Inspection on 23/02/06 for Pinford End House Nursing Home

This inspection was carried out on 23rd February 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

Pinford End House Nursing Home 02/07/08

Pinford End House Nursing Home 12/06/07

Pinford End House Nursing Home 03/11/05

Pinford End House Nursing Home 03/02/05

Pinford End House Nursing Home 02/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Pinford End House Nursing Home Hawstead Bury St Edmunds Suffolk IP29 5NU Lead Inspector Mike Usher Unannounced Inspection 23rd February 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pinford End House Nursing Home Address Hawstead Bury St Edmunds Suffolk IP29 5NU 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) 01284 388874 01284 386838 Pinford End Limited Miss Jill Hunt Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Pinford End House is situated in the rural hamlet of Pinford End, South of Bury St. Edmunds. The service offers nursing care for up to forty residents. There are views over the fields from most rooms and pleasant gardens laid to two sides of the house. The accommodation is over two floors linked by a large passenger lift. Most rooms are single with en-suite toilet facilities but there is provision for couples to share a bedroom if required and have an adjoining room as a private lounge. There is a dining room and large lounge on the ground floor and a further lounge on the first floor. There are a number of bathrooms throughout the home one of which includes an assisted spa bath. The building is attractively decorated with wide corridors and large windows giving a feel of space and light. A central courtyard planted with trees and shrubs is accessible to residents and attracts garden birds to feed from the peanut holders provided. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This (unannounced) inspection was the second statutory inspection undertaken in the current inspection year (April – March), in line with statutory requirements. The inspection focused on previous requirements and recommendations, current developments, and the views of service users. Methods used during the inspection included observation, interviews with service users, staff and managers, and examination of policies, procedures and records. What the service does well: What has improved since the last inspection? What they could do better: Attention must be taken to ensure that medication records are maintained accurately, and that the safety of medication is not compromised. The arrangement for the storage of controlled drugs needs to be reviewed to ensure that it complies with legal requirements. The seating arrangements in the lounge should be reviewed to ensure that residents watching TV are not inconvenienced by the constant passage through the room. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 6 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. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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 Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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): 2 These standards will be examined in more detail at future inspections. EVIDENCE: The home is reviewing the current contract, in the light of the recent OFT (Office of Fair Trading) report on care home contracts, and it is intended that the revised document will meet all the recommendations and guidance arising from that report. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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, 10 Residents are treated in a polite and respectful manner. The arrangements for medication are generally good, but attention is needed in some areas. EVIDENCE: The arrangements for the storage and administration of medication were examined. The home has introduced a new ‘Monitored Dosage System’ (MDS), supplied by a local pharmacy whereby the majority of medication (pills and tablets) is supplied in pre-loaded blister packs. This is a simple, straightforward system and has the advantage that the correct dosage is drawn up by the pharmacist and administered by staff. In addition, the pharmacist conducts an annual audit. In general the arrangements were satisfactory, but some issues need attention. Some of the blister packs examined had been punctured, which compromised the security and integrity of the medication. The records of administration were mostly in good order, but examples were found where doses of medication had been missed but recorded as given. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 10 The storage of medicines is secure, with a locked medications room containing all medicines, and having internal locked cupboards and cabinets. The arrangements for controlled drugs were somewhat cramped, and a larger cupboard is needed. This must conform to the relevant legislation – the Misuse of Drugs (Safe Custody) Regulations 1973. Those residents spoken with during the inspection confirmed that the staff treated them with respect, and that personal care was delivered in a sensitive and polite manner, but at the same time, friendly, warm and with good humour. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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): 12, 13, 15 Daily routines are relaxed and meet the needs of individuals, and the food provided is of a good standard. EVIDENCE: All the residents spoken with during the inspection spoke highly of the food provided. Although there has been a change of Chef recently, residents agreed that the food offered was tasty, with a good variety and choice, well presented and with good sized portions. Some of the service users spoken with during the inspection were sitting in the lounge watching TV. They were very happy with the routines of the home, which they felt were relaxed, and meet their needs well. Those residents spoken with in their rooms agreed, and also confirmed that they spend the majority of their time there, by preference, and that this is respected by the staff. It was observed during the inspection that the lounge is used as a passageway, with staff, visitors and service users constantly passing through. In this context, the arrangement of the seating meant that people were constantly passing between the seated residents and the TV, which is unsatisfactory. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 12 There were a number of visitors in the home during the time of the inspection, and confirmed that they are always welcomed and felt it was easy to come and go as they wished. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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, 18 Service users feel safe and well looked after. EVIDENCE: Service users and relatives spoken with during the inspection were very satisfied with the service provided, feeling safe and secure in the daily life in the home, and confident that any concerns would be listened to and addressed. The management were described as good at listening and keep in close touch with residents on a daily basis. This was much appreciated. None of the residents spoken with had any complaints or concerns, and the monthly reports arising from the visits undertaken by directors confirmed that there have been no complaints in recent months. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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, 20, 23, 24, 25, 26 The provider maintains a good standard of accommodation that is homely, and meets the needs of service users. EVIDENCE: At the time of this unannounced inspection, the home was found to be clean, tidy, warm, and comfortable, with no odour. The building is well maintained, with a Handyman carrying out a continuous programme of re-decoration. A number of service users were interviewed in their rooms during the inspection, and all agreed that bedrooms were large enough, and comfortable, and met their needs. They are able to bring in their own items of furniture and all the rooms seen were homely and personalised. All of the beds supplied by the home are now height adjustable, to enable ease of delivery of care. This supports the current trend reported by the manager, whereby the home is receiving more requests to provide palliative care. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 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): 27, 28, 29, 30 The home is well staffed, with a friendly and competent team of carers. Recruitment procedures are satisfactory. EVIDENCE: At the time of the inspection there were 4 carers on duty, led by the Deputy Manager and an RGN (Registered General Nurse). The Manager, Miss Hunt, was also present during the latter part of the inspection. All residents spoken with during the visit described staff in very positive terms, with several commenting on the good sense of humour, which they all have. This was very much appreciated, and contributed to the friendly and warm atmosphere. They also agreed that staff were polite, respectful, attentive to their needs, and competent. It was commented on several times as to how busy staff were, but this was qualified by the observation that they were ‘busy, but never rushed’. One resident summed the staff up simply as ‘lovely’. A check on recruitment procedures for two recently employed carers, and these were found to be satisfactory, with all the required checks and references being obtained. The recent demand for more palliative care has prompted the home to seek further training for staff, and an arrangement is being made for this to be provided by a nearby Hospice, and supported by local GP’s. The relative of a terminally ill service user described the care and support provided as ‘wonderful’. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 16 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, 32, 33, 37, 38 The home is well managed, and run in the best interests of service users. EVIDENCE: The cumulative evidence from previous sections of this report confirms that the home provides a safe and comfortable environment, with a very positive ethos of care. The manager continues to lead a team of competent staff, providing good leadership and maintaining good relations with staff, relatives and service users. The management continue to visit the home on a monthly basis, unannounced, as part of the company’s quality assurance process. These visits produce a report, which is shared among the directors, and also with the Commission, as required by regulation. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 17 The report contains a good amount of detail and covers essential areas of the home’s operation, including interviews with staff and service users, a review of any complaints or issues, and a tour of the building. The report also refers to any action required to address the issues identified. Policies, procedures and records viewed during the inspection were in good order, other than where previously identified (medication records). Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 2 3 Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 19 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 OP37OP9 Regulation 13 Requirement Records relating to the administration of medication must be accurate at all times. Where the packaging for medication is compromised, appropriate action must be taken, following advice from the supplying pharmacist The arrangements for the storage of controlled drugs must comply with the relevant legislation. Timescale for action 23/02/06 2. OP9 13 23/02/06 3. OP9 13 23/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP14 Good Practice Recommendations The seating in the lounge should be reviewed to ensure that people passing through the room does not inconvenience service users watching TV. Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Pinford End House Nursing Home DS0000024473.V284946.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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