Inspection on 08/06/07 for Pinewood Manor Residential Retreat

This inspection was carried out on 8th June 2007.

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

The inspector 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... 17/07/06

Pinewood Manor Residential... 10/04/06

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 8th June 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 Manor Residential Retreat DS0000060719.V340236.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.V340236.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 01892 653005 mala_hancock@pgen.net 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 Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Pinewood Manor Residential Retreat DS0000060719.V340236.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 seven (27). The care home provides personal care to older people aged sixty-five (65) or over on admission. 9th November 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 27 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. The cost of ‘in house’ activities are included in the fees and additional charges are made for hairdressing and outings the cost of which varies. Pinewood Manor Residential Retreat DS0000060719.V340236.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 10.00 am and 17.15 pm on the 8th June 2007. An Inspector from the registration team joined the Lead Inspector for the first 3 hours of the Inspection. This was to gain information in relation to a recent application made by the providers to provide nursing care in 7 new purpose built en-suite bedrooms. As part of the site visit the Inspectors joined residents in the dining room for their midday meal, had a tour of the building, spoke to a health care professional, the activities organiser, 4 residents, the acting manager and 5 members of staff team. Their comments will be reflected within the report. A range of records and documentation relating to the running of the home were also examined and included some of the homes’ policies, procedures & guidelines, daily records, residents’ care plans, medication records and records pertaining to health and safety. In addition to the site visit the Inspectors have also collated information gathered from a number of sources including, an Annual Quality Assurance Audit that provides statistical information in relation to the running of the home, the outcome of the homes own customer satisfaction survey, an improvement plan and monthly reports detailing the outcome of unannounced visits to the home to assess the quality of the services provided. Further information was obtained through the Random Inspection process and the outcome of investigations undertaken in relation to concerns raised directly with the CSCI. Information obtained from all these sources will be used in the writing of this report. At the last Key Inspection in July 2006 a number of serious matters were identified and a large number of requirements were made. In addition to this 6 separate individuals including health care professionals, residents their family and friends and staff raised a total of 15 separate concerns with the CSCI. As a consequence 2 Inspectors undertook a Random Inspection at the home on the 19th September 2006. The Inspectors findings were that regulations were being breached in relation to almost all of the complaints/concerns that had been raised and the majority of the requirements, whose timescales had passed, had not been met. A Warning letter was sent to the providers outlining the regulations that had been breached and of the possibility of enforcement action being taken if improvements were not made. A meeting was held in January 2007 with the providers to enable the Commission for Social Care Inspection to stress the seriousness of the situation regarding Pinewood Manor and the poor outcomes for residents who reside there. The providers were asked to produce an improvement plan and a business plan that included a financial breakdown of their projected income and outgoings over the next few Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 6 months. In addition to this, due to concerns regarding the administration of medication a CSCI pharmacist undertook and inspection on the 9th November 2006. Since the meeting in January the Providers have employed a consultant to assist them to raise standards of care in the home and improve the outcomes for the residents. The manager of the home has left and an acting manager has been employed on a temporary basis. The acting manager will remain in post until such time as a suitable permanent replacement can be found. It is anticipated that a new manager will be employed by the end of July 2007 and that this individual will apply to become the registered manager of the home. An internal Management Review meeting was held on the 25th June 2007 at the CSCI Maidstone office. This meeting was held in order to discuss what enforcement action should be taken against the providers in respect of their continual breach of the regulation related to recruitment. The providers will be informed of the decision made at this meeting in writing. What the service does well: What has improved since the last inspection?’ section of the report summary. All the residents at Pinewood Manor have been appropriately admitted to the home and all new residents had an assessment of their care needs prior to moving in. The atmosphere in the home is relaxed and informal. Staff and management are approachable and well liked by the residents. When the Inspector spoke to residents one resident said to ‘It was so good to see the acting manager back here again. It was so nice to see her friendly face.’ Another commented ‘Everything is so much better here now that the acting manager is in charge, she listens to what we have to say.’ Residents have a choice of what time they get up or go to bed and what time they have their breakfast. The quality of the food provided to the residents of Pinewood manor is good and all the comments received by the Inspectors in relation to the food were positive. There were several alternatives available for the midday and evening meals on the day of the site visit. Residents also commented that they enjoyed the entertainment provided by the home and the activities when they took place in particular Bingo was mentioned as being a favourite. Care staff have a good knowledge of the residents needs, likes and dislikes. The Key worker scheme that is in operation ensures that each resident is visited by their key worker on a regular if not daily basis. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 7 The medication administration policies and procedures adopted by the home are safe and staff are appropriately trained in medication administration prior to undertaking the task. What has improved since the last inspection? A new acting manager has been employed who has had a positive affect on the outcomes for those who live at the home. The improvement in the atmosphere was immediately apparent to the Lead Inspector and without exception everyone who the Inspector spoke with commented on how much better life in the home now was. The acting manager, senior care staff and a consultant employed to help raise standards in the home, all have worked extremely hard to meet the requirements outstanding from the last 2 Inspections and the majority of them are either met or nearly met as outlined below. The statement of the terms and conditions of residency, named by the home their ‘Welcome Pack’ is made available to residents before they move into the home. All new residents have been admitted appropriately and any residents who had showed signs of suffering from confusion and or dementia type illnesses that were displaying challenging behaviour have been reassessed. Those whose needs could not be fully met have now moved out of the home to somewhere more appropriate. This has had a very positive affect on the remaining residents and as a consequence their quality of life has greatly improved. Residents and or their relatives are now fully involved in the care planning, reviewing and assessment process. All care plans are kept under review and updated when changes in support needs occur. Residents who are admitted to hospital are 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 is updated. A record is now kept of all GP and hospital appointments. The homes practice in relation to the administration of medication ha been reviewed and amended. Now 2 trained and specified staff are responsible for administering medication at each shift and they both sign to show that the medication has been taken. All the requirements made by the CSCI Pharmacist Inspector have been met. An activities organiser has been employed and activities are now a more regular occurrence. Residents have a choice of food at meal times and the food stores are well stocked with fresh, wholesome food of good quality. Fresh food is delivered every few days. A table has been removed form the dining room making it more accessible and residents are served as soon as they are seated and ready. Mealtimes are relaxed and informal. A review of staffing levels has taken place and as a result staffing levels have increased meaning there are now sufficient numbers of staff on duty at all times to meet the care needs of the residents. In addition to this each shift there is a member of staff who speaks fluent English and care workers no longer have to make hot drinks and snacks. The relationship between Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 8 management, residents and staff is good and some care workers who had left have now returned. A gardener and maintenance man have been appointed and are able to respond to requests for work to be completed in a timely and efficient manner. Work has started on improving the grounds and gardens and the providers plan to upgrade the garden furniture in the hear future. The home has introduced a maintenance redecoration and renewal programme and all of the requirements made at the last Inspection in relation to the environment have been implemented. The home now has a fully functional adapted bathroom on the first floor. Windows in all areas of the home are furnished with curtains, the bedroom that was only accessible through the kitchen is now a staff room and the resident has been moved to another room on the ground floor. All rooms now have hot running water and the home is heated appropriately. The staff now have a staff room were they can change and store their belongings. This room can also be used to hold reviews and meet professionals in private thus maintaining confidentiality. Complaints and concerns raised with the manager are recorded and responded to appropriately and their have been no concerns or complaints made to the CSCI since the Random Inspection in September 2006. The CSCI are informed of all deaths and unplanned admissions to hospital etc as required. The Providers now undertake a monthly-unannounced visit to the home as part of their quality assurance and send a copy of the report to the CSCI. What they could do better: The consultant has updated the homes statement of purpose and resident guide however there are still discrepancies which need to be amended e.g. staffing numbers their qualifications and experience, room numbers and sizes/measurements and fees that are charged for these rooms. Improvements have been made in care planning and all the care plans examined were up to date, however more detail is required to ensure that they accurately reflected the residents’ health and social care needs and the guidance required by staff to support the residents appropriately and safely. The Providers must ensure that the home follows safe recruitment practices. Without exception all staff must have satisfactory security checks prior to being deployed to work in the home. Staff personnel files must contain all the required identification and information. Failure to comply with this is a breach in regulation and unlawful. Requirements have been made repeatedly in respect of recruitment over the last 2 years and the recruitment practice of the home is still poor. In respect of health and safety although the lift has been serviced and the majority of recommendations made by the engineer have been followed one made in relation to providing a fire extinguisher has not. In addition to this risk assessments have not been completed in respect of residents health and safety Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 9 when accessing the home and grounds. This is another requirement that has been repeatedly made over the last 2 years and has not been met. The homes’ policies and procedures need to be reviewed and amended to ensure that they are individualised and relevant to Pinewood Manor. The use of keypads on doors restricts access the freedom of movement. Risk assessments must be completed in relation to residents safety prior to them being used in the home. 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 Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 10 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.V340236.R01.S.doc Version 5.2 Page 11 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): 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are appropriately admitted to the home and are provided with the majority of the information they need in order for them to make an informed decision about whether to reside in there. The homes’ statement of purpose is incomplete. EVIDENCE: All prospective residents are now provided with a copy of the homes’ ‘Welcome Pack’ (otherwise known as the service user or residents’ guide). Under the previous management residents often didn’t get a copy of this documentation until after they had moved into the home. Improvements have also been made in relation to admissions to the home. In the past prospective residents who were displaying signs of confusion, or dementia type illness were being admitted to the home inappropriately and this was having a negative impact on the people who lived there. This practice has now stopped and as a Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 12 consequence the quality of life of those who live there has greatly improved. Furthermore when a resident is discharged from hospital a full reassessment of need is undertaken to ensure the home is able to meet their needs and care plans are updated accordingly. All prospective residents have a pre-admission assessment and this was confirmed when the pre admission documentation of one of the new residents was examined. Now 2 people undertake the pre admission assessment including either the manager or deputy manager. The prospective resident or their representative and the assessors then sign this assessment. The providers have identified that this is an area where they could still do better and in their annual Quality Assurance Assessment that ‘We are currently looking at putting together a more comprehensive pre-admission package.’ A copy of the homes’ ‘Welcome Pack’ was available in the hallway of the home on the day of the site visit. This document doubles as the homes’ statement of Purpose and also contains the terms and conditions of residency. It was examined by the Inspector and has been reviewed and revised since the last Inspection to contain information relating to the Providers previous experience and the staffing structure. However it does not contain information relating to room numbers and sizes and the charges for these rooms nor does it include details of staffing numbers, their experience or their qualifications, it also states that staff are trained in advocacy which they are not. Also some of the terminology used needs to be amended e.g. use of the words such as ‘patients’ etc that is inappropriate. It is required that a further review is undertaken of this document to ensure it contains all the required information. The Statement of Purpose is a legal document and as such should be factually accurate. Requirements in relation to this have been made at the last 6 Inspections. The acting manager stated that all existing and prospective residents have been provided with a copy. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit care plans have improved they do not contain all the information required by staff to support residents safely. The medication administration procedures adopted by the home are safe. EVIDENCE: The acting manager and staff have worked extremely hard to rewrite the care plans in order to meet the requirements made and to ensure that they are ‘user friendly’ documents. Six residents’ care plans were examined. All had been kept under review on a monthly basis and updated as required. They are now a lot easier to understand and contain information relevant to the care needs of the residents and are signed by a senior member of staff and the resident or their representative. However they are not robust and do not always contain sufficient information in relation to the guidelines that staff need to follow to ensure they are supporting residents safely and for this reason a requirement is made. Although the care staff are working at Pinewood Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 14 Manor have a good understanding of the residents needs and are able to meet them, new staff would not have this knowledge and would need more detailed and specific guidance to follow. Likewise for new residents, staff would have no knowledge of their needs so detailed and specific guidelines would be required for them to follow. For example one resident requires staff support with transfers e.g. in and out of the bath, whilst the care plan does highlight this it does not detail specifically what support is required and how it should be delivered. Another resident has a hearing aid but there is no information in relation to the care of this or how often it needs to be serviced etc. Information was also lacking in relation to catheter care, how to empty it or wash it out etc. During the site visit medication administration practices being used by staff were observed to be safe. The homes practice in relation to the administration of medication ha been reviewed and amended. Now 2 trained and specified staff are responsible for administering medication at each shift and they both sign to show that the medication has been taken. In addition to this only specified staff undertake the ordering and ‘checking in’ of medication and an audit is undertaken by a local pharmacist on a regular basis. The home has suitable storage for the medication in cupboards, in a medication trolley and in dedicated refrigerated storage facility. The acting manager stated that risk assessments are completed in respect of residents storing and self-administering medication upon admission. However this is not formally documented. In order to promote independence the manager must ensure that risk assessments are completed and documented for all residents in relation to them storing and administering their own medication or assisting in this process as much as possible. Where it is identified that residents can participate in this process then clear guidelines must be written for staff to follow. Health care referrals are made when required and that individuals health care needs are being met. A visiting healthcare professional commented on the fact that all the staff were happier under the new management and that there were no longer problems in relation to a frequent shortage of gloves being made available to staff. She also stated that referrals were made when needed and that she no longer had any concerns about the welfare of the residents I the home. During the site visit staff were observed treating residents with dignity and respect, residents stated that they didn’t have to wait long for their call bells to be answered and that the staff were kind and helpful. Care staff have a good knowledge of the residents needs, likes and dislikes. There is a Key worker scheme in operation and this ensures that each resident is visited by their key worker on a regular if not daily basis giving the resident the opportunity to have some individual time with a staff member. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitable entertainment and activities. The food provided is of good quality, varied and wholesome. EVIDENCE: One Inspector joined residents in the dining room for their midday meal. The mealtime experience was noticeable different to on previous Inspections. In the past residents struggled to get into the room with their walking frames, often residents suffering from dementia would find this an anxious time and would raise their voices and shout and no one was served until everyone was seated. The new acting manager has made changes that have had a positive affect on the whole mealtime experience. On the day of the site visit the dining room was calm and there were no raised voices, a table has been removed to make the remaining tables more accessible and residents are served as soon as they are seated and ready. The 2 Ladies who were sat at the dining table with the Inspector both commented on how much better meal times were and that they enjoyed coming for their meals so much more now. They stated that meal times are now relaxed and there is ‘no shouting anymore!’ ‘It’s lovely Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 16 here now’. They also informed the Inspector that they now are given a menu in their rooms at the beginning of the week and they can choose what they want for their meals. They said that there was always lots of choices and that they usually hand them in on the same day but that they could choose each day if they preferred. Discussions with the ‘acting manager’ and an examination of the choices available on the menu confirmed this. The food store cupboards were also examined and were all well stocked. There was a good variety of fresh and frozen vegetables and meat in addition to dairy products, tinned and dried foods. Through discussions with residents and staff and the examination of daily records and care plans it is evident that the home continues to provide residents’ the opportunity to participate in some group activities and on occasions entertainment is also provided. An Activities Organiser has now been employed at the home and the Inspector spoke with her in relation to her role. Both the Activities organiser and the manager stated that they had organised several outings and residents had said they wanted to go but when the time came they changed their minds. They both said that there were some activities that were really popular and well attended but that they would keep trying new things. Two residents said ‘We like the bingo best. We’ve got it this afternoon.’ Evidence was seen in respect of outings that had been organised. Unfortunately on 2 occasions residents had said they wanted to go on outings but on the day they changed their minds. Daily records showed that residents’ family and friends visit the home on a regular basis. The manger explained that it is usual practice for a tea tray to be prepared for visitors and that they are always welcome in the home. It was recommended at the last Key Inspection in July 2006 that a social history be included in residents care plans to help build a picture of the individual and the activities they may prefer. This recommendation will be repeated. The providers state in their Annual Quality Assurance that their plans for improvement over the next 12 months in this area include ‘Organising more outings, Improving on daily activities and to organize a barbecue in the lawns of the home and invite friends and family’. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home records and responds to complaints appropriately. The homes policies and procedures have the potential to place residents at risk of abuse. EVIDENCE: Since the last key Inspection in July 2006 6 individuals including residents and their representatives, staff and health care professionals made a total of 15 separate complaints to the CSCI. Some of the complaints were referred to the Providers for Investigation however their findings were that the majority of the complaints were unfounded. The CSCI continued to receive similar complaints so 2 Inspectors looked into them as part of a Random Inspection in September 2006. As a result of these investigations the Inspectors found that regulations were being breached in relation to almost all of the 15 complaints. A letter was sent to the Provider outlining the outcome of the Inspectors investigations into the complaints and Warning Letter was sent detailing all the regulations that had been breached at the Inspection. The breached Regulations included those in relation to care planning, staff recruitment, complaints and some health and safety issues. It is pleasing to note that there have been no complaints made to the CSCI since the September Random Inspection and that recent improvements have addressed the areas of concern raised as detailed elsewhere in the report. The home has identified that there has since been one complaint made to them Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 18 that the resident did not feel was investigated properly. This is an area that they hope to improve in. Some of the homes’ policies and procedures in relation to the protection of vulnerable adults were examined and found to be inappropriate with the potential to cause harm themselves’. The homes’ policy on ‘Abuse’ does not specify that Social Services, who are the lead agency, must be alerted whenever an incident of abuse is suspected. In addition to this there is no guidance for staff to follow on how to make an Adult Protection Alert. This guidance must be put in place and the providers must ensure that all the homes’ policies and procedures in relation to adult protection and abuse are in line with the Brighton & Hove and East Sussex Multi Agency Guidelines for the Protection of Vulnerable Adults, a copy of which must be obtained. The policy of ‘Restraint’ states that staff may use restraint in some circumstances however staff have not received any training in the use of restraint and it would be potentially dangerous should an attempt be made by staff to use it. The policy on ‘Absconding’ speaks of the use of security locks and keypads yet the use of these restricts individuals’ access in and around the home and there are no associated risk assessments in place that identify the need for them. Requirements are also made under the staffing section of this report in respect of poor recruitment which also has the potential to place residents at risk. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21&26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is in a good decorative order and provides residents with a clean, homely and comfortable environment. EVIDENCE: On the day of the site visit the home was found to be clean and hygienic and free from offensive odours. The Providers have purchased a new washing machine and there was no backlog of washing. A requirement was made at a previous Inspection for the home to implement a program 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 which have now been provided and the completion of the 1st floor bathroom that has been out Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 20 of operation for the last 2 years, this is now fully operable. All rooms now have running hot water. One residents’ bedroom was only accessible via the kitchen, this is now a staff room and the resident has been moved to another more suitable ground floor room. This means that not only is the resident living in the main part of the house where she can be easily observed by staff but staff now have a place to store their personal belongings and have the changing facilities they did not have before. A new extension to the home has almost been completed. When finished this will provide the home with an additional 7 en-suite bedrooms, another fully adapted bath, a staff/storage room and a sluice facility. The home proposes to provide nursing care in these rooms and in the bedrooms in the adjoining newer part of the building. The registrations team decision in relation to this application will be confirmed in writing to the providers. The newly appointed gardener and maintenance man are able to respond to requests for work to be completed in a timely and efficient manner and work has started on improving the grounds and gardens. The Providers state in their Annual Quality Assessment that ‘This summer we are planning to improve and create flower beds.’ That ‘Garden furniture could be improved’ and that ‘We have ongoing decorating plan where we involve the residents to show their preferences as regards colour scheme.’ Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff meet the needs of the residents. Recruitment policies and procedures are unsafe and staff induction does not meet the required standard. 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. Some staff that left the home over the last 2 years have returned to work at the home including the acting manager who had been the registered manager of the home for 23 years previously. The relationships between staff and the new acting manager are good. Staff stated that they find her approachable and that she listens to them and is supportive. The staffing levels and staffing rotas have changed since the last Inspection. There are now always sufficient numbers of staff on duty at all times to enable residents’ needs to be met. Care staff no longer have to prepare evening meal or hot drinks as domestic staff undertake these 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.V340236.R01.S.doc Version 5.2 Page 22 manual handling and medication. However, an examination of the training files showed that the inductions that are being completed do not meet the Skills for Care standards so requirements are made in respect of this. In addition the previous manager delivered much of the staff training provided in the home, in the future the training provided to staff must be provided by an accredited trainer. The manager assured the Inspector that she was aware of each staff members training needs and is in the process of booking the relevant courses. Requirements were made in relation to poor recruitment practices and the fact that all staff must have satisfactory identity and security checks in place prior to being employed by the home the at 6 Inspections over the last 2 years. This requirement has not been met and the regulation relating to this has repeatedly been breached. At the Random Inspection in September 2006 the then manager did not make available the staff recruitment and personnel files. When a selection of these files was examined at this Inspection none of the 3 files examined contained all the required information. None of the files examined contained 2 forms of proof of identity and 2 of them had none, employment histories were not complete and staff had worked in the home for in excess of 6 weeks in 2 instances prior to the required initial security check being carried out. The acting manager explained that some of the recently employed staff were known to her and had worked in the home previously, which is why they had been allowed to work in the home without the required checks. Without exception no member of staff should be deployed to work in the home until all the required information relating to previous employment history, references and identity checks have been received and the Protection of Vulnerable Adults (PoVA) first check has been satisfactorily completed. In addition to this no employee can work in the home unsupervised until such time as the Criminal Record Bureau (CRB) is returned and is satisfactory. Personnel records must be accurate and complete and include all the required information including 2 written references, 2 forms on identity and a full employment history. 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. Requirements are made. Other areas that the Providers have already identified as areas they need to improve in is, to have regular staff meetings and to audit the training schedule of each member of staff and assess their further training needs for the following year. They hope to achieve this within the next 12 months. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35&38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit the management approach of the home is positive and inclusive, residents’ health and safety is not always protected and promoted and the homes’ policies and procedures are not all reflective of current practice. EVIDENCE: The new acting manager was appointed to work in the home in February this year in order to help turn the home around, raise standards and provide management cover for the home after the last manager left. The acting manager had been the registered manager of Pinewood Manor for 23 years until she retired 3 years ago and as such has a good knowledge of the home Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 24 and many of the residents and staff. She has had a very positive affect on the home and has facilitated many changes that have resulted in the quality of life of the residents being greatly improved. Staff morale has also been boosted and the atmosphere in the home, in contrast to last year, is relaxed and informal. Without exception all the staff and residents that the Inspectors had discussions with spoke highly of the acting manager and commented on how much better life was at the home since she had returned. The acting managers employment at the home is a temporary arrangement and the long-term plans are for a new manager to be appointed who has a nursing background. This would enable them to manage the new nursing beds should they become registered. The acting manager explained that a suitable candidate has been identified and it is proposed that their employment will commence at the end of July 2007. It is envisaged that this individual will apply to become the registered manager. It is planned that initially the current acting manager will work alongside the new manager and support her in her role but that eventually she will go back into retirement. A deputy manager has now been employed one senior and both assist the manager in undertaking her responsibilities. Although the acting manager is experienced, qualified and has had regular meetings with the providers in relation to raising the standards of care provided at the home, she has not received documented supervision since being in post in February. Requirements have been made in respect of supervision for the manager at the last 3 Key Inspections and have not been met. All staff now receive supervision and appraisals from either manger or a senior member of staff on a regular basis. Supervision includes individual staff member practice being observed and appropriate training being given. Appraisals cover issues on a more personal level and also identify training needs. The providers have undertaken unannounced monthly visits to the home as part of their quality assurance and provided copies of the reports to the Commission for Social Care Inspection as was required. Resident views are gained in a number of ways including resident surveys, residents meetings, and through the use of a suggestion box, the manager also aims to meet with each resident on a weekly basis. A staff survey was also conducted the outcomes of these surveys have yet to be communicated to the stakeholders of the home. Improvements have been made in relation to the health and safety of residents and staff however some shortfalls were identified. The home and grounds have not been assessed as to residents’ safe access. The lift has been serviced and most the recommendations made by the engineer have been followed apart from the need for a fire extinguisher. The hot water from outlets accessible to residents are regulated at the recommended temperatures and monitored and recorded on a monthly basis. The Commission for Social Care Inspection Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 25 (CSCI) is now notified of all deaths and emergency admissions to hospital as is required. The homes’ policies and procedures have been reviewed and rewritten. The Inspector examined a sample of these and found that they were not all appropriate or individualized for Pinewood Manor. For example the homes policy on ‘Transferring residents’ speaks of the homes’ mini bus, but the home doesn’t have a mini bus. Other policies and procedures mentioned under the complaints and protection section of this report were also inappropriate for use at Pinewood Manor and need to be reviewed and either rewritten or removed. In addition to this despite having a resident with MRSA the home does not have a policy and procedure for staff to follow. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X X x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 2 Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 27 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. Standard 1. OP1 Regulation 4(1abc) 5(1b) Timescale for action The statement of purpose is a 31/08/07 legal document and as such must be accurate. A further review is undertaken of this document to ensure it contains all the required information. Requirements in relation to this have been made at the last 6 Inspections. To ensure residents’ care needs 31/08/07 are met appropriately and safely Care plans must be robust and contain all the guidelines that staff need to follow when supporting residents. Requirements in relation to this have been made at the last 2 Inspections. To promote independence. The 31/07/07 manager must ensure that fully documented risk assessments are completed for all residents in relation to them storing, administering or assisting in the process of administering their own medication. In order to ensure residents 31/07/07 health and safety and to protect them from abuse the home must DS0000060719.V340236.R01.S.doc Version 5.2 Page 28 Requirement 2. OP7 12(1ab 13(2,4,6) 14(1abcd,2 ab) 15(1,2bcd) 16(2mn) 3. OP9 12(1ab) 13(2) 17(1a) schedule 3 (ikm) 4. OP18 12(1ab) Pinewood Manor Residential Retreat 5. OP28 18(1abc) 6. OP29 19(1ab,2,3, 4abc,5abc) 17(2,3ab) Schedule 2 Schedule 4 7. OP30 12(1) 18(1ac,2) 8. OP31 9(1,2abc,3) 12(1ab) 9. OP36 18(1abc(i), 2abc) obtain a copy of the Brighton & Hove and East Sussex Multi Agency Guidelines for the Protection of Vulnerable Adults. Guidance must be provided to all staff to ensure that they are ware of how to make an Adult Protection Alert and who they need to contact. To ensure the health safety and welfare of residents. The home must ensure that they employ a 50 or more of the staff they employ have a National vocational Qualification (NVQ) in Care at Level 2 or above. In order to protect and promote residents’ health and safety and protect them from abuse the registered providers must ensure that all staff have satisfactory identity and security checks in place prior to being deployed to work in the home and that up to date and accurate personnel records contain all the required information including 2 forms of identity, 2 written references and a full employment history. Requirements have been made at the last 5 Inspections in respect of recruitment. In order to ensure residents’ health and safety and protect them from harm all staff must complete the Skills for Care Induction or equivalent prior to working unsupervised in the home. The home must have a permanent suitably qualified and experienced manager in place and an application must be made to the CSCI for them to become the registered manager. Arrangements must be made for the acting Manager to receive DS0000060719.V340236.R01.S.doc 31/12/07 08/08/07 15/07/07 30/09/07 31/08/07 Page 29 Pinewood Manor Residential Retreat Version 5.2 10. OP37 17(2) 12(1ab) 11. OP38 23(1a,2cdjk 4abcd) 12(1a) formal documented supervision. Requirements have been in respect of this at the last 4 Inspections. To ensure consistency and safe 30/09/07 practice all the homes’ policies and procedures must be reviewed and amended to ensure that they are reflective of the current and accepted practice in the home and that they are individualised for Pinewood Manor. That health and safety of service 31/07/07 users and staff must be protected. Recommendations made by the lift engineer must be followed. Documented risk assessments must be completed in respect of residents’ safe access to the home and grounds any restrictions to access must be recorded in individual care plans. Requirements have been in respect of this at the last 4 Inspections. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations That a social history is included on each service users file. Pinewood Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Manor Residential Retreat DS0000060719.V340236.R01.S.doc Version 5.2 Page 31 - 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. 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