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Inspection on 21/07/04 for Pinewood Tower

Also see our care home review for Pinewood Tower for more information

Care Home For Older PeoplePinewood Tower30 Tower Road Branksome Park Poole Dorset BH13 6HZUnannounced Inspection21st July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Pinewood Tower Address 30 Tower Road, Branksome Park, Poole, Dorset, BH13 6HZ Email address Name of registered provider(s)/company (if applicable) Mrs Gene Mangold Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 14 Tel No: 01202 762855 Fax No: 01202 762880Category(ies) of registration, with (number of places) Dementia - over 65 years of age (14), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) Registration number D080000312 Date first registered Date of latest registration certificate 3rd October 1984 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 30th July 2002 YES NO 27/01/04 If Yes refer to Part CPinewood TowerPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 321st July 2004 10:30am Tracey CockburnID Code101051Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionClaire DiffeyPinewood TowerPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementPinewood TowerPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Pinewood Tower. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Pinewood TowerPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Pinewood Tower is situated in a residential area of Branksome Park; the nearest amenities are approximately ½ mile away in Westbourne. A regular bus service goes from Westbourne into Bournemouth (approx 2 miles) and Poole (approx 3 miles). Pinewood Tower is registered as a care home to provide accommodation for 14 service users in the category older people with dementia over 65 years of age. The home is set back from the road in mature secluded gardens. Service users accommodation is situated on the ground and first floor. The ground floor provides an entrance hall with stairs to first floor, lounge/dining room, toilet, kitchen, laundry and four bedrooms. A further seven bedrooms are situated on the first floor, accessed by the main stairway. Two bathrooms with W.C. and washbasin and one separate W.C. are situated on the first floor. Of the service user rooms, two provide shared accommodation although only one is used at any one time as a double. There is no passenger lift.Pinewood TowerPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection took place without prior warning between the hours of 10:30am and 2:00pm. The registered manager was unavailable during the inspection. A senior member of staff assisted the inspector. At the time of the inspection there were 13 service users accommodated. There were 4 members of care staff on duty. There was also a cleaner and handyman in the home. The inspector viewed a variety of staff records, policies and procedures, service user records and training records. The inspector talked to service users and staff on duty. Since the last inspection the registered manager had arranged for the premises to be assessed by an occupational therapist. At the time of the inspection the recommendations from the report had not yet been implemented. There are 2 requirements and 4 recommendations as an outcome of this inspection. Choice of Home (Standards 1-6) 3 of the 4 standards assessed were found to be met. The homes statement of purpose is the document by which prospective service users and their representatives will base their decision to choose a particular home it is therefore vital that the document reflects accurately the services provided and makes clear how the needs of individuals with dementia will be cared for within the home. Each service user has a written contact and statement of the terms and conditions with the home. No service user moves into the home without having his/her needs assessed and been assured that these will be met. Health and Personal Care (Standards 7-11) All of the 4 standards assessed were found to be met. Each service users health, personal and social care needs are set out in an individual plan of care. Most service users in this home would find making decision about their lives very difficult, assistance is provided at all times by care staff to encourage choice and decision making but the reality is that decisions are made by other people who have the service users best interests at heart. These decisions about health are taken in conjunction with the service users legal representatives. The home has policies and procedures in place for dealing with medicines. Service users and their families should be assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Pinewood TowerPage 6 Daily Life and Social Activities (Standards 12-15) All of the 3standards assessed were found to be met. The capacity for social activity will vary according to the individual and all the service users in this home need special support and assistance in engaging in the activities of daily life. It is important to maintain the health and wellbeing of service users food has a central role to play. The quality and style of presentation of food and the way in which staff assist service users at mealtimes are crucial in ensuring service users receive a wholesome, appealing and nutritious diet. Complaints and Protection (Standards 16-18) The 1 standard assessed was found to be met. Service users have the right to be protected from abuse, the home has a detailed policy and care staff understand the importance of it. Environment (Standards 19-26) 5 of the 8 standards assessed were found to be met. People with dementia have particular needs for the layout of the communal spaces and the associated signage to aid their remaining capacity. Staffing (Standards 27-30) 1 of the 3 standards assessed was found to be met. Service users with dementia require care from appropriately skilled staff. This home has provided appropriate training for all care staff. Staff are competent to do their jobs. Management and Administration (Standards 31-38) 3 of the 5 standards assessed were found to be met. Service user benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of the service users. The homes record keeping policies and procedures safeguard the rights and best interests of service users. The home continues to be well managed and issues are addressed within agreed timescales.Pinewood TowerPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Pinewood TowerPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 17(2) Schedule 4 OP29 (6)(f) The registered manager must ensure that all care staff have up to date documentation in place confirming they are able to work in this country. Care staff must receive a minimum of three paid days training per year (including in house training). 30/09/04218(1)(c)OP3030/09/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues, which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The statement of purpose should reflect in detail the specialist service the home offers to service users with dementia and dementia type illnesses. The registered manager should consider experimenting with different signage to promote service user independence around the home1OP12OP21Pinewood TowerPage 9 3 4OP33 OP38Results of the questionnaires issued to service users or their representatives, health and social care professionals and other stakeholders should be made public. Hazardous substances should be stored securely.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Pinewood TowerPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES NO NO YES NO YES NO YES NO YES NO YES YES NO YES 5 0 0 NO NO YES YES 11 0 21/07/04 10:30 3.5Pinewood TowerPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Pinewood TowerPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceYES HAIRDRESSER, CHIROPODIST, NEWSPAPERS, DRYCLEANING, TAXIS. 2 Standard met?The statement of purpose and service user guide provides information on the philosophy of the home, the service provided, the facilities and the aims and objectives of the home. However there is a lack of information on the specialist nature of the service provided by the home and the specialist training that care staff receives. It is difficult to ascertain from the document that the home has developed a person centred approach to the care of service users and there is no information on the focused activities that the home endeavours to support the service users to participate in.Pinewood TowerPage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Each service users representative is provided with a statement of the terms and conditions of the home. The inspector saw evidence of this in service users files. The terms and conditions cover: · the room to be occupied · the care and services covered by the fees · period of notice The terms and conditions also cover the homes policy on pets, furniture and complaints. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? All service users but one currently accommodated in the home are under contract with the local authority. The home has care management assessments; there is also a detailed life history of the service user on their file, which is incorporated into the care plan.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The care staff in the home have recently undertaken training on person centred dementia, including dementia care mapping and staff are using this information to assist in developing care to each individuals needs. The staff members on duty on the day of the inspection were keen to explain their recent training to the inspector. The inspector also saw evidence of specialist services for individuals including advice from psychiatrists and community psychiatric nurses.Pinewood TowerPage 14 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met?Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home is not registered to provide intermediate care and therefore this standard is not assessed.Pinewood TowerPage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The inspector viewed the care plans of four service users. Each file contained a detailed plan of the daily routines of each individual. This included information such as their preferred time for getting up, how they liked to be assisted, what they could do for themselves and what care staff would need to do for them. Each service user has an oral hygiene assessment. Risk assessments describe the risk, the undesirable outcome and the plan to achieve a desirable outcome. For example one of the service users refuses to eat which could lead to illness, the action is to monitor their food intake on a daily basis, recording and reviewing weekly, this individual is weighed weekly and there was evidence in the daily records that the GP is consulted if there are concerns. Each key worker has weekly duties for the 4 individuals that are their responsibility including: · reviewing their care · updating their records · monitoring their weight · monitoring their mental health · up dating their life histories The inspector noted that the detailed life histories for each individual help to inform the care plan especially around activities.Pinewood TowerPage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X 0 Standard met? 3The inspector saw evidence of oral hygiene assessments, this information was then detailed in their care plan and care staff informed the service users that they undertake the care for each service user based on the care plan for which the key worker is responsible for updating monthly. Each service user has their mental health checked on a monthly basis, key workers complete a modified mini Norton scale test and record their findings, the inspector then saw evidence in a service users file of professional advice being sought if their were concerns about any changes. The inspector saw evidence of service users food intake being recorded on a daily basis. Each service user is weighed monthly and advice sought. The service users files contain information on their dentist, chiropodist and care manager. Information is recorded on when hearing and sight tests are due and it is the responsibility of the key worker to ensure that appointments are made. The inspector saw evidence of weekly blood sugar test for a service user who was diabetic. There was also evidence of medical advice being sought when the blood sugar level was outside the normal range for that person.Pinewood TowerPage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home has a detailed policy and procedure on the receipt, storage, handling and disposal of medicines. All staff that administers medication has received training. There is also policy on covert administration of medication. The inspector saw evidence of the registered manager seeking advice from a pharmacist. The inspector also saw evidence in 2 service user files of medication being reviewed. Medication is received in blister packs from the pharmacist and dispensed directly to the service user at prescribed times throughout the day. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met?Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The home has a policy on the care of the dying and last offices. There is also a statement entitled If I were dying I would want this document includes statements such as: · I would wish to be cared for in my own room · I would want my friends and family around me Ascertaining the wishes of individual is recognised as being difficult but within the personal files of each individual are statements by relatives and friends about the individuals known wishes.Pinewood TowerPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? It is difficult to establish if the home meets each individuals expectations however the detailed life history for each person does try to establish what their leisure and social activities might have been and therefore can inform the staff on what activity might stimulate some memory. Meal times are at set times but some service users have their own routines to suit their needs. Each service users room has photographs on the wall of people who are important to them and they also have a memory box with personal items which enable them to participate to some degree. The home also have activities divided into four weekly topics: · week 1: sensory · week 2: movement · week 3: communication · week 4: expression Each day service users are involved in an activity related to the topic of the week. For instance on week one activities may include: · an aromatherapy massage · smelling flowers in the garden · guessing the smell · textures · listening to old tunes · watching a black and white movie The care staff told the inspector that it is sometimes difficult to involve service users in activities. A record is kept of each service users participation and progress; this is reviewed if the activity does not suit the service user.Pinewood TowerPage 19 Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The staff informed the inspector that service users are able to see visitors in private. There is information in the service user guide on the homes policy on maintaining relative and friends involvement with service users. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met?Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? All meals are recorded in a meal book. There is a menu plan for 2 weeks. The menu lists the main meals, breakfast, lunch and supper. On the day of the inspection the lunch- time meal was: roast chicken, roast potatoes, stuffing, gravy and carrots, courgettes and sweet corn. The pudding was apple crumble and ice cream. No service user had their food liquefied. Service users are assisted to eat if necessary. The inspector noted that staff records in the activity book when the weather is nice the service users have lunch in the garden. There were hot and cold drinks available to the service users throughout the day. Service users individual preferences as to the time they eat and where they eat were noted by the inspector, one service user chooses to eat at very different times to every one else.Pinewood TowerPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure, which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. Of complaints made to the home during last 12 months No. Of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 0 X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met?Pinewood TowerPage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 3The home has a clear adult protection policy and staff understands what action they should take if there is any allegation made. The manager is aware of the introduction of the POVA* list and has the appropriate address. The home has policies and procedures in place on how staff should deal with physical and/or verbal aggression. The home also has policies and practices in place regarding service users financial affairs, wills and receipt of gifts. *POVA : Protection of Vulnerable AdultsPinewood TowerPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is situated in a quiet residential street, the home is set back from the road in mature gardens, and the garden is secure. There is a programme of routine maintenance. On the day of the inspection the handyman was in the home working on the recommendations from the Occupational therapists assessment of the premises. The inspector noted that the grounds were tidy, the lawn was newly mown, and the flowerbeds were in full bloom. Service users have access to the flower garden via patio doors from the lounge. There is a ramp into the garden. On the day of the inspection there was one service user sitting in the garden smoking. He said he also enjoyed the flowers and watching the birds. The inspector saw evidence of the environmental health departments last inspection. There is no CCTV.Pinewood TowerPage 23 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home has a large lounge and dining room. It is large enough to accommodate all service users living in the home. The outdoor space is accessible for service users with mobility problems as there is a ramp from the patio. Lighting throughout the communal rooms is domestic in character, there are a variety of different lamp heights and the rooms are bright enough to facilitate activities such as reading. The chairs in the communal rooms are domestic in character but also suitable for the mobility needs of the individuals accommodated in the home. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? There are accessible toilets clearly mark with written signs. There are also arrows pointing the way. There is a toilet close to the lounge and dining room. The home does not have a sluice. There are two bathrooms in the home. One bathroom has a powered bath hoist. There is no bath aid in the second bathroom.Pinewood TowerPage 24 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? Service users have access to all parts of the communal space. The home does not have a passenger lift. Service users need assistance to reach their private rooms. There are grab rails in the toilets and bathrooms. There is a call system, which is accessible from every room. The registered manager has recently commissioned an assessment by an occupational therapist. This assessment made 3 recommendations: · The ramp that leads into the garden is quite steep for the walking residents. It should have a handrail to one side to provide additional support. The rail should be 900mm high. · A handrail fitted on the wall over the bath would provide additional safety and security for residents when using the powered bath seat. · The toilet frame in the bathroom should also be replaced as it is now becoming corroded. This work has not yet been completed.Pinewood TowerPage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence The shared rooms are currently single occupancy. This care home continues to provide rooms with the same useable space for each service user as at 16th august 2002. NO YES NO 10 1 2 0 Standard met? 3 10 00 0 2 0Pinewood TowerPage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Each service users own private accommodation has a picture of them on the door with their name underneath. The inspector viewed all the rooms in the home and each bed had clean bed linen and a protected mattress. There were curtains on all windows. There was overhead as well as bedside lighting. Not all rooms were carpeted, two rooms had a floor covering more appropriate for the needs of the individual. All doors were fitted with locks. There was screen in both double rooms. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? All rooms are individually and naturally ventilated. All radiators and exposed pie work are covered. The lighting throughout the home is domestic in character and there is also table level lamp lighting. There is also emergency lighting, there was evidence that this is regularly tested and serviced.Pinewood TowerPage 27 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? On the day of the inspection the home was clean, hygienic and there were no malodours. There are hand-washing facilities in the laundry area. The laundry room is sited in a room near the back door. The laundry floor has an impermeable finish and the walls are readily cleanable. There is no sluice in the home.Pinewood TowerPage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 11 2 Standard met? 3The inspector viewed the staff rota for the current week and the following few months. On the day of the inspection there were 4 members of care staff on duty, one cleaner and one handyman. There is 11 care staff employed by the home. One member of staff cook the main mid day meal, leaving 3 members of staff to provide care to the service users.Pinewood TowerPage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector viewed 7 staff files on the day of the inspection. Each member of staff had two written references obtained prior to commencing work. All staff had a satisfactory CRB*check. All staff receive a copy of the GSCC* code of conduct. The inspector noted that all staff had received a copy of their terms and conditions attached to their contract. Several members of staff are from overseas and have the appropriate paperwork to work in this country. One of the members of staff did not have an up to date stamp from immigration on their file. *CRB: Criminal Records Bureau *GSCC: General Social Care CouncilPinewood TowerPage 30 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Pinewood Tower has a comprehensive training programme for all staff. Care staff are about to complete their person centred dementia course and other are about to undertake training in person centred activities and adult protection and moving and handling. The inspector saw evidence on the staff rota that some courses are undertaken on the member of staffs day off.Pinewood TowerPage 31 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met?Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? On the day of the inspection the registered manager was unavailable for personal reasons. The inspector found the staff in the home to be very knowledgeable, willing to assist the inspector and very capable in caring for and supporting the service users in the home. The care staff told the inspector that they feel very supported by their manager and enjoy working in the home.Pinewood TowerPage 32 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The home has a quality assurance system in place. There was evidence of questionnaires being returned from health and social care professionals. Questions such as: · Do you feel that we provide an individual tailored programme of care for our residents · Do you feel we provide enough stimulating activities The answer to both these questions was yes. The inspector could not find evidence of the details of the surveys being published. Action to implement requirements if there are any have been, have been within agreed timescales. The inspector saw evidence of policies and procedures being reviewed annually. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met?Pinewood TowerPage 33 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 X X 0No service user currently accommodated within the home has control of their own money. The registered manager does not handle the finances of any individual. There are secure facilities for the safekeeping of valuables.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met?Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The records required by regulation are kept securely and the inspector found them to be accurate and up to date. The home is aware of the data protection act 1998 and records are kept with these requirements in mind. Service users and their representatives are given information in the service user guide on how to access personal records.Pinewood TowerPage 34 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? All staff have received training in: · Moving and handling · Fire safety · First aid · Food hygiene · Infection control On the day of the inspection the inspector noted that the storage of hazardous substances in the laundry room was not safe. Windows on the first floor are restricted. The kitchen equipment and laundry machinery is regularly maintained. Water temperature is regulated and stored at the corrected temperature. The premises are secure. All accidents are recorded; there is safety notices posted around the home. The fire officer inspected the home in May 2004. The fire alarm system is checked weekly, the last check was on 18/07/04,staff receive training every 3 months. The emergency lighting was last checked on 19/07/04.Pinewood TowerPage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager Date Public reportsTracey CockburnSignature Signature SignatureTracey CockburnIt should be noted that all CSCI inspection reports are public documents. Pinewood Tower Page 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on Wednesday, 21st July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possiblePinewood TowerPage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 23rd August 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONOYESOther: enter details here NOPinewood TowerPage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, ................................... of Pinewood Tower confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, ................................... of of Pinewood Tower am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Pinewood TowerPage 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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