Inspection on 02/08/05 for Pinewood & Hollywood

This inspection was carried out on 2nd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinewood & Hollywood 03/04/07

Pinewood & Hollywood 31/10/06

Pinewood & Hollywood 06/12/05

Pinewood & Hollywood 13/01/05

Pinewood & Hollywood 28/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Pinewood & Hollywood Smiths Field, Old Heath, Colchester, Essex CO1 2HP Lead Inspector Jane Greaves Unannounced 14th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pinewood and Hollywood Address Smiths Field, Colchester, Essex CO1 2HP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pinewood - 01206 791455 Hollywood - 01206 795971 01206 795971 crichardson@rchl.org.uk Redbridge Community Housing Limited(RCHL) Mrs Patricia Marie Petrocochino Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration apply. Date of last inspection 13/01/05 Brief Description of the Service: Pinewood & Hollywood is a care home providing personal care for 8 adults with learning disabilities. The home was opened in 1995, consists of two semidetached bungalows and is situated on a quiet residential development to the south of Colchester town centre close to local ameneties. Each property has four single bedrooms, one bathroom, one shower room, a kitchen/dining room and a large lounge area. There is an enclosed garden to the rear of the property and ample car parking facilities to the front. the regsitered manager is Mrs. Patricia Marie Petrocochino and the registered organisation is Redbridge Community Housing Limited. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 14th June 2005 over 3 ½ hours. 14 of the 43 National Minimum Standards were assessed with 9 being met. For the purpose of this report the people living at Pinewood and Hollywood prefer to be referred to as residents. The deputy manager, support staff and the two residents available on the day contributed greatly to the inspection process. Records relating to residents’ welfare, staff recruitment and health and safety were scrutinised. Overall the standard of care, support and management was good with a positive and warm interaction observed between staff and residents. As this inspection was unannounced it was not possible to contact families and representatives in advance, therefore part of the inspection process was to forward a questionnaire to each resident’s next of kin to obtain their views on the care service provided. What the service does well: What has improved since the last inspection? What they could do better: The residents would benefit from the organisation providing the option of a 7 day break outside the home as part of the basic contract price. Support staff training in mandatory areas such as the Protection of Vulnerable Adults and infection control is necessary to protect the health welfare and safety of the residents living at the home. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 6 The deputy manager was not able to demonstrate that the organisation had a Quality Assurance system of canvassing views from residents, families and other stakeholders regarding the standard of care, facilities and lifestyle of residents at Pinewood and Hollywood. 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 & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective residents’ needs and aspirations were assessed prior to admission to ensure the home was able to provide appropriate care. EVIDENCE: Four residents’ files were scrutinised during this inspection. On all files there were the Redbridge Community Housing Limited assessment of needs. These were comprehensive and detailed, covering every aspect of daily life. Assessments had been made for any activities that could potentially place a resident at risk, for example boiling a kettle or walking to the day centre without staff supervision. The resulting actions to minimise these risks were documented clearly. The deputy manager stated that family contact is encouraged and most residents frequently spend time with their family both at Pinewood & Hollywood and at their family homes. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 10 Assessed and changing needs of residents are reflected in their individual plan of care ensuring their continued safety and well being. Confidential information within the home is handled appropriately and residents know that their confidences are kept. EVIDENCE: Care plans sampled at this inspection contained regular reviews of the healthcare, personal and spiritual needs of the residents. These reviews detailed any changes in care regimes and were signed and dated appropriately with on going reviews scheduled and planned for. Where the assessment of needs had identified any restrictions on choice and freedom of the resident this was clearly documented with scheduled dates for review. The organisation had a corporate policy and procedure on confidentiality and this was available to all residents and their families/representatives. Support staff training with regard to confidentiality was provided in the home’s induction process. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 10 On the day of the inspection the deputy manager and a member of the support staff were observed discussing an individual’s needs, this was done in a very discreet and respectful manner. Residents’ individual records were stored in the office which was locked when not in use. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 17 Residents enjoyed varied leisure activities but were not provided with a 7 day holiday as part of the contract. Residents were provided with a healthy diet and enjoyed their meals and mealtimes. EVIDENCE: Both houses had a good selection of family board games and activities such as jigsaws, craft books and videos. Group trips to the Zoo were planned and some residents went bowling occasionally. The home had it’s own minibus to transport residents and were considering replacing the vehicle for a newer model. The organisation does not provide residents with the option of a 7 day break away from the home as part of the basic contract price. The deputy manager stated that this is a matter of funding and is being negotiated by RCHL with Social Services. The two residents spoken with at this inspection confirmed they liked the food provided and were happy with the system of menu planning at the home. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 12 Each of the four residents living in both houses selected the meals for the week by use of pictures with Makaton symbols alongside. A record of meals eaten by whom and when was maintained by support staff but both houses had gaps in these records. Food cupboards were well stocked with ingredients required to provide the planned menu choices. Residents were encouraged to participate in kitchen activities as much as their disabilities would allow. The sink and adjacent work unit were adjustable in height allowing residents in wheelchairs to participate. Mealtimes were flexible allowing for individuals’ independent lifestyles; one resident was happily eating breakfast at 11am on the day of the inspection. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Residents were protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Redbridge Community Housing Limited had a comprehensive policy and procedure for the safer handling and administration of medicines. Support staff had received accredited competency based training from an external source as well as the organisations in house training. Two new staff members had not received external training at the time of this inspection, the deputy manager confirmed that it was planned to take place. Medication Administration Records were maintained appropriately within both houses. There were no residents self-medicating at the home and there were no controlled drugs maintained on the premises. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents felt their views were listened to and acted on. Residents were protected from abuse, neglect and harm by Redbridge Community Housing Limited policies and procedures. EVIDENCE: RCHL had policies and procedures outlining the complaint process and the timescale for action. Support staff work closely with the residents and consequently daily issues are addressed immediately and do not develop into complaints. Neither the home nor the Commission for Social Care Inspection had received any complaints regarding this service in the past twelve months. The deputy manager stated the manager is trying to secure advocacy services for a nonverbal resident at the home. The manager had undertaken specific training in the Protection of Vulnerable Adults, this had not yet been provided for the support staff. RCHL induction training included adult protection. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Residents live in a home that is safe, accessible and comfortable. On the day of the inspection the home appeared clean and hygienic. EVIDENCE: Both houses were clean and free from offensive odours. The premises were safe and accessible to all residents. Individual rooms had been personalised according to residents’ choice and the communal areas of one house had been recently re-decorated according to residents’ wishes. The residents selected new carpeting and furnishings for the house. The premises met with the requirements of the local fire service and environmental health department. On the day of the inspection both houses appeared clean and hygienic however, support staff required training in the control of infection. Laundry facilities were appropriate and sited away from food storage or preparation areas. The home did not have a sluicing facility but the washing machines did have a sluice program. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 36 Residents’ needs were met by experienced staff members, however, some mandatory elements of training were not being provided therefore creating potential for risk. Residents benefited from well-supported and supervised staff. EVIDENCE: Pinewood and Hollywood had a training and development plan and RCHL had a designated training officer. An updated list of training attended was supplied to the home periodically to assist the unit in maintaining accurate training records. This inspection identified the need for training in the Protection of Vulnerable Adults, the control of infection and refresher training in safer moving and handling for support staff. Staff members spoken with confirmed they receive good management support and have supervision sessions at intervals of approximately six weeks. Records of supervision were available for scrutiny. The deputy manager produced a sheet identifying the supervision schedule for all staff at the home. Evidence of a schedule for annual appraisals was observed however all paperwork relating to appraisals was still held at the personnel department. All staff spoken with confirmed attending annual appraisals This paperwork was not made available for inspection, RCHL had advised managers that, due Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 17 to confidentiality of employees’ personal information, some of which may be sensitive, the content of annual appraisals is not to be disclosed. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 41 Residents’ views underpinned constant review and development of the home. The home’s record keeping policies and procedures safeguard the residents’ rights and best interests. EVIDENCE: Redbridge Community Housing Limited had conducted annual quality assurance surveys. The organisation is continuing to work on the Quality Assurance system to make it more service user friendly. RCHL have a quality assurance board and a service user is actively involved on the board. A copy of the report is forwarded to the individual projects within RCHL and issues addressed accordingly. The registered manager was informed that a summary of the service user/staff/family questionnaires and resulting action required to address issues raised must be forwarded to the Commission for Social Care Inspection. Previously it had not been possible to assess the home’s recruitment policies and practices because relevant paperwork was not maintained on the Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 19 premises. The organisation had altered policy and 2 staff files were sampled at this inspection. The only documentation not available for scrutiny were the records of annual appraisals but these were confirmed by staff members and an appraisal schedule available on the day. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x 2 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pinewood & Hollywood Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 3 x x I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 21 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 YA23 Regulation 13(6) Requirement The registered person must ensure training is provided for all staff in the Protection of Vulnerable Adults from Abuse. The registered person must ensure training is provided for all staff in the control of infection. The registered person must ensure training and refresher training is provided for all staff. The registered person must continue to develop and maintain a system for quality assurance within the home and forward a copy of any such report to the Commission for Social Care Inspection. Timescale for action 31st September 2005 31st September 2005 31st September 2005 31st September 2005 2. 3. 4. YA30 YA35 YA39 13(3) 13(5) 24 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 YA14 Good Practice Recommendations The registered person should ensure that residents have the option of a holiday as part of the basic contract price. Pinewood & Hollywood I56-I05 Pine Wood Holly Wood UI S17910 V232248 130605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Fairfax House Address 2 Causton Avenue Colchester. CO1 1RJ 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. 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