Inspection on 19/09/06 for Pinfold Lodge Nursing Home

This inspection was carried out on 19th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pinfold Lodge Nursing Home 06/08/08

Pinfold Lodge Nursing Home 29/08/07

Pinfold Lodge Nursing Home 01/06/05

Pinfold Lodge Nursing Home 14/12/04

Pinfold Lodge Nursing Home 17/08/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Pinfold Lodge Nursing Home 6 Sheepdyke Lane Hunmanby Filey North Yorkshire YO14 0PS Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 19th September 2006 09:45 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 Pinfold Lodge Nursing Home DS0000028007.V312633.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. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinfold Lodge Nursing Home Address 6 Sheepdyke Lane Hunmanby Filey North Yorkshire YO14 0PS 01723 891069 01723 892575 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) Complete Care Homes Limited Mr Jeremy Peter Harry Brockett Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age range 60 years upwards Date of last inspection 2nd November 2005 Brief Description of the Service: Pinfold Lodge provides personal and general nursing care and accommodation for up to 34 people from 60 years of age. The home is located in Hunmanby village and is within walking distance of the local amenities. Pinfold Lodge is a detached premises situated in its own grounds with parking facilities for visitors and staff. The accommodation is provided in both single and double bedrooms over two floors. The double bedrooms are used for single occupancy. There are two passenger lifts and level access to and around the home. The home is owned by Complete Care Homes Limited and was first registered with the Commission in 2002. Prospective service users are invited to look around the home before moving in. Information is provided to them in the form of a brochure that reflects the Statement of Purpose. A copy of the most recent inspection report is also made available on request. The fees charged at 19/9/06 range from £350.00 to £500.00 with additional charges made for hairdressing (£4-£21) and Newspapers (varied prices) Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from 8 service users and 11 relatives. No comments were received from the GPs and Care managers that were surveyed. A visit to the home carried out by one inspector. A site visit was carried out and lasted for five and a half hours. Five service users, two relatives and five staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Pinfold Lodge for the people that live there. The Manager was available to assist throughout the day. What the service does well: People like living at Pinfold lodge. The atmosphere is warm and welcoming. The management and staff are open and encourage service users and their relatives to express their wishes and opinions. The meals provided are presented well and nutritious. The cook is aware how to enrich diets. The staff spend a lot of time with the service users and arrange a wide variety of social activities to suit differing tastes and interests. All of the service users looked well cared for, comfortable and the staff were observed to kind and considerate to all their needs. Service users are provided with lockable facilities to safely store medication should they want to look after this theirselves. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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. Pinfold Lodge Nursing Home DS0000028007.V312633.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 Pinfold Lodge Nursing Home DS0000028007.V312633.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): 3. 6 is not applicable Quality in this outcome area is good. Service users can be assured their needs will be met. This judgement has been made using available evidence including a visit to this service EVIDENCE: The statement of purpose was looked at and it gave information about the homes’ aims and objectives, the services and facilities that are provided. A copy of the statement of purpose is available in the home and individual copies on request for service users and their relatives. All prospective service users are assessed prior to their admission being agreed. A number of assessments were looked at and there was good information recorded about their personal and nursing care needs. A relative spoken with stated they knew about the assessment and had contributed information about their relative’s care and social needs. People are invited to visit the home to look at the facilities prior to them moving in. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is good. Service users health care needs are met. This judgement has been made using available evidence including a visit to this service EVIDENCE: A number of service users care plans were looked at. Some progress has been made to improve the systems for assessing risks and planning care for service users. Staff have signed the daily records. The daily records gave good information about the service users day to day lives and healthcare needs but in some cases the care plans had not been amended or updated to reflect this. All the necessary risks had been assessed and relevant plans of care put in place to address these although they are not always reviewed. The service users looked well cared for and comfortable in their surroundings. There was a wide range of equipment available to assist with mobility and for the relief and treatment of pressure sores. One service user said, ‘The staff Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 10 are excellent, if I need to go to bed I just ask’. This was confirmed by a relative who said, ‘The nursing care is excellent here’. The monitored dosage medication system is used in the home and medications are handled and administered safely. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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): Quality in this outcome area is good. Service users enjoy their lifestyles at Pinfold Lodge This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged and supported to keep in contact with their family and friends. Visitors are welcome at anytime and are involved in the care of their relative and with the activities that take place in the home. A Summer Fayre had taken place a few weeks before the visit that had been thoroughly enjoyed by service users The atmosphere was happy and staff were seen spending time with service users and engaging them in conversation. Staff were able to give sufficient time to service users so that they were able to take part in conversations. The manager has a special rapport with service users of the home and they were clearly very fond of him. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 12 Service users were able to take their meals where they wished and those needing assistance were given this in a sympathetic and appropriate manner. This helped to ensure that mealtimes are an enjoyable event. The meals provided looked appetising and nutritious. The cook was knowledgeable about diets and was planning to undertake a ‘healthy eating’ course. She explained clearly about enriching diets for those service users who may be ill and not have much appetite. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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): 16 and 18 Quality in this outcome area is good. Service users are listened to and protected by the homes policies and procedures and well trained staff. This judgement has been made using available evidence including a visit to this service EVIDENCE: Service users and visitors to the home are given information about how to make a complaint against the service. There were systems in place to record all comments, concerns and complaints. The procedure assures people that their complaints will be taken seriously, investigated and any outcome will be given in writing. All staff have attended abuse awareness training and are now familiar with the local authorities procedure for reporting suspicions and/or allegations of abuse. Those spoken with were able to confirm this. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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): 19, 22, 26 Quality in this outcome area is good. Service users live in a safe, warm and welcoming home. This judgement has been made using available evidence including a visit to this service EVIDENCE: All parts of the home were found to be clean bright and cheerful, the dining room and lounge are bright and spacious accommodating wheelchairs and hoists comfortably. Storage is available for equipment so that it does not pose a Health and Safety hazard. The domestic staff keep the home very clean and fresh. The laundry staff ensure that service users always look clean and well dressed There is a programme of ongoing maintenance and the required safety certificates were in place. Requirements from the Fire Safety Officer had been met. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 15 All of the service users rooms are well kept and they have their personal belongings around them. There is a good supply of equipment for moving and handling and for pressure relief. Bed rails in use were fitted safely and securely but there was no system in place to ensure that they are regularly checked for safety. Access to the home is level and there are two lifts for access to the upper floors. The garden outside is well maintained and appreciated by the service users. There are handrails along the corridors, which help people maintain their independence around the home. A health and safety company has been retained to ensure that this area is fully addressed at all times. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. Staff are well trained to meet the needs of the current service users. Recruitment procedures need to be more robust to fully protect service users. This judgement has been made using available evidence including a visit to this service EVIDENCE: The qualified nursing staff have the relevant general nursing qualifications and the care staff have the opportunity and are encouraged to work towards NVQ qualifications in care. Currently 44 of care staff hold an NVQ qualification in care at level 2. Evidence was seen that induction and mandatory training is completed. A member of staff said that they had undertaken an induction into the home and that they received ongoing support from qualified staff. There are currently two members of staff undertaking the Overseas Nursing Programme with support from the registered manager. Staff receive regular supervision. All staff employed have a current CRB in place. However when looking at the records it was clear that two out of the four staff that were looked at had been appointed and deployed prior to the home receiving the CRB check and with no POVA 1st check. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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): 31,33,35, &38 Quality in this outcome area is good. The home is well managed. This judgement has been made using available evidence including a visit to this service EVIDENCE: The registered manager is a qualified nurse and has a number of years of experience in managing a care home with nursing. He has almost completed the Registered Manager’s Award and intends to address this now a new training provider has been secured. He operates an open door policy and transparent way of working. He is well liked and respected by service users, staff and visitors to the home. A clear process for the recruitment and selection of staff must be implemented to ensure continued safety of service users. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 18 Quality assurance systems are in place and the home hold the Investors in People Award. The quality assurance system needs to be built upon to ensure sufficient stakeholders in the home are surveyed. The information obtained should be used to inform the annual development plan for the service. The home has a health and safety policy and procedure in place and all staff undertake the required training. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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 OP7 Regulation 15 (2(b)) Requirement Timescale for action 21/10/06 2. OP22 13(4)(c) 3. OP29 19 Sch 4 The registered person must ensure that the care plans are kept up to date, accurate and reviewed to reflect the current needs of service users. A system must be put in place to 29/09/06 ensure that bed rails are checked on a regular basis to ensure continued safety. The registered person is required 22/09/06 to undertake the required checks on all staff and have the required records in place before that person is deployed at the home Outstanding from the previous inspection Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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. Refer to Standard OP28 OP33 Good Practice Recommendations The registered person should continue to encourage care staff to undertake and achieve an NVQ qualification in care at level 2 or above. It is recommended that the quality assurance system be further developed to better inform the annual development plan for the service. Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Pinfold Lodge Nursing Home DS0000028007.V312633.R01.S.doc Version 5.2 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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