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 17th July 2006 03:00 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.V295469.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 Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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.V295469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The maximum number of service users to be accommodated 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. 10th April 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.V295469.R01.S.doc Version 5.2 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 3.15 pm and 10.15 pm on the 17th July 2006. The Inspectors had a tour of the building, joined service users in the dining room for their evening meal and had the opportunity to meet with one visiting relative. The Inspectors had discussions with the visitor, 9 service users, the 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. In addition to the site visit the Inspectors have also collated information received by the Commission for Social Care Inspection (CSCI) in relation to the care received by the residents, the management of Pinewood Manor Residential Retreat, concerns raised and the progress the home has made to the requirements made at the last Inspection on the 13th April 2006. What the service does well: What has improved since the last inspection?
The home has either met or nearly met a number of the requirements made at the last Inspection in April. The service users admitted to the home have been admitted appropriately and some of the service users who showed signs of suffering from confusion and or dementia type illnesses have been reassessed. Service users and or their relatives are now fully involved in the care planning and assessment process. All the staff employed at the home have had the relevant security checks undertaken and only a few shortfalls were identified in relation to proof of identity. This is a big improvement. There is always a staff member on duty
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 6 that has a good command of the English language and the communication skills of the staff employed by the home have also improved. The home has introduced a maintenance redecoration and renewal programme and some of the requirements made at the last Inspection in relation to these have been implemented. The home has purchased 2 chiller fridges for the kitchen and a medication fridge. Appropriate storage has been found for the medication cupboards, medication trolley and service users care plans. What they could do better:
At the last inspection in April 2006 a number of serious matters were identified. Due to the number of requirements made and the fact that many of these requirements were outstanding from previous inspections a meeting was held in May 2006 with the providers and the registered manager of the home. The purpose of the meeting was to enable the Commission for Social Care Inspection to stress the seriousness of the situation regarding Pinewood Manor and the poor outcomes for service users who reside there. As many of these requirements have still not been met the providers have now been asked to produce an improvement plan. The manager has worked hard to update the homes statement of purpose and service user guide however there are still discrepancies which need to be amended e.g. staffing structure/levels. These documents along with a statement of the terms and conditions of residency must be made available to service users before they move into the home. Improvements have been made in care planning however, not all the care plans examined were up to date, accurately reflected the service users health and social care needs or provided the guidance required by staff to support the service users appropriately. All care plans must be kept under review and be updated when changes in support needs occur. Service users who are admitted to hospital must be fully reassessed prior to them being readmitted to the home to ensure the home can still meet their needs. Upon readmission to the home the individuals’ care plan must be updated. Requirements were made at the last Inspection in relation to staff being aware of and competent in following the home’s policies and procedures for the administration of medication. Shortfalls were identified again at this Inspection and although the manager has identified the need for additional staff training further requirements have been made including the need for information about any homely remedies that service users are self administering to be documented in the care plan along with any associated risk assessments. On the day of the site visit the home still only had one bathroom in use for all the residents. This has been the case for over a year and is not acceptable. Staff stated the facilities in the newly converted bathroom had only been used for a few days before the equipment stopped working and the bathroom still not been completed. The radiator had not been fitted and bricks were being
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 7 stored there. Other environmental shortfalls that were identified included the fact that many light bulbs were not working and some lampshades were missing. There were no paper towels in the ground floor bathroom, the floor was wet, the door warped and hand washing facilities are poor in the lavatory adjoining the residents lounge as there is no hot water tap. There are still no curtains or window dressings in many areas of the home and this has been outstanding form the last two Inspections. There are some health and safety issues in relation to service users in the home including the fact that the lift has been serviced but the recommendations made by the engineer have not been followed, the hot water from some of the hot water outlets accessible to service users is above that recommended and these temperatures are neither monitored or recorded as they should be. In relation to staffing and management issues, the requirements made at the last Inspection in relation to the poor recruitment practices of the home and the lack of security and identity checks of largely been met however there are still some shortfalls in relation to the home obtaining proof of identity for all staff. Not all staff have had formal, documented supervision and although the manager has had an appraisal in relation to her role, she too has not received supervision. The Commission for Social care Inspection (CSCI) has not been informed by the manager of the emergency admissions of service users to hospital or of service users deaths as is required. Lastly the providers have not undertaken monthly unannounced visits to the home. All these issues were raised at the last Inspection and requirements made. Some of these issues are outstanding from the last 2 Inspections. 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.V295469.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Since the last Inspection service users have been appropriately admitted to the home however they have not been provided with the information they require in order to make an informed decision about whether or not to reside there prior to moving into the home. EVIDENCE: A visiting relative of service user who had recently moved into the home explained that they had been able to visit the home prior to making a decision about whether the home was suitable and that they had been involved in the assessment process and the writing of their relatives care plan. However, their relative had not yet been given their terms and conditions of residency and the service user guide and statement of purpose formed part of a welcome pack that they had found in their room on admission. It is required that all this information is made available to prospective service users prior to them being admitted to the home. With regard to the content of these documents, there have been requirements made in respect of the homes’ service user guide and statement of purpose accurately reflecting the services offered by the home in
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 10 the last 4 Inspection reports. Although Improvements have been made there are still discrepancies that must be rectified. Through the examination of care plans, observations at the site visit and discussions with service users, relatives and staff it appears that the four service users admitted to the home since the last Inspection have been admitted appropriately. The last report required that any service user resident in the home on a trial basis or otherwise, who displayed signs of confusion, or dementia type illness, must be reassessed and the appropriate documented action taken without delay. This requirement has now been met for some service users but not all and further reassessments are needed. One service user recently readmitted to the home from hospital had not been reassessed. It is important that when a service user is discharged from hospital that a full reassessment of need is undertaken to ensure the home is able to meet their needs. Care plans must be also be updated accordingly. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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. Not all Care plans are reflective of service users health and social care needs. The medication administration procedures adopted by the home are safe. However these procedures are not followed consistently. EVIDENCE: Six service users care plans were examined. Through observations at the site visit, discussions with service users, their relatives and staff it is evident that care plans are not always reflective of service users needs. One service user was readmitted to the home from hospital but there was no information in relation the District Nurse visits in the care plan and she had not been reassessed prior to moving back into the home. For another service user their past mental health needs were not documented and there was no guidance for staff to follow or information in relation to what sort of things they should look for as an indication that the mental health of the individual may be deteriorating. There is no indication on individual care plans to indicate that some service users display a level of confusion that it is usual for them to wander around the home. Staff seemed to be struggling to support one individual in relation to moving and handling and it was disappointing to note
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 12 that the care plan for this individual was not reflective of her current needs despite the fact that the service user concerned had an infection and her mobility had been affected as a consequence. Care plans must be reflective of service users needs and provide staff with the guidance they need in order to ensure they can provide the support that is required. They must be kept under review and updated as required not just at the mandatory monthly review. During the site visit medication administration practices being used by staff were observed to be safe. However, one of the service users had several homely remedies in their room but this was not indicated on their care plan. An examination of medication administration sheets showed that there were gaps where medication had not been signed for. Staff stated a service user was refusing to take some medication but this was not clear and another service user was changing from self-administering her medication to staff administering it for her and again this was not clear. Risk assessments must be completed in respect of the individual self-administering homely remedies and that information in respect of all medication is kept on the individuals care plan. The manager has identified staff training needs in respect of the administration of medication. She explained that this training should ensure that the requirement made for all staff to be aware of and competent in following the homes medication administration procedures, is met. The home has supplied suitable storage for the medication cupboards and medication trolley dedicated refrigerated storage facility for medication has also been provided. It appears that health care referrals are made when required and that individuals health care needs are being met. During the site visit staff were observed treating service users with dignity and respect, service users stated that they didn’t have to wait long for their call bells to be answered and that the staff were kind and helpful. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 13 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 home provides suitable entertainment and activities. The food provided is of good quality, varied and wholesome. EVIDENCE: One Inspector joined the service users in the dining room for their evening meal. 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 at each mealtime. On the day of the site visit the Inspector spoke to a visiting relative who confirmed that there were no restrictions as to when they could visit and that they are welcomed into the home. 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 and entertainment is now provided twice a week. The manager explained that it is the homes’ intention to employ an activities organiser at which time a planned activity timetable could be put into operation. The residents meetings where service users are able to raise issues of concern or
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 14 just get together for a social event and used to happen weekly but in recent months they have not taken place on a regular basis. Two service users stated to an Inspector that they enjoyed the entertainment brought into the home and participating in the activities when they took place e.g. playing skittles but that they hadn’t played for a while. Some care plans specify individuals’ interests but not all and so it is not possible to ascertain whether or not all the service users preferences in relation to activities are being catered for. It is appreciated that the activities co-ordinator will further develop personalised activities however it is important that the home ensures that in the mean time an equal opportunity to participate in stimulating and appropriate activities is provided for all service users both within the home and in the community. Unfortunately the homes’ mini bus is still out of operation so access to the community is limited to those who have family to support them. It is recommended that a social history is included in service users care plans to help build a picture of the individual and the activities they may prefer. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Complaints are managed and investigated appropriately by the home. The policies and procedures adopted by the home in relation to adult protection are safe. EVIDENCE: A recent complaint made to the manager in relation to a service user getting sunburnt had been managed, investigated and responded to appropriately. The manager had written to the complainant apologising for the incident and detailed the steps the home would take to ensure that this did not happen again. The home has its own recording system as laid down in their complaints procedure. This recording system had not been used and it is recommended that it be used in future to show clearly what action was taken to investigate and report on any complaints made to the home. There have been no recorded incidents that would require an adult protection alert to be raised and the policies and procedures that the home has adopted in relation to adult protection issues and abuse are safe. The staff on duty on the day of the site visit were aware of the fact that there is local guidance and knew what constituted abuse and who to they should report a suspected incident of abuse to. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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): 19,21,22,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Albeit some redecoration has been completed and the home has a written programme of redecoration, the home and grounds have not been assessed as to service users safe access and there are insufficient bathroom and hand washing facilities available to service users. 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. This programme has been implemented and many improvements have been made. However, on the day of the site visit curtains and window dressings remained to be hung and the new bathroom on the 1st floor was out of operation. Staff confirmed that it had only been available to use for a few days before equipment was out of order. In addition to this the radiator had not been fitted and bricks were being stored in the
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 17 room. The hand washing facilities in the toilet adjoining the lounge are inadequate due to the lack of a hot water tap. The floor in the bathroom on the ground floor was wet, there were no paper towels with which to dry your hands and the door to the bathroom was warped making it difficult to close properly. A large number or light bulbs were missing throughout the home and some lamp shades were also missing. A suitable and accessible place has been found for the storage of service users care plans however, 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. One bedroom can only gain access to the lounge and other areas of the home through the kitchen. As a result it has been turned into a medication room. As it is no longer a bedroom, the registration of the home needs to be amended to reflect this fact. On the day of the site visit, building work had commenced to the rear of the main building. As a result, one of the fire doors on that side of the building, near to many of the bedrooms on the ground floor, had been locked and deemed inoperable. Confirmation from the Fire Safety Officer needs to be obtained that this is safe. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff struggle to meet the needs of the service users due to staffing levels. Improvements have been made to the recruitment policies and procedures, which are now followed. EVIDENCE: Problems were identified at the last Inspection in relation to the ability of some of staff employed by the home to communicate effectively in English. These issues have now been addressed. The standard of English spoken has improved and there is a member of staff who speaks English fluently on duty at all times. Service users have the use of two lounges and a dining room at all times and the lay out and size of the home is such that service users in these rooms cannot be observed unless staff are actually present in the room. Current staffing levels are not high enough for this to happen when staff are also needed to attend to service users personal care needs, prepare drinks and snacks and administer medication. A requirement was made at the last two Inspections for a full review of the staff rota to be undertaken this has not been met. Both Inspectors observed service users wandering throughout the home without staff supervision and service users were left in both the lounge and dining room alone while staff carried out other tasks. Staff confirmed that they have received an induction when they started work at the home and also have received a range of training including food hygiene,
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 19 manual handling and medication. However, Inspectors observed a member of staff assisting one resident inappropriately and so a requirement has been made that all staff receive manual handling training with particular emphasis on assisting particular residents. Requirements were made in relation to the fact that all staff must have satisfactory identity and security checks in place prior to being employed by the home the at the last 3 Inspections. This requirement has almost been met and the majority of the required security and identity checks have been undertaken for most staff. However, there are still some gaps, particularly in relation to proof of identity. This was discussed with the manager on the day of the site visit. Documentation in relation to evidencing the fact that new staff have undergone an induction programme is now contained on their personnel files and this is completed within the National Training Organisations timescales. 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. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced but is not appropriately supervised. Service users financial interests are protected but their health, safety and welfare is not always promoted and protected. Further improvements could be made to ensure that the home is run in the best interests of the service users. EVIDENCE: The registered manager is experienced and qualified however she has still not received documented supervision. Requirements have been made in respect of supervision for the manger at the last 3 Inspections. The manager must ensure that all staff receive formal documented supervision at least 6 times a year. There is still no deputy manager and only one senior, although another is currently going through their probationary period for this post. This results in the manager having little support to fulfil all aspects of her role.
Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 21 The providers have undertaken one unannounced visit to the home and provided one report to the Commission for Social Care Inspection (CSCI) and to the manager since the last Inspection in April 2006. These must be completed on a monthly basis. Service users views are gained in a number of ways including service user surveys, residents meetings, and through the use of a suggestion box. The home is not involved with service users finances. Improvements have been made in relation to the health and safety of service users and staff however, it is still not always protected and promoted. The lift has been serviced but the recommendations made by the engineer have not been followed. The hot water from outlets accessible to service users must be regulated at the recommended temperatures and monitored and recorded on a monthly basis records showed these checks are not being undertaken as required. In addition to this on the day of the site visit the temperature from some of the hot water outlets exceeded these temperatures posing a potential risk to service users. 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 of this or of the death of service users as is required. As indicated earlier in the report, a fire door had been locked due to the building work to the rear of the building. This needs to be checked with the Fire Safety Officer to ensure it is safe. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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 1 2 3 2 X X 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 3 17 x 18 3 2 X 1 1 X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 1 Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 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. Standard OP1 Regulation 4(1a,b,c) 5(1,b) Timescale for action That the statement of purpose, 30/09/06 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. It is required that this information accurately reflects the services offered and the staffing levels specified. That the statement of purpose, 30/08/06 service user guide and terms and conditions of residency are available to prospective service users before they move into the home. That service users readmitted to 30/08/06 the home must under go a full reassessment of need. That service users care plans 30/09/06 must be kept under review, be reflective of current needs and provide the guidance required for staff in order for them to support service users to meet their needs. That the involvement of any 30/08/06 health care professional is fully recorded in the home’s care
DS0000060719.V295469.R01.S.doc Version 5.2 Page 24 Requirement 2. OP2 4(1a,b,c) 5(1,b) 3. 4. OP4 OP7 12(1) 14(1d) 18(1a) 15(1) 5. OP8 12(1ab) 13(1b4bc) 15(1) Pinewood Manor Residential Retreat 6. OP9 13(2) 17(1a) Sch3 (k) 7. OP9 13(2) 17(1a) Sch3 (k) 16(2mn0 14(1a) 8. OP12 9. OP13 16(2mn) 14(1a) 23(1a) 23(2b,d) 10. OP19 11. 12. OP21 OP22 22(2j) 13(3,4,6) 13. OP27 18(1a) planning documentation. That the homes’ medication administration procedures are followed at all times. All staff must be aware of and competent in following these procedures. Timescale 14/05/06 not met. That information in relation to homely remedies is documented on the service users care plans and that the appropriate risk assessments are completed. That each service users care plan specifies their interests and that all service users have an equal opportunity for stimulation through leisure and recreational activities in and outside the home. That arrangements are made for service users to access the community. Timescale 30/06/06 not met. Curtains/window dressings must be provided for all communal areas. Timescales for completion must be specified. Timescales 30/03/06 and 30/06/06 not met. That work is completed in the 1st floor bathroom. Timescale 30/06/06 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. This is outstanding from previous Inspections. Timescales 30/01/06 and 30/06/06 not met. 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 2 Inspections. Timescales
DS0000060719.V295469.R01.S.doc 30/08/06 30/08/06 30/10/06 30/11/06 30/09/06 30/09/06 30/09/06 30/08/06 Pinewood Manor Residential Retreat Version 5.2 Page 25 14. OP29 15 OP30 16. OP33 17. OP36 18. 19. OP36 OP38 20. 21. OP38 OP38 22. OP38 30/01/06 and 30/05/06 not met. 19(1a,b) All the required documentation including proof of identity, security checks, work permits and references must be obtained for all staff employed in the home. This was required at the last Inspection two Inspections. Timescales 11/01/06 and 14/05/06 not fully met. 13(5) That all staff receive training in 18(1aci) manual handling with reference to meeting the needs of particular residents. 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 previous Inspections. Timescales 30/01/06 and 30/05/06 not met. 18 (1abc2 Arrangements must be made for abc) the Registered Manager to receive regular formal documented supervision. Timescales 30/01/06 and 30/05/06 not met. 18(1abc2 All staff must receive formal abc) documented supervision at least 6 times a year. 23(4abc) That the water from all hot water outlets accessible to service users is regulated at the recommended temperatures and that these temperatures are monitored and recorded on a monthly basis. 23(4abc) That the advice given by the lift engineer is followed. 23(4abcd) That advice is sought from the Fire Safety Officer to ensure that the locking of the external fire door is safe. 37(1abcde That the CSCI is notified without
DS0000060719.V295469.R01.S.doc 30/08/06 30/09/06 30/08/06 30/08/06 30/09/06 30/08/06 30/10/06 30/08/06 30/08/06
Page 26 Pinewood Manor Residential Retreat Version 5.2 fg2) delay of the death of any service user including the circumstances, any serious injury to a service users any event in the home which adversely affects the wellbeing or safety of any service user. All notifications must be confirmed in writing. Timescale 30/05/06 not met. 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 OP16 Good Practice Recommendations That a social history is included on each service users file. That the home completes their own recording systems for all complaints made to the home. Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Pinewood Manor Residential Retreat DS0000060719.V295469.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
