Inspection on 31/10/06 for Pinewood Nursing And Convalescent Home

This inspection was carried out on 31st October 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pinewood Nursing And... 01/12/05

Pinewood Nursing And... 14/07/05

Pinewood Nursing And... 20/01/05

Pinewood Nursing And... 13/10/04

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 Nursing And Convalescent Home Conifers, Cot Lane Chidham Chichester West Sussex P018 8ST Lead Inspector Ms J Hartley Unannounced Inspection 31 October 2006 1:15pm 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 Nursing And Convalescent Home DS0000024196.V302355.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 Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood Nursing And Convalescent Home Address Conifers, Cot Lane Chidham Chichester West Sussex P018 8ST 01243 572480 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) Mr Lawrence Marsh Mrs Deryl Ann Marsh Mrs Deryl Ann Marsh Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Pinewood is a care home registered with the Commission for Social Care Inspection to provide nursing care for up to twenty-one older people. The service is owned by Mr and Mrs Marsh, Mrs Deryl Marsh, a first level nurse, is the registered manager. Nineteen rooms provide accommodation of which seventeen are singles and two are doubles. Nine of the rooms have en-suite facilities. All first floor rooms are serviced by a passenger lift. The home is situated in the village of Chidham, some four miles west of Chichester with its shops, pubs, banks and other amenities. The detached home stands in beautiful grounds with stunning views of the sea and countryside. There is a large car park at the front of the house to accommodate staff and visitors. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over four hours. The registered manager Mrs Marsh and her husband, who is also the registered provider with Mrs Marsh, were present throughout the inspection and provided the information required. The inspector examined information held on the service file since the last inspection in December 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose. Evidence was also gathered from the pre-inspection questionnaire completed by Mr Marsh and the results of a survey, completed prior to the inspection by five residents. During the inspection the inspector spoke to many of the residents, and three members of staff, two care assistants and the cook. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. The fees range from between £600 and £650. What the service does well: What has improved since the last inspection? Many items of equipment in the home have been replaced since the last inspection. Several areas have been redecorated including some bedrooms. New lighting has been installed in the lounge. There is a continuous Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 6 maintenance programme in place that ensures that the home remains in good condition. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with up to date information about the home to enable them to make an informed choice about where to live. The home undertakes full assessments prior to admission to ensure they are able to meet the needs of the individual. Residents are able to visit and move into the home on a trial basis. Pinewood does not provide intermediate care; therefore Standard 6 does not apply. EVIDENCE: Pinewood has an up to date Statement of Purpose and Service User Guide that provide detailed information about the home. Three residents’ files were inspected and found to include full assessments that were undertaken prior to admission. The registered manager, Mrs Marsh, said that she Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 9 visits prospective residents prior to admission to undertake these assessments herself. For residents referred through Care Management arrangements there were also copies of the referring authorities assessment and care plan on file. Residents confirmed that they are able to stay at the home for a trial period prior to making a final decision about staying. Mrs Marsh informed the inspector that when residents are first admitted the staff and manager continue to monitor and assess the resident so they are able to adjust the initial care plan to enable the home to meet the individual needs of the resident more fully. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in individual care plans. Health needs are fully met. At present there are no residents selfmedicating at Pinewood. The home has clear policies and procedures in place regarding the administration of medication. Residents feel that they are treated with respect and dignity by the staff and management of the home. EVIDENCE: Care plans seen during the inspection gave detailed accounts of residents’ current health, personal and social care needs. It was clear that they had been drawn up with the involvement of the resident and/or their relatives. Evidence was seen that care plans are reviewed every month and relevant changes made to meet changes in needs. Residents’ files included risk assessments for falls, pressure sores, continence and manual handling. Weight is monitored every three months or more Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 11 frequently if required. Specialist equipment such as hoists and air mattresses were seen in use to meet residents’ assessed health needs. Residents are registered with a local GP and have access to opticians, dentists and chiropodists. All medical appointments are recorded with the outcome. A sample of medication administration records were looked at during the inspection and found to be well maintained with no errors or gaps. Controlled drugs were recorded in a separate register, records of administration signed by two witnesses, and safely stored. Disposal of unused medication is carried out with the clinical waste company procedures and documented and signed for. Staff were witnessed treating residents with respect and dignity. Personal care is carried out in private. Residents spoke highly of the staff and said that they feel they are treated with respect. Five residents’ surveys were returned to the inspector. Four said that residents always receive the care and support they need, and one said it is usually received. Screening is provided in double rooms for privacy. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. Residents are offered a good range of social activities both in the home and in the community. Family and friends are encouraged to visit the home and maintain contact. Residents are helped to exercise choice in their lives. The home provides residents with a choice of well-balanced food. EVIDENCE: Residents’ individual interests and hobbies are clearly stated in their care plans. The home provides a good variety of activities both in the home and in the community. These include indoor games, crafts, entertainers, walks, BBQ’s and pub visits. The home was inspected on 31st October and was decorated throughout with witches hats, pumpkins etc. The home had taken into consideration residents’ religious beliefs prior to decorating the home in this way. Residents told the inspectors that visitors are welcome in the home. The visitor’s book reflected this with many visitors signed in each day. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 13 Residents confirmed that they are able to exercise choice over such things as what time they get up, what activities they take part in, what they eat and what they wear. The menu was seen to include a varied diet. Residents are offered a wide choice of breakfasts, including cooked breakfast. The kitchen was seen to be clean, well stocked with a variety of food including fresh vegetables. The inspector spoke to the cook who had a detailed knowledge of individual residents’ likes and dislikes. A liquified meal was seen during the inspection, each item was liquefied separately and was well presented. The majority of residents who replied to the survey or spoke to the inspector praised the food. One person said that they sometimes enjoyed the meals provided but did not expand further in their explanation. As the survey stating this was returned anonymously it was not possible to follow this up with the respondent during the inspection. Special diets are provided for, including liquified food and meals for an insulin dependent diabetic. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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. Residents are confident that any complaints they have will be listened to and acted upon. The home’s policies, procedures and staff training ensure that, as far as possible, residents are protected from abuse. EVIDENCE: The home’s complaints procedure was seen and found to be simple, clear and accessible. Information on how to complain is included in the Service User Guide and is displayed in the entrance hall of the home. Residents know how to make a complaint and said that they feel any complaints made would be taken seriously. The home has not received any complaints since the last inspection. Policies and procedures on Adult Protection and Whistle Blowing were seen and found to be clear and robust. There is a copy of the West Sussex County Council Adult Protection Procedures available in the office for staff. Staff training records show that staff have all received training on Adult Protection. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pinewood provides a safe, comfortable, well-maintained environment for residents. The home has a high standard of safety checks. The servicing of equipment is regularly completed and thoroughly recorded. The home is clean, pleasant and hygienic. EVIDENCE: Pinewood is a detached property situated in extensive well-kept grounds in the village of Chidham, close to Chichester. A tour of the premises found the home to be fresh, clean and well maintained throughout with no offensive odours. Rooms are redecorated prior to a new resident moving in. Pinewood is comfortable and homely. Both the home and grounds are accessible. One resident commented that “the home is well looked after, conscientious cleaning staff are in action daily.” New light fittings have recently been fitted in the lounge. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 16 Pipe work and radiators are covered and water temperatures are regulated to maintain a safe temperature. The home had a Legionella test this year. There is emergency lighting throughout the building. Records seen show that regular maintenance checks for equipment and appliances take place. The home has a high standard of safety checks. The servicing of equipment is regularly completed and thoroughly recorded. The laundry is well equipped and is sited away from food preparation and storage areas. Policies and procedures regarding the control of infection were seen and found to be clear and informative. Residents’ bedrooms were seen to be well decorated, well furnished, and individualised with residents’ own belongings. A panel on an en-suite bath was found to be cracked. This was pointed out to the owner who said it would be dealt with immediately. Since the last inspection the home has renewed many pieces of equipment including a cooker, dishwasher, washing machine, fridges and tumble drier. Flat screen televisions are gradually being added to residents’ rooms to replace the current televisions. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met by the numbers and skills mix of staff who are trained and competent to do their jobs. The home has exceeded the required standard of having fifty per cent of care staff with an NVQ Level 2. Residents are supported by the home’s recruitment policy and are in safe hands. EVIDENCE: The current staff rota was seen during the inspection. There are adequate numbers of care staff and trained nurses on duty throughout the day and night. Residents feel that the home has enough staff on duty and that staff respond to their calls quickly. Staff training records were seen and showed that staff are offered a varied programme of training including mandatory health and safety courses alongside courses specific to the needs of the residents. The home has exceeded the required standard of having fifty per cent of care staff with an NVQ Level 2. Staff confirmed that they received induction training. Staff morale was high and staff spoken to felt that everyone worked well together. Several staff have worked in the home for many years. As well as Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 18 care staff and qualified nurses the home employs a housekeeper, cleaners, cooks and an administration worker. One resident commented, “The staff are always very kind and caring. It is a very happy environment. The staff make a lot of effort to ensure peoples’ needs are met.” Three staff files were examined to check recruitment procedures. All files contained the required documents including application forms, Criminal Records Bureau checks and two written references. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 19 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, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run, in the interests of the residents by an experienced manager. The home does not manage the finances of residents. The health safety and welfare of the residents and staff are promoted and protected. EVIDENCE: The registered manager is a qualified Level 1 nurse with many years experience of running Pinewood. She has a Registered Managers Award and continues to undertake periodic training relevant to the home. Staff spoken to said that they feel very supported by the manager and owners, Mr and Mrs Marsh. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 20 Evidence was seen that the home has a quality assurance system in place that seeks the views of residents on the care provided by the home. The home does not look after the financial affairs of any residents. This is done by relatives, solicitors etc. Evidence was seen that the owner carries out regular in-house maintenance checks. The servicing of equipment is regularly completed and thoroughly recorded. Fire alarm systems and equipment checks are carried out at required intervals. Emergency lighting, lift, electrical equipment, heating systems and hoists are serviced and maintained within appropriate timescales. Staff records show that staff have up to date health and safety training certificates. The Environmental Health Inspection carries out in June made two recommendations both of which have been met. Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 4 Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pinewood Nursing And Convalescent Home DS0000024196.V302355.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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