Inspection on 07/08/07 for Pinewood Lodge

This inspection was carried out on 7th August 2007.

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

The inspector 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 Lodge 21/07/06

Pinewood Lodge 23/01/06

Pinewood Lodge 07/07/05

Pinewood Lodge 18/11/04

Pinewood Lodge 05/08/04

Pinewood Lodge 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Pinewood Lodge Oxhey Drive Watford Hertfordshire WD19 7HR Lead Inspector Yoke-Lan Jackson Unannounced Inspection 7th August 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 Lodge DS0000019496.V348235.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 Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood Lodge Address Oxhey Drive Watford Hertfordshire WD19 7HR 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) 0208 421 7900 0208 421 7961 www.quantumcare.co.uk Quantum Care Limited Katie Heather Jane Dalton Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2006 Brief Description of the Service: Pinewood Lodge, provided by Quantum Care Limited, is a residential care home registered for 60 residents in the Old Age and Dementia category. The building is a purpose-built home that was completed in 1997. It comprises of a two-storey building with a main entrance to the first floor at upper ground level and a lower ground floor. There are parking facilities to the front of the building. Accommodation is offered in four 15 bedded units. Each unit has a separate lounge and dining area, a fully fitted kitchenette, a medication storage area and a staff workstation. All bedrooms are in excess of 12 sq. metres in area and have en suite toilets and sinks. The assisted bathroom and assisted shower room are nearby. The home has an administrative section on the ground floor, a fully fitted stainless steel equipped kitchen with appropriate storage rooms and cold storage equipment and a well equipped laundry. Other facilities available to residents include a ground floor conservatory and a first floor hairdressing salon. The gardens extend around the home, which is screened from the road and neighbouring buildings by mature hedges and trees. There are pleasant patio areas with seating for residents and visitors. The garden is accessible to wheelchair users. The home charges £400 - £565 per week. Further information can be obtained from the home’s Statement of Purpose and the Service User Guide. A copy of the CSCI inspection report should be available in the home. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The deputy manager was present. There is currently one vacancy with 59 people in residence. The inspection began with a tour of the building. All 4 units were inspected. Some time was spent observing how the staff interacted with the residents. Staff, residents and their relatives were spoken with. Documents were examined and the inspection ended with a general discussion with the deputy manager. To gain the views of people who use the service and those who visit socially and professionally the Commission sent survey forms to residents, relatives and health & social care workers. Their comments have been included in this report. Information received by the Commission since the last inspection has also been reviewed. This includes the Annual Quality Assurance Assessment (AQAA) which providers of registered services are required to complete. The AQAA focuses on how well outcomes are being met for people using the service. What the service does well: What has improved since the last inspection? Since the last inspection, the dementia units have been moved onto a single floor. In this way, the needs of all client groups can be met appropriately and efficiently. All the care plans are now kept in a lockable cupboard in accordance with the Data Protection Act 1998. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 6 The home has purchased four medication trolleys, one for each unit, and they are kept securely in a medication storage room. 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 Lodge DS0000019496.V348235.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 Lodge DS0000019496.V348235.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): Standard 1, 2, 3 & 4. Standard 6 is not applicable to Pinewood Lodge. People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Prospective residents have the opportunity to visit and assess the facilities and suitability of the home. They have the information they need to make an informed choice. A thorough assessment is carried out prior to admission of a prospective resident so that they and the home can be sure that their individual needs can be met. EVIDENCE: A unit manager and a senior care worker will carry out a full assessment on a prospective resident. On admission, the new resident will meet the same care worker who is then their key-worker. The manager will explain to the prospective resident what the service is and how to provide for their care needs and preferences. Sometimes an admission is delayed until any appropriate equipment needed for the resident has been delivered. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 9 Both the home manager and the deputy manager ensure that all the care needs of a prospective resident can be met before an admission is agreed. The home will only admit residents whose care needs can be met. The pre-admission assessment documents were available in the care plan files examined. Pinewood Lodge DS0000019496.V348235.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): Standards 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Residents have access to specialist medical treatment and other healthcare services as appropriate to meet their needs. Each resident has a written care plan so that staff are aware of individual needs and how to meet those needs. People who use the service safety is maintained as medication is administered in accordance with legislation and good practice. EVIDENCE: In general, residents are well cared for. However, on the day of the inspection, it was noted that two care workers were using a hoist to lift a female resident (who was wearing a short dress) in the lounge without using a covering sheet or blanket. The care worker said that they do normally but it was too hot on the day to use a blanket. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 11 Since the last inspection, the units have been reorganised to ensure that all dementia clients are in the two units on the lower floor. Being on the same floor benefits those residents who tend to walk about, because there is more communal space available. In addition, the needs of all client groups can be met more appropriately and more efficiently. In a recent CSCI survey a resident commented, “The staff are excellent in their response to medical needs. They seemed to contact the doctor immediately they were informed of my problems.” Residents are able to choose their own doctor, and the home has a good rapport with the district nurse, who will visit the residents to attend to any nursing tasks such as wound care and dressings. In addition, the management meet with the district nurse manager every three months to discuss any concerns. The administration of medicines is by a trained member of staff. Since the last inspection 4 medication trolleys have been purchased, one for each unit. These are stored securely in a lockable medication storage room on the ground floor. The storage room temperature is closely monitored. The Medication Administration Record Charts examined were correctly filled in. The staff have regular refresher course on medication. Pinewood Lodge DS0000019496.V348235.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): Standards 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Residents are helped to exercise choice and control over their lives. However, there is a lack of recreational activity and mental stimulation for the residents, including those with dementia. Residents maintain contact with their family and friends. The meals provided are nutritious and wholesome. EVIDENCE: In Oxhey Unit, which is a dementia unit, there were three staff attending to 15 residents. Most of the residents were quite restless and the staff were kept busy attending to each resident’s personal care needs right through to lunchtime. There were a number of visitors in the Oxhey unit. The relatives interviewed were not able to comment since the resident was only recently admitted. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 13 In Dove Unit, it was noted that a care worker was left on their own to attend to 8 residents in the dining room. Two residents were left on their own to have lunch in the lounge without supervision. A care worker was busy assisting a resident in their bedroom. Another care worker had gone to fetch the medication trolley. Shortly afterwards, the unit manager came to assist. Hot dishes were served at lunchtime. The meals provided were reasonably presented and most residents seemed to enjoy their lunch. In both units there were no recreational activities or mental stimulation for the residents, who have dementia. A member of staff said that there is an activity co-ordinator but she was busy in one of the other residential units (called high dependency units). In the residential units, the activity for the day was ‘knitting.’ It was noted that the residents in the lounges appeared ‘bored’. In a recent CSCI survey, a relative commented, “Activities are rather few and far between but when they are available they are very good.” The management said that more activity hours are being considered and the home is in the process of employing an additional activity coordinator. Currently there are two part-time activity coordinators. Only one was on duty on the day of the inspection. Pinewood Lodge DS0000019496.V348235.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): Standards 16, 17 & 18. People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. There is a robust Complaints Policy and Procedure in place and people can be assured that their complaint will be taken seriously. Residents can be assured that their legal rights will be protected and will be protected from abuse. EVIDENCE: Residents’ meetings are organised on a regular basis. Residents’ views are taken into consideration and appropriate changes are made. Staff receive training on abuse and issues concerning Safeguarding Adults (protection of the vulnerable) and Whistle-blowing . The Hertfordshire County Council joint agency Safeguarding Adults procedure and guidelines is followed. Since the last inspection there have been two cases that are being investigated under the Safeguarding Procedure. One of these proved unsubstantiated. The other is still being investigated. Pinewood Lodge DS0000019496.V348235.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): Standards 19 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely environment that meets their needs. To ensure the upkeep of the home there is a planned maintenance programme. EVIDENCE: On the day of the inspection, the home appeared clean and well maintained. The bedrooms examined appeared clean and tidy. Residents spoken to seemed content with their bedrooms. There were items that reflected their individual lifestyles. In response to the CSCI survey a visitor commented that the home is “fresh and clean.” Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 16 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): Standard 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment policy and practices. The training programme and the skill mix of the staff ensure that the care needs of the residents are being met. EVIDENCE: On the day of the inspection, members of staff were observed to interact well with the residents. However, it was observed that, at times, residents were left unsupervised in the lounge during lunchtime on the Dove unit. Induction training is provided for new staff and there is also a mandatory training programme for all staff. All care staff are expected to complete their NVQ2. The home has 4 trainers and three assessors among the senior staff. The unit managers have unit days so that they can work alongside the care workers and assess the care practice. Since the last inspection, the home has been busy recruiting permanent staff. As a result the number of agency workers has been reduced. Also the retention of staff has improved. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 17 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, 32, 33, 34, 35, 36, 37 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standards of administration and management of the service have been maintained to meet the Statement of Purpose and service users interests. The health, safety and welfare of the residents are promoted and protected. Their rights and best interests are safeguarded by the policies and procedures in place. EVIDENCE: Staff interviewed said that the managers are approachable and supportive. Staff have regular supervision. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 18 There is a quality assurance and monitoring system in place. Questionnaires are sent out to residents, relatives, healthcare professionals and others once a year. All new residents receive written questionnaires a few weeks after admission to provide feedback. A report is concluded at the end of the year and shared with residents, relatives and any other interested parties. The registration certificate and the home’s public liability insurance certificate are on display on the wall in the reception area. All servicing and financial records are maintained and kept in accordance with the Data Protection Act 1998. The recently introduced CSCI Annual Quality Assurance Assessment forms issued to the home for this inspection were returned on time. The contents were detailed and informative. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 19 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 3 3 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP12 OP12 Good Practice Recommendations Members of staff should be readily available to assist residents during mealtimes. The activity programmes should be reviewed to ensure that residents’ recreational and social needs are being met. Pinewood Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Lodge DS0000019496.V348235.R01.S.doc Version 5.2 Page 22 - 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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