Inspection on 04/07/05 for Pinxton Manor Nursing Home

This inspection was carried out on 4th July 2005.

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

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

Other inspections for this house

Pinxton Manor Nursing Home 19/01/09

Pinxton Manor Nursing Home 14/11/06

Pinxton Manor Nursing Home 08/09/05

Pinxton Manor Nursing Home 23/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE PINXTON MANOR CHURCH STREET WEST PINXTON DERBYSHIRE NG16 6NA Lead Inspector ROSE VEALE Unannounced Inspection on Monday 4th July 2005 at 09:30am 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 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. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pinxton Manor Address Church Street West Pinxton Derbyshire NG16 6NA 01773 819191 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pinxton Manor Ltd Mrs. S. Akbar Care Home with Nursing 40 Category(ies) of OP registration, with number of places PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/11/2004 Brief Description of the Service: Pinxton Manor is situated in the village of Pinxton, close to Junction 28 of the M1, on the boundaries of Derbyshire and Nottinghamshire. The home is modern and purpose built. Accommodation for residents is on the ground and first floors of the home. There is a garden and large patio area accesible to residents. The home provides personal care and nursing care for up to 40 older people. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five hours on one day. The care records of four residents were examined, plus other documents related to the staffing and management of the home. A tour of the home was carried out. Residents, staff and a visitor were spoken with during the inspection. As the manager was on annual leave, the Service and Administration Manager was available and very helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Although procedures around the administration of medication at the home were generally satisfactory, the home’s medication policy needed amending to include all aspects of the safe handling of medication. The home’s policy for adult protection needed amending to refer to Derbyshire County Council multi-agency procedures and also to refer to whistle blowing, to ensure staff were clear on the appropriate action to take. Staff recruitment procedures and records needed review to ensure all the required information was available for the protection of residents and selection PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 6 of appropriate staff. An Immediate Requirement was made regarding a member of staff who was working unsupervised before a Criminal Records Bureau disclosure had been obtained. The environment of the home was generally safe and pleasant, but action was needed to store some cleaning products safely and to get rid of an unpleasant odour in one of the stairwells. 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. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 standard(s) 2 and 5 The rights and choices of residents were supported by the home’s statement of terms and conditions and by the practice of trial visits / admissions. EVIDENCE: The statement of terms and conditions for residents was seen. This included all the required information under Standard 2. The terms and conditions seen had been signed by representatives of the resident and of the home. The Service Manager said that residents were offered a visit to the home before admission wherever possible and that all admissions were on a trial basis. The care records for one resident showed that the resident had come to the home for day care on one day a week and then for a short period of respite care before moving permanently to the home. A relative of a resident at the home confirmed that the resident had been admitted on a trial basis. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 9 Residents’ health and personal care needs appeared to be well met, including access to other healthcare professionals. The administration of medication in the home was generally satisfactory, although some work was needed to ensure staff follow fully robust procedures for the safety and welfare of residents. EVIDENCE: Care records were examined of four residents; two of these were assessed as needing nursing care. All the care plans seen were detailed and well organised with clear objectives and instruction for staff on the action to be taken to meet residents’ needs. All the care plans seen had been reviewed monthly up to date. There was no documented evidence to show that residents or their representatives were involved in care planning or monthly reviews. However, the Service Manager said that residents and / or their representatives were always invited to care reviews held by the care managers and records were seen of these reviews. There was no formal process to provide similar reviews for self-funding residents without care managers. A relative of a resident at the home confirmed that the home involved her in the care of the resident and always kept her informed of any changes in his condition. A member of staff spoken with was a keyworker and was responsible for monthly reviews of care PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 10 plans. She said that residents were involved in care manager care reviews as appropriate and that she would approach residents’ representatives as necessary to discuss changes to the care plan. All the care records seen contained assessments for moving and handling, nutrition, and risk of developing pressure sores. In three out of the four records examined these assessments had been regularly reviewed up to date. On one record no reviews had been recorded since January 2005. All the records seen included appropriate risk assessments, including falls and the use of bed rails. There were records of the input of other health care professionals in all the records seen, such as GP or District Nurse visits. One resident’s condition was causing concern in the home due to increased aggression and agitation. There were records of the GPs involvement and it was noted that a referral to a consultant had been requested. The policy for the safe handling and administration of medication in the home needed amending to include the procedure for the ordering of medication and also to include the information that medication should be retained in the home for 7 days after the death of a resident in case of a coroner’s inquest. Satisfactory records were seen of the receipt and disposal of medication in the home. Medication Administration Records (MARs) were generally satisfactory. However there were some handwritten entries that were not signed by the person who had written or countersigned by another member of staff who had checked the entry. Medication (Lactulose) prescribed for one resident was being used for other residents. The home did not have available a copy of the Royal Pharmaceutical Society guidelines for administration of medication in care homes. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 standard(s) 13 The home recognised the importance of residents maintaining contact with family, friends and the local community and ensured this through policy and staff attitudes. EVIDENCE: Many of the residents in the home were local people and so local family and friends were able to maintain contact. Staff in the home said that some residents had recently attended local community events. The home had an open visiting policy and residents were able to see visitors in private in their own rooms. A visitor was spoken with during the inspection and said that she was always made welcome by the staff. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18 There was good awareness in the home of adult protection issues to safeguard residents. However, the home’s policy did not contain all the necessary information. EVIDENCE: The home’s adult protection policy was seen. This needed updating to refer to the Derbyshire County Council multi-agency procedures and to include a whistle blowing policy. Staff spoken with had undergone adult protection training and were aware of the correct procedures to follow. Staff said they would be able to raise any concerns about adult protection with the manager. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 21, 24 and 26 The home generally provided a well-maintained, pleasant, comfortable environment for residents. However, there were issues to be addressed to fully ensure the comfort and safety of residents. EVIDENCE: The home was purpose built and fully accessible for residents. There was a large patio area and garden with suitable furniture and shade for residents. The home appeared well maintained. On the day of the inspection the hairdressing room was being redecorated and the Service Manager said that a vacant bedroom would be redecorated before the next admission. The Service Manager said that there was an ongoing programme to ensure all areas of the home were in good decorative order. The home was inspected by the Environmental Health department in May 2005 and received a good report with no requirements made. The fire officer had visited in March 2005 and had reported on the necessary requirements to convert a bathroom to a storeroom. This work had not started and so the requirements had not been actioned. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 14 All the bedrooms in the home had en-suite toilets with wash-hand basins. There were three bathrooms and a shower room in use at the home, including a Parker bath and two assisted baths. There were plans to convert a storeroom to another shower room and a bathroom not currently being used to a storeroom. There were sufficient accessible toilets in communal areas for residents to use. A mechanical sluice was provided. Cleaning chemicals were stored in the sluice room but the door was not kept locked. All the bedrooms seen were clean, pleasant, well decorated and comfortably furnished. Residents had brought their own furniture and possessions to personalise the rooms. Residents spoken with were happy with their rooms. A visiting relative spoken with was pleased with the bedroom provided and said that the home was always clean. The home had complied with conditions required in 2004 that adjustable beds should be provided for residents assessed as needing nursing care. The Service Manager said that all residents who required nursing care were provided with an adjustable bed. The bedrooms seen contained appropriate beds. The home was clean and generally free from unpleasant odours, although there was an odour in one of the stairwells. The home’s laundry was sited in the basement area and met all the requirements of Standard 26. The Service Manager said that all staff had undergone infection control training and this was confirmed by three members of staff spoken with. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 There was a good programme of staff training at the home, ensuring that staff were trained to meet the needs of residents. Recruitment procedures in the home needed reviewing to ensure residents were fully protected. EVIDENCE: The staff training records were seen and showed that nearly 75 of care assistants at the home had achieved or were working towards NVQ Level 2 or 3 in care. All basic training for care assistants was up to date – such as food hygiene and moving and handling. Staff had also undertaken training in dementia awareness and infection control. Senior care assistants and the Service Manager had undertaken training in medicine management. The induction programme for new staff was satisfactory. Staff spoken with felt that training was a high priority at the home. The files of four members of staff were examined. On one file the application form did not contain any employment history. The Service Manager said this would have been discussed at interview, but no notes were kept. Three of the files contained a Criminal Records Bureau (CRB) disclosure. One file did not have a CRB disclosure and the member of staff had started work at the home at the end of May 2005. An Immediate Requirement was made that this member of staff must not work unsupervised until a satisfactory CRB disclosure had been obtained. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 and 37 It was clear that the home was working towards the development of quality assurance and staff supervision systems to ensure the home was run in the best interests of residents. Record keeping in the home was generally good, although some further work was required to fully ensure the protection of residents. EVIDENCE: Quality assurance systems in the home included monthly reports by the owner, an annual questionnaire to residents, relatives and staff, and involvement of residents and their representatives at care review meetings. The Service Manager said that the owner was very involved in the running of the home, usually visiting twice a week. There were no formal resident / representative meetings in the home. The visitor spoken with said that the manager was open and approachable and she felt she could go to the manager with any PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 17 concerns. The quality assurance questionnaires completed in October 2004 were seen, but no report was available of the results of the survey. Records were seen of residents’ personal money held in the home. The records showed clearly documented transactions with receipts obtained. The Service Manager said she administered this system and no other staff dealt with residents’ personal money. A system for staff supervision was being developed in the home and the Service Manager said that care staff were having formal supervision three or four times per year. Records were seen of recent supervision. Records kept in the home were generally in good order, well organised and kept securely where appropriate. However, there were gaps in policies and records as identified in Standards 9, 18 and 29. PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x 3 x x 3 x 2 STAFFING Standard No Score 27 x 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 2 x 3 3 2 x PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 19 NO Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement The policy for the administration and control of medication in home must refer to keeping medication in the home for 7 days after the death of a service user, and must include the arrangements for ordering medication Medication prescribed for individual service users must not be given to others Hazardous substances used in the home must be stored safely A report must be produced in respect of the review of the quality of care at the home and made available to service users Timescale for action 31/08/05 2. 3. 4. 9 19, 38 33 13(2) 13(4)(a) (c) 24(1)(2) 31/08/05 31/08/05 31/12/05 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 9 Good Practice Recommendations Handwritten entries on Medication Administration Records should be signed by the person making the entry and countersigned by another member of staff who has checked the entry C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 20 PINXTON MANOR 2. 3. 4. 18 26 36 The homes adult protection policy should be amended to include reference to Derbyshire Multi-Agency Procedures and should include a whistlle blowing policy The home should keep all areas free from offensive odours Staff should receive supervision six times per year PINXTON MANOR C52 CO2 S62064 Pinxton Manor V235457 040705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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