Inspection on 10/04/06 for Pinewood Manor Residential Retreat

This inspection was carried out on 10th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Manor Residential... 08/06/07

Pinewood Manor Residential... 17/07/06

Pinewood Manor Residential... 04/01/06

Pinewood Manor Residential... 25/07/05

Pinewood Manor Residential... 15/02/05

Pinewood Manor Residential... 12/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pinewood Manor Residential Retreat Old Lane St Johns Crowborough East Sussex TN6 1QR Lead Inspector Elaine Green Key Unannounced Inspection 10th April 2006 08:00 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 Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pinewood Manor Residential Retreat Address Old Lane St Johns Crowborough East Sussex TN6 1QR 01892 653005 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) Ampersand Care Ltd Ratna Malar Hancock Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accomodated at any one time is twenty eight (28). The care home provides personal care to older people aged sixty-five (65) or over on admission. 4th January 2006 Date of last inspection Brief Description of the Service: Pinewood Manor Residential Retreat is a large, privately owned care home registered to provide care and accommodation for 28 older people. The current owners registered the home in June 2004. The detached property is set in its own mature gardens that overlook Ashdown Forest. Service users accommodation is situated on two floors with a shaft lift and two staircases providing access to the first floor. The home was extended in 1997 to provide additional ground floor accommodation and lounge. There is level access to the grounds. The home is about one mile from the amenities of Crowborough town centre which is accessible by taxi. The nearest train station is at Jervis Brook which is approximately 2 miles away. Train services provide links to Tonbridge, Tunbridge Wells and London. The bus services provide links to Brighton and local towns of Uckfield and Tunbridge Wells as well the local villages. A copy of the Commission for Social Care Inspection report can be found in the entrance hall at Pinewood Manor. The fees range from £325 - £500 per week. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of Pinewood Manor Residential Retreat a site visit took place to the home. This took place between 8 am and 4.30 pm on the 10th April 2006. The Inspector had a tour of the building, joined service users in the dining room for their midday meal and had the opportunity to meet with two visiting relatives and a visiting health care professional. The Inspector had discussions with the visitors, 9 service users, manager and members of staff team and their comments will be reflected within the report. A range of records and documentation were also examined and included some of the homes’ policies, procedures, guidelines and daily records, service users care plans, medication records and records pertaining to health and safety. Service user questionnaires were sent by the CSCI prior to the visit and feedback form the one completed questionnaire received will be included within the report. In addition to the site visit the Inspector has also collated information received by the Commission for Social Care Inspection (CSCI) in relation to the care received by the residents, concerns/complaints raised, the management of Pinewood Manor Residential Retreat and the progress the home has made to the requirements made at the last Inspection on the 3rd January 2006. What the service does well: What has improved since the last inspection? The manager now has a job description that reflects her roles and responsibilities. Some progress has been made towards meeting a number of the other requirements made although they remain outstanding. The manager has worked hard to produce a new statement of Purpose and Service user Guide that is almost complete. Applications have now been made for all the staff employed at the home to have the relevant security checks and identity checks undertaken. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 6 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. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 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 Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users have been inappropriately admitted to the home and information provided to them prior to admission was inadequate. EVIDENCE: The registered manager has worked hard to implement a new service user guide and statement of purpose. This is almost complete and the manager assured the Inspector that this will be reflective of the services offered and will be available for both current and prospective service users. This home is registered to admit Older People. It is not registered for and cannot meet the needs of people suffering from dementia type illnesses. Following the concerns raised within the last report the Inspector was assured by the provider and manager that the home had not admitted anyone out of category. Observations on the day of the site visit, discussions with service users, relatives and staff all indicate that two service users were suffering from dementia type illnesses when they were admitted to the home and that issues Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 9 relating to their associated behaviours were discussed with the manager prior to their admission. The last report required that any service user resident in the home on a trial basis or otherwise, whose needs could not be met, must be reassessed and the appropriate documented action taken without delay. This requirement has not been met, no action was taken and further requirements are made. All residents suffering from any level of confusion must be reassessed as a matter of urgency, a record of this process must be maintained and be available for Inspection. The service users relative and or care manager must be informed and involved in this process. A relative explained that they had been able to visit the home prior to making a decision about whether the home was suitable. They stated that they had not been involved in any of the assessments and had no knowledge of any care plan. Service users or their relatives must be involved in the assessment and care planning processes. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are not reflective of service users current health and social care needs. Medication administration practices are poor and have the potential to place service users at risk. EVIDENCE: Four service users care plans were examined. Through discussions with service users, their relatives and staff it is evident that the care plans are not reflective of their current needs. One service user was admitted to hospital after falling and sustaining a serious injury but no detail of this is recorded in the care plan or daily records for this individual. Another service users’ level of mobility had dramatically reduced and yet the care plan indicated that they were fully mobile. Other service users are known to display a level of challenging behaviour but this is not indicated on the care plan so there is no guidance for staff to follow in relation to any intervention that may be required or ways that the risk of this occurring could be minimised. Not all care plans contained a property list. A health care professional raised concerns about the lack of any foot care for one service user and yet this should have been part of the pre Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 11 admission assessment and care planning process. Requirements are made to ensure that care plans are based on a thorough and complete assessment and are kept under review. During the site visit medication administration practices were observed to be poor. The practice of potting up several service users medication at once was observed and this can lead to mistakes being made and the wrong medication being given. A relative confirmed to the Inspector that this had happened to their relative recently. Staff were also observed to leave medication in pots on the medication trolley unsupervised in the hallway, this too poses a risk to service users. The Inspector asked a member of staff what one of the service users medication was for but they were unable to say indicating that a lack of r knowledge of the medication they are administering. One of the service users had several homely remedies in their room and some prescribed medication but this was not indicated on their care plan. The providers have supplied more suitable storage for the medication but the medication trolley still has to be taken out of the cupboard to be stocked and it is recommended that a more suitable location is found for both the cupboards and trolley. A requirement was made at the last Inspection for suitable refrigerated storage facility to be provided for medication. Medication was again found in the food fridge and this was being stored at above the required temperature. A further requirement is made. During the Inspection staff were observed treating service users with dignity and respect and a visiting health care professional treated service users in the privacy of their own rooms. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provision of activities is limited. The food provided is of good quality, varied and wholesome. EVIDENCE: Through discussions with service users and staff and the examination of daily records and care plans it is evident that the home continues to provide service users the opportunity to participate in some group activities. The home also holds weekly residents meetings where service users are able to raise issues of concern or just get together for a social event. Some care plans do specify individuals’ interests but there are no guidelines for staff to follow in relation to supporting service users pursue these interests or an individualised timetable of activities. Unfortunately there is currently no provision for staff to accompany service users into the community. The home does have a mini bus but this has been out of operation for several years. The requirement made to provide activities and entertainment to meet the individual needs of the service users has not been met and further requirements are made. The Inspector joined the service users in the dining room for their midday meal. The food provided was hot, wholesome and nutritious. It was well Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 13 presented and service users did not have to wait long between courses. There was an alternative on offer and staff were observed interacting appropriately with service users during the meal, offering assistance when required. Service users stated that they could have their breakfast in their room or in the dining room and that they can choose when to get up or go to bed. There is a choice of several alternatives for breakfast and supper. On the day of the site visit the Inspector spoke to 2 visiting relatives who confirmed that there were no restrictions as to when they could visit. Visitors appeared to be welcomed into the home. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The investigations undertaken by the provider are not robust. The home does not follow local guidance in respect of issues relating to adult protection. EVIDENCE: A relative and staff members have raised several concerns to the Inspector. The provider was asked to investigate these matters and gave assurances that satisfactory investigations had been completed for all the concerns raised. One of the complaints made was in relation to staff being employed without the required security checks being satisfactorily completed. The provider was asked to investigate this matter and indicated to the Commission for Social Care Inspection (CSCI) that all the relevant checks had been completed. Due to the fact that no documentary evidence to support the providers’ findings was ever produced, the Inspector requested this information on the day of the site visit. The records examined showed that the applications for these security checks had only recently been made and had not yet been completed for the majority of the staff employed. The provider had also been asked to investigate a complaint into the fact that there was a communication problem relating to some staff that do not speak fluent English. The providers’ findings were that this was unfounded. Observations at the site visit and discussions with service users and staff confirmed that, due to their poor command of the English language, some staff could not communicate effectively with the service users. Indications are that this is having a negative impact on the service provided to the service users in the home because staff cannot always Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 15 communicate effectively with each other and service users cannot always make their needs known. The lack of day-to-day conversation is also affecting the quality of life experienced by those who reside there. It is required that all investigations into complaints are undertaken impartially are robust and accurate. A relative confirmed to the Inspector that they had raised concerns with the provider and had received responses from them within reasonable timescales. Several service users asked the Inspector who they should go to if they had a complaint indicting that they are unaware of the homes, complaints policies and procedures. Discussions with staff indicate that there is a level of aggressive and sometimes violent nature between a couple of service users. Relatives and other service users confirmed this. Care plans and daily records were examined and were not reflective of this. Advice had not been sought from the local social services department in relation to these issues as is required by local guidance. Some staff were asked about their knowledge of adult protection issues and only a few of those asked had any knowledge of the local guidance and procedures. It is required that all staff are familiar with and competent and confident in using local guidance as specified in the Brighton & Hove and East Sussex, Policies, Procedures and Guidelines, for the Protection of Vulnerable Adults. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Albeit the some redecoration has been completed, the home does not have a written programme of redecoration. The home and grounds have not been assessed as to service users safe access. There are insufficient bathrooms. The level of hygiene and cleanliness of the home is poor at times. EVIDENCE: A requirement was made at the last Inspection for the home to implement a programme of maintenance and redecoration and for improvements to be made to the environment. These included the provision of curtains or window dressings for all windows in communal areas of the home and the redecoration of the older part of the building. These requirements have not been met and further requirements are made. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 17 The manager stated that 2 service users bedrooms and 2 vacant rooms had been painted since the last Inspection. Care plans are currently stored in a locked filing cabinet in the residents lounge. This was not considered to be appropriate place to store an office filing cabinet and it is recommended a more suitable and accessible place should be found. None of the care plans examined contained any environmental risk assessments indicating where in the building the service users could access safely, where they required support to access or where access was restricted. The home has not been assessed by an Occupational Therapist or advice sought re adaptations. These were requirements made at the last Inspection that has not been met and further requirements are made. The adapted bathroom on the 1st floor is being upgraded and adapted but has now been out of operation for more than 12 months due to continuous delays in the work being completed. As a consequence there is only one bathroom available for the 18 service users currently resident in the home. It is required that work is finished on this bathroom as a matter of urgency. The home employs domestic staff but there is no cleaner employed at the weekend. Relatives and service users commented that the home is not as clean at the weekends. On the day of the site visit most of the home was found to be clean however, discussions took place with the manager in relation to the odour in one room and the fact that soiled gloves and clinical waste were found unwrapped on the floor of one of one of the toilets. Requirements are made. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users needs are not always met by the mix number of staff on duty and therefore they are not always in safe hands. Not all staff are adequately trained and recruitment policies and procedures are not followed. EVIDENCE: A high number of the staff employed at the home do not have a good command of the English language and therefore cannot adequately communicate with the service users. As described in the Complaints and Protection section of the report this concern has been raised to the Commission for Social Care Inspection (CSCI) by a relative and one that the provider has investigated. The providers’ findings indicated that communication was not a problem but discussions with service users, their relatives, staff and observations on the day all confirm that the lack of understanding and effective communication is a real problem and one that needs addressing as a matter of urgency. Requirements are made. An examination of the rota confirms that staff are not required to be present at a handover period between shifts. This means valuable important information may not be passed over to the next shift. Some service users require a high level, in one case, constant supervision, the responsibility for this is not indicated on the rota and the level of staffing currently in the home would not allow for this to happen at all times. On some shifts none of the staff on duty Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 19 are fluent in English or have been employed by the home for more than 6 months. The Inspector sat in the lounge area of the home for an hour on the morning of the site visit where 8 service users were left without any supervision. The service users stated that the staff were always very busy and discussions with the staff later indicated they were supporting service users elsewhere in the building. A requirement was made at the last Inspection for a full review of the staff rota to be undertaken this has not been met. Further requirements are made and for the rota to clearly indicate the times of day that the manager is working on the floor as a carer, the person responsible for medication, the shift leader and the staff members responsible for supervising individual service users. Requirements were made in relation to the fact that all staff had satisfactory identity and security checks in place prior to being employed by the home the at the last 2 Inspections. The provider gave assurances that all staff had the appropriate checks in place after they were asked to investigate this matter following a concern being raised to the CSCI. As previously described in the Complaints and Protection section of the report the Inspector found that applications for these checks to be undertaken had only just been made and confirmation that they were satisfactory had not yet been received for the majority of the staff employed. Other issues were identified as being unsatisfactory in relation to the lack of proof of identity and appropriate references. This is a serious matter that has the potential to place service users at risk and further requirements are made. Although the manager explained she has introduced staff training and induction programmes staff the personnel files did not contain any evidence that these had been completed. A requirement is made for training to meet the National Training Organisation’s workforce targets within the required timescales and that documentary record is kept and available for Inspection. The home has not met the target of 50 or more of the staff employed by the home to obtain a National vocational Qualification (NVQ) in Care at Level 2 or equivalent. Where alternative qualifications are held confirmation that they are equivalent to the NVQ Level 2 must be obtained. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced but is not able to discharge her responsibilities fully. Service users financial interests are protected but their health, safety and welfare is not always promoted and protected. The home is not run in the best interests of the service users resident in the home. EVIDENCE: The manager has a job description that specifies her responsibilities. Many of the areas she has responsibilities for have a cost implication e.g. staffing and recruitment but she has no control over the budget for this so is therefore unable to discharge her responsibilities fully. It is required that a line of accountability is established in regard to this issue and that she is not prevented from discharging her responsibilities. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 21 Although the home has recently introduced a service user survey it is inadequate and improvements are required. The providers have sent one completed report following an unannounced visit to the home to the Commission for Social Care Inspection (CSCI) and to the manager since the requirement was made in January 2006. These must be completed on a monthly basis. There is currently no provision for monitoring staffs’ performance and the manager and staff team do not receive regular, documented supervision. This has been required at the last 2 Inspections and further requirements are made. Service users stated that they rarely see the manager or providers and that the staff are always busy, too busy to spend much time with any of them on an individual basis. Care plans do not provide any detailed information about service users likes and dislikes or contain a personal history. The services provided are not tailored to the individual. Other than a weekly residents meeting, which is often used as a games session, little effort is made to establish service users opinions on the service that is provided for them. The home is not involved with service users finances. The health safety and welfare of service users is not always protected and promoted. Staff stated that the maintenance man had fit the new gas cooker and that he is not Corgi registered. The manager could not provide documentation to the contrary. Food fridges were recording temperatures double those recommended by the Environmental Health Department and the fridges had not been replaced as advised by the Environmental Health Officer at their last visit. Requirements are made for this advice to be followed. Through discussions with staff and service users and an examination of daily records it is evident that not all accidents and incidents are recorded and reported appropriately. It is required that all accidents and incidents are recorded including the action taken by staff and that a record of this is kept on service users individual care plans. A service user was recently admitted to hospital after falling in the home and sustaining a serious injury. The Commission for Social Care Inspection (CSCI) was not informed as is required. Requirements are made. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 22 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 2 X 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 2 2 X x x 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 x 3 1 X 1 Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 23 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 1. Standard OP1 OP2 Regulation 4(1a,b,c) 5(1,b) 4(1a,b,c) 5(1,b) 4(1a,b,c) 5(1,b) 4(1a,b,c) 5(1,b) 14(1c,d) (2a,b) Requirement That the statement of purpose, service user guide and terms and conditions are further updated to include all the information required.. This was a requirement made at the last 3 inspections. The timescale 30/03/06 not met. This was a requirement made at the last 3 inspections. The timescale 30/03/06 not met The service users relative and or care manager must be informed and involved in the assessment care planning and reassessment processes. All care plans must be based on a thorough assessment of need and kept under review. Any service user resident in the home on a trial basis or otherwise, whose needs cannot be met, must be reassessed and the appropriate documented action taken without delay. Timescale 30/01/06 not met. This applies to all service users who are suffering from confusion or dementia type illnesses. DS0000060719.V288706.R01.S.doc Timescale for action 30/05/06 30/05/06 1 1 2. OP2 OP2 OP3 30/05/06 30/05/06 30/05/06 3. OP4 12(1)14(1 d)18(1a) 30/05/06 Pinewood Manor Residential Retreat Version 5.1 Page 24 4. 5. OP9 OP9 13(2) 17(1a) Sch3 (k) 13(2) 17(1a) Sch3 (k) 13(2) 6. OP9 7. OP12 16(2m,n) 14(1a) 8. 9. 10. OP13 OP16 OP16 16(2m,n) 12(4b) 22(1,2,3, 5,6) 22(1,2,5, 6) 11. OP18 12(1a) 13(6) 12. OP19 23(1a) 23(2b,d) 13. OP22 13(3,4,6) That all staff receive adequate training in the administration of medication. That medication administration procedures are followed at all times. Alls staff must be aware of and competent in following these procedures. It is required that appropriate refrigerated storage facility is provided. Timescale 30/03/06 not met. The home must provide activities and entertainment to meet the individual needs of the service users. Timescale 30/03/06 not met. That arrangements are made for service users to access the community. That all complaints are investigated and recorded fully. That all service users and their relatives are made aware of and provided with, a copy of the homes’ complaints policies and procedures. All staff must be aware of and be confident and competent in following the local guidance for the protection of vulnerable adults. Curtains/window dressings must be provided for all communal areas. A programme for redecoration of the home must be introduced and include the hallways in the older part of the building being redecorated. Timescales for completion must be specified. Timescale 30/03/06 not met. That all areas of the home are risk assessed for use by the service users and any identified restrictions to access be recorded in the care plans of those individuals affected. An DS0000060719.V288706.R01.S.doc 30/07/06 14/05/06 30/05/06 30/05/06 30/06/06 14/05/06 14/05/06 30/05/06 30/06/06 30/06/06 Pinewood Manor Residential Retreat Version 5.1 Page 25 14. 15. OP21 OP26 16. OP27 17. 18. OP28 OP29 19. OP31 20. OP30 occupational Therapist should be contact and her advice sought re adaptations. This is outstanding from previous 2 Inspections. Timescale 30/01/06 not met. 22(2j) That work is completed in the 1st floor bathroom. 12(la) That the home is kept clean at 16(2,k) all times including weekends. 23(1d) That all staff are aware of infection control procedures. 18(1a) The staffing rota must be reviewed and revised to ensure adequate numbers of staff are on duty at all times. This was required at the last Inspection. Requirement 30/01/06 not met. There must be sufficient numbers of staff on duty at all times to meet service users assessed needs and to communicate effectively with the service users and each other. The capacity in which staff are working must be indicated. 18(1a,b,c) That a minimum of 50 of the care staff employed hold an NVQ or equivalent at level 2 or above. 19(1a,b) All the required documentation including proof of identity, security checks, work permits and references must be obtained before a new member of staff is employed in the home. This was required at the last 2 Inspections. Timescale 11/01/06 not met. 12(1ab) The Manager must not be restricted from discharging her responsibilities in relation to recruitment, staffing rota, staffing levels and the provision of induction and training. A line of accountability must be established. Timescale 30/01/06 not met. 12(1ab)18 Training and induction must be (1ac) provided that meets the NTO DS0000060719.V288706.R01.S.doc 30/06/06 30/06/06 30/05/06 30/12/06 14/05/06 14/07/06 30/06/06 Page 26 Pinewood Manor Residential Retreat Version 5.1 21. OP33 22. OP33 23. OP36 24. OP38 25. OP38 workforce training targets within the required timescales. 24(1a,b) The home must introduce a system for obtaining and recording service users views on the running of the home. Timescale 30/03/06 not fully met. 26(1)(3,4, The registered provider must 5) undertake an unannounced monthly visit to the home. A report of the visit must be sent to CSCI and be available to the Registered Manager. This was a requirement at 3 previous Inspections. Timescale 30/01/06 not fully met. 18(1abc2) Arrangements must be made for 19 (1abc) all staff including the Registered Manager to receive regular formal documented supervision. Timescale 30/01/06 not met. 16(2j) All recommendations and or 23(5) advice given by the Environmental Health Department must be followed within the recommended timescales. 17(1a2) All accidents, injuries must be sch3(l) recorded including any action taken by staff, a record must be sch4 12 kept on service users individual care plans. 37(1a,b,c, d,e,f,g,2) 30/06/06 30/05/06 30/05/06 30/05/06 14/05/06 26. OP38 27. OP38 All accidents, injuries and 30/05/06 incidents of illnesses or communicable diseases must be recorded and reported to the CSCI as required. 23(4a,b,c) Documentary evidence must be 30/05/06 provided to that the gas cooker was installed by a competent person i.e. a member of the Council of Registered Gas Installers (CORGI) Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 27 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 OP9 OP19 Good Practice Recommendations The location of the storage of medication within the house should be reviewed and an alternative found. The location of the storage of care plans within the house is reviewed and an alternative found. The filing cabinet should be removed from the residents lounge. Pinewood Manor Residential Retreat DS0000060719.V288706.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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