Inspection on 01/11/05 for The Pines

This inspection was carried out on 1st November 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines 10/07/07

The Pines 09/05/06

The Pines 25/05/05

The Pines 15/11/04

The Pines 22/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pines (The) 39 Portchester Road Charminster Bournemouth Dorset BH8 8JU Lead Inspector Stephanie Omosevwerha Unannounced Inspection 1st November 2005 10:00 Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 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 Pines (The) DS0000003994.V263464.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 Adults 18-65. 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. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pines (The) Address 39 Portchester Road Charminster Bournemouth Dorset BH8 8JU 01202 555048 01202 567682 Helenluckystar@ad.com 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) Sandbourne House Ltd Mrs Sarah Alison Dixon Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (13), Physical disability (1) of places Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A service may be provided to people in the category of PD in the respite room only. The Manager must complete the Registered Managers Award by 31.12.05. A job description must be in place clarifying the roles and responsibilities of the Manager. 25th May 2005 Date of last inspection Brief Description of the Service: The Pines accommodates 13 adults, with the purpose of providing care and support to residents who have a learning disability. The home was first registered in 1986, and in February 2002 a new provider, Sandbourne House Ltd took over the service. The Pines is a large converted family house. It is a detached property and occupies a corner plot in a residential area of Charminster. Bournemouth town centre, local shops and various community amenities are within easy reach of the home. The home is situated on a bus route. Residents accommodation is provided in two double and eight single bedrooms. Communal facilities comprise a separate lounge and dining room on the ground floor and an activities room in the garden, which is accessed via a walkway from the kitchen. Two bathrooms and WCs are located on the first floor, one shower and WC on the ground and a further WC on the top floor. An internal staircase accesses all floors. There is a large office on the ground floor with staff sleeping in facilities. The registered persons have now converted the previous owners accommodation into a respite room with ensuite facilities. This can be separated from the main accommodation by an internal corridor and its own external access if necessary, which is accessible to wheelchair users. Outside there is a large, well-maintained garden with patio area and a further tarmac area providing car parking facilities. The home is staffed 24 hours of the day and is able to provide a comprehensive range of daytime pursuits for those residents not engaged in activities outside the home. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the home this year carried out as part of the planned inspection programme for care homes undertaken by CSCI. The inspection took place over approximately 5 hours and addressed the requirements and recommendations made at the previous inspection and the core standards that were not assessed on that occasion. For a fuller picture of the home, it is recommended that this report is read in conjunction with the report of the unannounced inspection carried out on the 25th May 2005. During the inspection the inspector had the opportunity to talk with 5 residents both in private and in the communal areas. In addition the inspector also spoke with the manager, senior care assistant and 3 members of staff. A tour of the premises was carried out and all the communal rooms were viewed and a sample of 3 service users bedrooms. Various records and documentation were looked at including health and safety records, medication records, financial records, staffing records, rotas and policies and procedures. What the service does well: The Pines provides a comfortable, homely environment and residents express a great deal of satisfaction about their care. Residents are offered positive choices in their daily lives and have also had opportunities to contribute to service development e.g. participating in a video explaining service user contracts in an accessible format. Service users are regularly involved in the running of the home and take part in shopping, meal planning and preparation, household chores and organising trips and outings. Staff morale is excellent and they told the inspector they enjoy their work and feel well supported. There is a high level of interaction between service users and staff, and residents are treated with genuine care and respect. Good communication throughout the staff group ensures service users support needs and preferences are well known. Staff are able to undertake a variety of training courses that ensure they have the specialist skills they need to work with adults with learning disabilities. The home promotes good links with family, friends and the local community, ensuring service user have good opportunities for socialisation. The Pines has been assessed through previous inspections as a service that consistently achieves good outcomes for service users. The home has a good track record of working with the regulatory body and this was demonstrated by the fact there were no outstanding requirements from the previous inspection. Pines (The) DS0000003994.V263464.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. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. A video has been produced to explain the terms and conditions to residents in a more meaningful way facilitating residents understanding of their contract with the home. EVIDENCE: A service user contract has now been made in video/DVD format to make it fully accessible to all residents. Service users were encouraged to participate in the making of the DVD giving them the opportunity to contribute to new service developments. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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. Service users have opportunities to make decisions about their daily lives and they are supported to make positive choices that promote their well being. EVIDENCE: There was evidence throughout the day of residents being able to make their own decisions. Examples included choosing their meals, choosing what to do for their birthday celebration, deciding whether to join in with social events. Where there were some restrictions on choice, this was agreed as part of the residents care plan e.g. supporting residents with their personal hygiene by encouraging them to take regular baths despite one service user being reluctant to do so. The home has information about local advocacy groups and some residents are active members of a local service user led forum. A sample of financial records was checked as part of the inspection. Most service users need assistance with managing their finances and access their money through the post office. Records were seen to be up-to-date and accurate. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 17. The home has good links with family and friends and service users are supported to maintain their personal relationships. Service users enjoyed a varied and balanced diet and were able to contribute to meal planning, shopping and meal preparation. EVIDENCE: The manager said relatives were welcome to visit the home and service users were encouraged to maintain contact with their families. Service users confirmed they were able to see their visitors in private and gave examples of times they had gone to visit family members. Residents have opportunities to attend social groups outside the home and have made friends who they can invite to the home. The home offers a respite service and residents look forward to service users coming for respite stays, as many of these are friends they know from the various groups/clubs they attend. A sample of menus was viewed as part of the inspection. A balanced and varied diet was offered. A member of staff told the inspector he regularly Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 11 consulted with service users about their likes and dislikes when planning the weekly menus. Service users confirmed they liked the food and observation on the day showed service users were encouraged to participate in shopping for the food and meal preparation. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The home has made significant improvements to the administration of medication in the home ensuring that service users health needs are now supported more effectively. EVIDENCE: There was a satisfactory policy and procedure in place for the administration of medication. The home has now got a locked medicine cupboard in the office and uses a monitored dosage system. MAR sheets are now kept with medicines and these were checked and found to be up-to-date and accurate. Staff receive training in first aid and the administration of medication. The home have also sought specialist advice where necessary, e.g. arranging for a Diabetes nurse to visit and give staff training on managing this condition. A member of staff told the inspector that they were supervised administering the medication until the manager signed them off as competent. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. The manager and staff have good awareness of local protection procedures however, they must ensure the homes recruitment procedure follows the current guidance about obtaining POVA checks prior to appointment. EVIDENCE: The home has policies and procedures in place concerned with the protection of vulnerable adults. These included Awareness and Prevention of Abuse, Aggression towards staff, Bullying, Management of Service Users money and Whistleblowing. The manager confirmed her knowledge of local procedures. Most staff have undertaken training in the Awareness of Abuse. It was noted in the staff records that some staff had been employed prior to a full CRB check being obtained. Whilst written practices were in place to supervised the member of staff, provide induction training and limit access to confidential information, current guidance from the Department of Health now requires a POVA first check to obtained if a member of staff is to commence employment prior to a full CRB check being received. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The Pines is well maintained and provides the residents with a comfortable, homely environment. The home is clean and hygienic with good procedures in place for controlling infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal rooms were seen including the lounge, dining room, kitchen and laundry room and a sample of 3 service users bedrooms. The repairs that were required at the last inspection had been carried out. The premises were well maintained and decorated in a comfortable, homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. The premises were found to be clean and hygienic with good procedures in place to prevent the spread of infection, e.g. handwash was available by the door for all visitors to use prior to entering the home. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 15 Residents told the inspector they liked their environment and their bedrooms and observation of practice showed residents clearly felt comfortable and freely accessed all communal areas or spent time in the privacy of their rooms, e.g. one resident was happy watching TV in the privacy of his room, other residents were enjoying helping in the kitchen with the preparations for the evening meal. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Service users are supported by a motivated and enthusiastic staff team who have a good understanding of both the individual and collective needs of the service users. The recruitment procedure needs to be more robust and follow recent guidance about obtaining POVA first checks prior to employing members of staff. The home provides a good range of training courses that link to the aims of the home and service users needs. Staff receive good support and supervision ensuring that they feel confident in being able to carry out their duties. EVIDENCE: As part of the inspection a sample of 4 staff records was looked at. Recent rotas were analysed and 3 members of staff spoke to the inspector. Rotas showed that there were usually three members of staff on duty during the day and one member of staff sleeping. Staff on duty had handover meetings in the morning and again at lunchtime to agree their duties on shift and identify any tasks that need completing. Discussion with members of staff indicated most had previous care work experience. They said they felt well Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 17 supported in their role and able to consult informally with the manager about any issues concerning their work in the home. The home had a policy on recruitment. Staff records showed that application forms were kept, alongside interview notes. References were in place prior to staff commencing employment and CRB checks had been applied for. There was a procedure in place to ensure members of staff commencing employment prior to a full CRB check were adequately supervised and received induction training, however, the home had failed to obtain the necessary POVA first check that is required prior to staff commencing work in the home. Residents told the inspector they had been involved in meeting prospective members of staff. Records showed that staff had completed a range of courses such as First Aid, Health and Safety, Food Hygiene, Fire Safety, Awareness of abuse, Medication, Principles of Care, Breakaway Techniques, Infection Control and Makaton. Staff confirmed the training was good and they were able to discuss their training needs at supervision and suitable courses were identified for them to attend. It was noted that as well as the required courses ensuring safe working practices the home promotes additional courses that reflect the home’s aims and service users needs. There are currently 10 permanent members of staff employed by the home of these 4 members of staff have achieved NVQ Level 3 and 1 member of staff has achieved NVQ Level 2 meaning the home is currently meeting the target of having 50 of staff qualified. All new staff follow a comprehensive induction. However, it was recommended that a basic induction checklist be set up to evidence that new members of staff are provided with the necessary information after their initial appointment before embarking on the more comprehensive programme. Records showed that staff had regular supervision. There was also an ‘open door’ policy when staff could regular consult with the manager of senior members of staff on an informal basis. Regular team meetings were held and staff said they could add items to the agenda and put forward any concerns. There is still an outstanding recommendation for the manager to set up a system of annual appraisals to review staff performance against their job descriptions and agree career development plans. Staff spoken with were enthusiastic about working in the home. They felt well supported and said the Pines providing an excellent working environment. Residents told the inspector they liked the staff. They felt able to approach the staff and talk to them and were confident they would be listened to. Observation of practice demonstrated a high degree of interaction between staff and residents and it was clear positive relationships had been formed. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. The home actively seeks to improve the quality of the service provided based on feedback received by service users and their representatives. Health and safety are generally well managed in the home and service users are encouraged to follow safe working practices. EVIDENCE: The home has a system in place for monitoring quality in the home. The manager has recently sent out questionnaires to service users, relatives and staff in October 2005 and these were shown to the inspector. The manager was currently in the process of collating the results to form the basis of an annual plan. This would provide action points/targets to further improve the quality of service in the home. Records showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 19 facilities were regularly serviced and maintained. A written health and safety policy for the home has been completed and safety procedures are displayed throughout the home. The manager confirmed her awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. Although the manager stated that fire training was carried out on a regular basis, the records did not reflect this. The home needs to ensure that accurate records relating to fire training are kept, i.e. 6 monthly for day staff and 3 monthly for night staff. The accident book was seen and there had been no recorded accidents since the last inspection. Observation of practice demonstrated staff followed correct procedures and encouraged service users to work safely e.g. when helping with meal preparations. Pines (The) DS0000003994.V263464.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 4 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pines (The) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000003994.V263464.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 19 Requirement Timescale for action 31/12/05 2 YA42 23 The registered provider must obtain a POVA first check prior to care workers commencing employment in the home. The registered provider must 31/01/06 ensure that all records concerning fire training are upto-date, i.e. 6 monthly for day staff and 3 monthly for night staff. 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 YA35 Good Practice Recommendations It was recommended that a basic induction checklist be set up to evidence that new members of staff are provided with the necessary information after their initial appointment. It was recommended that a system of annual appraisals be set up to review members of staff performance against their job descriptions and agree career development plans. 2. YA36 Pines (The) DS0000003994.V263464.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. 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