account the accumulated evidence of the activity at the home since the new owners were registered in December 2006 The inspection took into account the homes Annual Quality Assurance Assessment (AQAA), which was completed shortly before the visit to the home. Included in the inspection was an unannounced site visit to the home, which took place on the 15 May 2007. Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and service users. It was also possible to gain the views of people living at the home and the inspector had the opportunity to speak with 3 visitors to the home, 8 service users, 5 members of staff and 1 visiting health care professional. The inspector also viewed completed satisfaction surveys from 5 service users and 7 relatives. The home manager was not available, however the inspector was assisted by the care staff on duty at the home. The home is registered to provide support for 16 service users but at the time of the inspection there were only 13 service users living at the home. What the service does well: The home provides a homely and welcoming environment and service users spoken to all told the inspector that the homes staff provide an excellent service and comments received included “I couldn’t wish for a better place” and “ the staff are wonderful”. The inspector observed staff interacting with service users and it was clear that there was a good relationship between service users and staff. 3 visitors to the home spoke with the inspector and all were very happy with the care their relatives receive and said that their was always a nice atmosphere in the home and that they were always made welcome. All service users spoken with said that meals were very good, they said that they enjoyed the home cooking and all sat down together in the dining room for meals. All of the staff at the home have either completed or are in the process of completing a minimum of NVQ 2. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New service users have a needs assessment undertaken prior to moving into the home and this allows both the home and the service users to see if the home can meet the service users needs The home does not provide intermediate care. EVIDENCE: The most recent service users moved into the home in December 2006, there was a needs assessment on file and the inspector was informed by staff on duty that the manager goes out to visit service users before they move into the home. The Annual Quality Assurance Assessment completed by the homes manager also states that no service user moves into the home without being fully assessed, however it also states that they do not have a policy for referral and admission and the staff on duty were not aware of any policy on admissions. The inspector recommends that a policy and procedure be put in place, as this would be beneficial for staff and service users. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 9 Assessments are carried out using an assessment form and case tracking of 3 service users showed that needs assessments were available and on file and those service users and relatives spoken to confirmed that someone from the home assessed their needs before they moved into the home. Intermediate care is not provided by the home. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the health, personal and social care needs of service users are set out in an individual plan of care, however some amendments are needed and risk assessments need to be reviewed. Service users are protected by the homes policies and procedures for dealing with medicines but the home must ensure that clear records are kept to protect service users. EVIDENCE: Care plans were inspected for 3 service users and these plans had information for staff on service users ability, problems and needs also the aims of the care plan and how care should be delivered, however one service user had on occasions, potentially contagious bouts of sickness and diahorrea and the care plan did not give clear instructions for staff on the procedures to follow and there was no infection control advice or risk assessment in place. There were no risk assessments in place for any of the service users tracked even though there were some risks identified, the inspector looked briefly through other Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 11 care plans and where risks assessments were in place they did not contain clear details of the risk and the actions to be taken to minimise risks and they had not been regularly reviewed. Service users are registered with 4 different GP surgeries all of which have a number of different GP’s and service users may keep their own GP if they wish. Dental and optician services are provided in the local area as required and GP practices provide a district nurse service and also provide referrals to other health care professionals as required. The inspector had the opportunity to speak with a visiting nurse who said that she thought that care in the home was good and she had no concerns about the home and that she felt that the health care needs of the service users were met. The home has a policy for the receipt, storage, return and administration of medication and generally medication recording was clear, however the home uses its own codes to record when service users refuse medication and this could be confusing. Therefore a key to the codes used by the home needs to be put in place to avoid any misunderstandings. It was also noted that some service users are prescribed paracetamol and co-codamol 1 or 2 to be taken when required. The medication administration sheet was signed but it did not give clear information on how much medication had been given and the home must ensure that clear records are kept of the amount of medication given on each occasion it is administered. All staff at the home who administer medication have received training and specimen signatures are kept Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for service users and the recreational interests of service users at the home are generally provided for. Service users are able to maintain contact with family and friends and visitors are welcome at any time. Service users are supported to exercise choice and control over their lives and are provided with a wholesome and balanced diet in pleasant surroundings at a time convenient to them. EVIDENCE: Staff spoken to stated that the manager was keen to introduce more activities into the home. Currently the home provides a range of activities for service users and there was a programme of planned activities on the notice board in the home, activities included, hairdressing, manicure, visiting singer, visiting organist, ball games, skittles, crafts, dancing, DVD’s and films. Some of the service users spoken with said that they would like more activities in the afternoons and staff stated that they try to arrange spontaneous activities. The homes AQAA recognised that that they need to arrange more activities in the afternoons. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 13 The home has a visiting policy and there are no restrictions on visitors. They are encouraged to visit and are invited to any social gatherings held in the home. The inspector had the opportunity to speak with 3 visitors to the home and they stated that they were always made welcome and were very happy with the home. One visitor stated that more staff training in supporting service users with dementia would be beneficial. Service users spoken to were able to confirm that they are able to make informed choices and were able to control their own lives as much as possible. The manager writes up menus for the home four weeks in advance and takes into account service users likes, dislikes and preferences. The home does not employ a cook and cooking duties are carried out by one of the care staff, those spoken to enjoyed doing this and said that they were still able to help out with care duties if needed. Service users are offered a choice at meal times and are able to eat their meals in the dining room or elsewhere if they prefer. Service users and visitors spoken to stated that meals at the home were good and that there was always plenty to eat. One service user was having a different meal to that on the menu. The inspector observed lunch being taken in the dining room and this was a social occasion and service users were seen chatting to each other over lunch. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect service users from any form of abuse. EVIDENCE: The home has a clear complaints procedure, which contains all of the required information. There is a complaints book placed in the entrance hall of the home and no complaints have been recorded. Service users and visitors spoken to were aware of the homes complaints procedure and were confident about raising any concerns they may have and stated that they would address any complaint they may have to a staff member or to the homes manager. Staff members spoken to were aware of the homes complaints procedure. Staff have received training on adult protection as part of their initial induction and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well maintained environment and have access to comfortable indoor and outdoor facilities and the home is clean pleasant and hygienic. EVIDENCE: The inspector toured the building and all areas of the home were clean and tidy and furniture was in a good state of repair. The home comprises of 2 floors with a chair lift to aid access. There is a large communal lounge/dining area and also a smaller TV lounge, there is also a small conservatory that leads to the rear garden, which is accessible to all service users and this was tidy and attractive. The home employs a maintenance man who carries out routine maintenance and rectifies any defects as they arise. Decoration of the home is on a needs led basis. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 16 The home has a laundry with industrial washing machine with sluice facility and can wash clothing at appropriate temperatures and there is also an industrial tumble drier. Care staff at the home carry out laundry duties and all staff have received training with regard to infection control. All areas were clean and there were no offensive odours. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff on duty to ensure service users receive the support they require. Staff were found to be well motivated and competent to do their jobs and service users are protected by the homes recruitment procedures. The home provides training for staff to enable them to carry out their roles effectively, however more training in dementia care practices would be beneficial for staff and service users. EVIDENCE: The inspector looked at the staffing levels and this showed that there are three staff members on duty between 0800 & 1400 and 2 staff on duty between 1400 and 2000. Between 2000 and 0800 there are 2 staff on duty with one of these able to sleep between 2200 and 0600. In addition there is a cleaner employed 5 days per week who works 3 hours per day and the homes manager works 5 days per week between 0900 & 1700 but staff said that she is available at other times if required. Staffing numbers were discussed with the staff on duty they stated that with the present numbers of service users, staffing levels were sufficient. Service users and visitors said that there was always enough staff around. The home employs a total of 11 care staff and has 4 members of staff who already have NVQ and 5 staff members currently undertaking NVQ training. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 18 The homes manager was unavailable so recruitment records were not inspected on this occasion as records were kept securely locked away, however staff spoken to confirmed that they had completed application forms and that CRB and POVA checks were carried out before they started work at the home. Staff training records were looked at and this showed that staff have received mandatory training in first aid, food hygiene, moving and handling, fire, infection control and adult protection. Additional training is provided in medication and dementia care. One of the visitors spoken with felt that staff would benefit from more information and training on how to support service users with dementia and staff spoken to felt that extra training would be beneficial, therefore the inspector recommended that the home should investigate the provision of more training in dementia care practices. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users and the homes manager is experienced and competent to run the home. Service users, relatives and other interested parties are consulted about the running of the home and how it is meeting its aims and objectives. There are adequate financial procedures in place and the health safety and welfare of service users and staff are generally promoted and protected, however the home must address the issues identified in the fire safety audit of the 3 May 2007 to protect and promote the health, safety and welfare of service users and staff. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has only been in post since December 2007. She demonstrated her fitness to manage the home as part of the registration process that was carried out prior to her registration being approved by CSCI. Staff and service users spoke positively about the homes manager. Service users confirmed that the manager is available most days and that the manager seeks their views about any changes to the home. The home is developing its quality assurance systems and the AQAA states that quality assurance is very important. There were surveys available for service users and visitors to the home. On audit of the completed questionnaires the inspector saw that 5 had been received back from service users and comments were positive. There were 7 returned from visitors and comments such as “this is moms 4th home and this is the first one where mom is happy to stay” “it’s a great relief to know my mother is well looked after” and “ I have always found staff very friendly and caring” Staff were not aware of the procedures regarding service users finances, however they did say that some service users have their own personal money and that the manager does hold some monies for service users for safe keeping and this is kept locked in the safe. The home has a fire risk assessment for the building and the fire logbook was inspected and all required recording and testing had been carried out. The home had requested a fire safety audit from Hampshire Fire and Rescue and this was carried out on 3 May 2007. There were a number of issued identified from the audit and from touring the building it was evident that these had not yet been addressed by the home. Therefore the home must address the issues raised in the fire safety audit to protect and promote the health, safety and welfare of service users and staff. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The manager must ensure that care plans include all of the information needed so that staff can provide the appropriate support to all service users. Risk assessments must be put in place when any risk is identified and risk assessments must be reviewed on a regular basis. 2 OP9 13(2) The manager must ensure that Medication recording codes are clear to avoid any misunderstandings. The manager of the home must ensure that clear records are kept of the amount of medication given on each occasion it is administered. 3 OP38 23 The manager of the home must ensure that appropriate action is taken to address the issues identified in the fire safety audit. 30/06/07 30/06/07 Timescale for action 30/06/07 Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations Staff would benefit from further training in caring for people with dementia. Pinewood Care DS0000069022.V336156.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Care DS0000069022.V336156.R01.S.doc Version 5.2 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. 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