Inspection on 29/11/05 for Pinewood Tower

This inspection was carried out on 29th November 2005.

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 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 Tower 22/11/06

Pinewood Tower 05/07/05

Pinewood Tower 28/01/05

Pinewood Tower 21/07/04

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

CARE HOMES FOR OLDER PEOPLE Pinewood Tower 30 Tower Road Branksome Park Poole Dorset BH13 6HZ Lead Inspector Debra Jones Unannounced Inspection 29th November 2005 09:20 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 Tower DS0000004072.V269878.R01.S.doc Version 5.0 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 Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinewood Tower Address 30 Tower Road Branksome Park Poole Dorset BH13 6HZ 01202 762855 01202 762880 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) Mrs Gene Mangold Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14) Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Pinewood Tower is a care home providing personal care and accommodation for 14 older people who have mental disorders or dementia. The home is situated in a quiet residential area of Branksome Park. The nearest amenities, including shops, banks, post office, churches and doctors surgeries etc, are approximately half a mile away in Westbourne. Car parking is provided for visitors to the home and further parking is available on nearby roads. A regular bus service goes from Westbourne into Bournemouth (approx 2 miles) and Poole (approx 3 miles). Pinewood Tower is a large detached property that has been adapted to provide residential care. The home is set back from the road in mature secluded grounds with a peaceful, enclosed area of garden where residents may sit and a separate activity area. Accommodation for residents is provided on the ground and first floors. There are ten single bedrooms and two providing shared accommodation. Access to the first floor is via the stairway as there is no passenger or stair lift. The home also has a lounge/dining room with patio doors to the garden. There are two bathrooms with W.C. and washbasin, and two separate W.C.s. Pinewood Tower provides 24-hour personal care, all meals, laundry and domestic services. The home offers stimulation in the form of regular daily activities. Pinewood Tower is owned and personally managed by Mrs Gene Mangold, assisted by an experienced team of staff. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 hours on the 29 November 2005 and was the second of the two anticipated inspections of the year. The national minimum standards not inspected at the last inspection were looked at and the 2 requirements made at the last inspection were followed up to see if they had been addressed. The Inspector looked around some of the building and a number of records and related documentation were inspected. The owner/ manager – Mrs Gene Mangold was spoken to. All staff on duty at the home were very pleasant and helpful. The Inspector met with the residents in the lounge. At the time of the visit 13 people were living at the home. What the service does well: Pinewood Tower provides a service for older people with dementia and long term mental disorders in a well-decorated and comfortably furnished house. The home has a comfortable and relaxed atmosphere and residents are clearly at ease. The home is owned and managed by Gene Mangold who has years of experience in caring for residents. Medication is well managed and residents can have confidence that staff look after their medicines well and administer them properly. Residents are able to make choices as to the way they live their lives at the home and be in touch with relatives and friends as they wish. The home demonstrates a commitment to protecting residents by providing information and training to staff about adult protection. Residents are further protected by good recruitment procedures. Staff have access to relevant training to help them understand the needs of residents and how to care for them. Systems are in place and records kept, that demonstrate the homes commitment to providing a safe environment for residents to live in. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Tower DS0000004072.V269878.R01.S.doc Version 5.0 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 Tower DS0000004072.V269878.R01.S.doc Version 5.0 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): 3 (Standard 1 was met at the last inspection) 6 is not applicable. Pre-admission assessments are carried out to ensure that only those whose needs can be met by the home are offered places there. However, without written confirmation, prospective residents cannot be fully assured that their needs will be met. EVIDENCE: At the last inspection it was noted that Mrs Mangold carries out her own preadmission assessment to ensure that Pinewood Tower is the correct placement for prospective residents. No written confirmations as to the outcome of any assessments were provided, so the prospective resident could not be fully assured that his/her care needs would be met. Since the last inspection only one new resident has been admitted and this was as an emergency. Mrs Mangold is about to carry out a pre admission assessment for a prospective new resident and is aware of the need for written confirmation to be made that the home can meet assessed need. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 9 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): 9 (Standards 7,8 and 10 were met at the last inspection) The medication at this home is generally well managed promoting the good health and well being of residents. EVIDENCE: A robust system for the ordering, administering and recording of medication is in place at the home. Patient information leaflets are available in the home about the medication in use. Only staff members that Mrs Mangold has considered to be competent and confident in administering medication carry out this task. Staff attend a course run by staff at the home called ‘giving medication safely’. Medication records sampled were up to date and matched the medicines in the home. Where staff copy details of new medicines on to the medicine charts Mrs Mangold is aware that these entries need to be countersigned to show that the details have been checked. Medicines were tidily stored in the medication cupboards. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 10 No medicines needing refrigeration are currently in use at the home. Mrs Mangold was advised that when it is next the case that medicines need to be stored in a fridge that they be kept in a lockable plastic box. She was also advised that in line with Guidance from the Royal Pharmaceutical Society on the handling of medicines the home obtain a thermometer for and monitor and record the maximum and minimum temperature of the fridge used to store medicines daily when in use (normal range 2°-8°C). No residents are currently looking after their own medication. Mrs Mangold said that resident’s medication was reviewed regularly by their GPs in line with recommendations in the National Service Framework for older people. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 11 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): 13 & 14 (Standards 12 and 15 were met and exceeded at the last inspection) Residents’ lives are enriched by the social opportunities afforded by their visitors. Visitors are made welcome at the home and can come whenever it suits the residents. Residents are helped and encouraged to exercise choice in their daily lives at the home. EVIDENCE: Residents are able to see their visitors in the lounge / dining room or their own rooms as they wish. Most residents are visited by family members and go out with them on trips. Where families live further away staff help them stay in touch by letters and e-mails. Where residents do not wish to be in contact with their families the home support them in this. The visitors’ book confirmed the number and range of visitors to the home. The local church also supports some residents. Pinewood Tower is run in a manner that encourages residents to make the choices they can and have as much control over their lives as they want. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 12 Information is collected where possible about residents’ interests, life histories and likes and dislikes. Residents, although not always able to say what they enjoy, are very able to make their preferences clear. Preferences for daily routines are observed and staff encourage residents to make choices daily e.g. what they want to wear, what they want to eat and what they want to do that day. Visual aids are available to help staff communicate with residents to help them make choices. A half day training course is run at the home called ‘choices, privacy and dignity’. This is based around the home’s policy. Information is available about access to local advocacy services. One resident has recently used Help and Care. A tour of the premises showed that residents are able to bring personal possessions with them into the home. Residents and their relatives are encouraged to be involved in care plans and reviews but none have expressed interest in looking at their personal records. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 13 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): 18 (Standard 16 was met at the last inspection) The availability of adult protection information and training demonstrates the homes commitment to understanding abuse and of protecting residents. EVIDENCE: The home has up to date information about how to respond to allegations of abuse as provided by the Local Authority. Staff have attended or are booked to attend training run by the Borough of Poole about protecting vulnerable adults. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 14 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): Standards 19, 20, 23, 24 and 26 were met at the last inspection. EVIDENCE: None of these standards were assessed on this occasion. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 15 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): 28, 29 and 30 (Standard 27 was met at the last inspection) Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home although not all staff had POVA first checks or full Criminal Record Bureau certificates for Pinewood Tower. Residents are cared for by staff who mostly have relevant qualifications from abroad along with access to local training to enable do their jobs well. EVIDENCE: A recruitment procedure is in place at the home and staff files are kept that demonstrate the recruitment process in action. The recruitment procedure could do with updating to reflect the changes brought about by the introduction of the Protection of Vulnerable Adults list held by the Department of Health. Staff can now only start working at the home once they have had a Criminal Records Bureau check for Pinewood Tower or a POVA 1st check. The home employs some workers from abroad. It was clear from the files that the home was obtaining the right sort of information about people’s rights to work in the country and any restrictions on that work. A few gaps were found in the documentation that must be obtained for staff prior to them starting to work at the home. Two files sampled had CRB certificates for homes other than Pinewood Tower. 3 files showed that staff had begun working at the home prior to them having received their CRB Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 16 disclosures or POVA 1st checks. Where POVA 1st checks are applied for evidence should be kept of this and of the outcome of the check once received. Staff have contracts of employment that state when the person started to work at the home and in what capacity. Most care staff employed at the home are from other countries and Mrs Mangold believes that a number have qualifications that are more than the equivalent of NVQ level 3, but at present there is no documentary evidence to support this. Training is taken seriously at the home. Staff are thoroughly inducted both at the home and through attending the local borough’s 5 day induction course. They also have access to other training courses relevant to their work e.g. person centred care and activities, and dementia care. Records are kept that show how much training staff have had and when they had it. This makes it easy to see at a glance when refresher training is due. Staff have at least three days paid training each year. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 17 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 and 38 (Standards 33 and 35 were met at the last inspection) The health, safety and welfare of residents is promoted and safeguarded by the way the home is conducted. EVIDENCE: There are clear lines of accountability within the home. Mrs Mangold is an experienced home owner and manager running the home to its stated aims and objectives. Mrs Mangold keeps herself up to date with good practice by attending courses with staff and keeps her nursing registration live (Registered General Nurse) with the Nursing and Midwifery Council All records kept in the home were made available to the inspector as requested and are appropriately stored. An up to date insurance certificate was on display along with Pinewood Tower’s registration certificate. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 18 Fire records were in place. Checks are being carried out by the home to ensure that their fire equipment works and these records show that this is being done at regular weekly and monthly intervals. Fire training and fire evacuations are taking place. Staff are up to date with their fire training – which they attend every three months. Dorset Fire and Rescue Service last inspected the home in the spring of 2004. They are next due to inspect in May 2006. Accident records are kept appropriately. Essential training relating to safe working practices is covered in the induction programme e.g. moving and handling, first aid, food hygiene and infection control. The home has a health and safety policy and a health and safety poster is prominently displayed. The covering of radiators and the limiting of water temperature promote a safe environment for residents. Evidence was not available that the home has taken steps to control the risk of legionella i.e. storing water at at least 60 degrees and distributing it at 50 degrees minimum. The home has a risk assessment of products used in the home that might be hazardous and has data product sheets about these substances. Staff sign to say that they have looked at the file. This file was last updated in 2004 and needs reviewing to ensure that all products in use at the home are included. Portable appliances were last tested in June 2005. Environmental health visited the home in July 2005 and looked at health and safety practices. In January 2005 they visited to look at food hygiene. They noted at that time that ‘the kitchen was found to be in good repair and was maintained in hygienic condition.’ Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 19 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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 x 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x 2 Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d) Requirement The registered person must confirm in writing to the service user that, having regard to the assessment, the care home is able to meet his/her care needs in respect of health and welfare. (previous timescale of 31 August 05) A minimum of 50 of care staff employed by the home must have NVQ level 2 or equivalent. Where the home does not have Criminal Record Bureau (CRB) disclosure certificates for Pinewood Tower for staff who have started work since 26 July 2004 - these must be obtained. Staff must not start working in the home unless they have a CRB for Pinewood Tower or proof of a POVA 1st check for Pinewood Tower. Timescale for action 31/12/05 2. 3. OP28 OP29 18(1)(c) 19 31/12/05 31/12/05 Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP29 OP38 OP38 Good Practice Recommendations It is recommended that the recruitment policy be updated to reflect the impact of the introduction of the POVA list on practice at the home. It is recommended that the home provide evidence that there is no risk of legionella at the home from the way water is stored and distributed. It is recommended that the COSHH file be updated with all products used in the home. Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pinewood Tower DS0000004072.V269878.R01.S.doc Version 5.0 Page 23 - 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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