Inspection on 13/08/07 for The Pines

This inspection was carried out on 13th August 2007.

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

The Pines 09/05/06

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Pines 1 Woodbine Terrace Ashington Northumberland NE63 8PP Lead Inspector Allan Helmrich Unannounced Inspection 10:00 13 and 15 August 2007 th th 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 The Pines DS0000065947.V346254.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. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Pines Address 1 Woodbine Terrace Ashington Northumberland NE63 8PP 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) 01670 816349 no email Mr Sunny Okukpolor Humphreys Position Vacant Care Home 28 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (17) of places The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: The Pines was originally a domestic residence that has been extended and now provides accommodation with personal care for 28 older people, 11 of whom may have a dementia. It has accommodation on two floors with 24 single bedrooms, 10 bedrooms have ensuite toilet and hand basin and 2 double bedrooms without ensuite. At the front of the home is a large, well-maintained, secluded garden with lawns and a sitting area. Weekly charges range from £358 - £414 per week. Information about the home is readily available on request. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The is the home’s periodic Key Inspection and follows the resignation of the registered manager. The inspection was done over two days and took 13 hours. The deputy is currently acting manager and a member of senior care staff is promoted to deputy. Time was spent talking to both of them some care staff, several residents and their visitors. Some of the home’s care records were reviewed together with the systems that maintain residents’ safety. Some residents’ case records were specifically assessed against the style of care provided. This is called ‘Case Tracking’. The acting manager completed an assessment of care document prior to the inspection and questionnaires were provided for residents and visitors to the home. Responses were received from two relatives. Information provided by them is used in the report. What the service does well: What has improved since the last inspection? Following the resignation of a manager and the appointment of new management, little improvement is visible in the home. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 6 The manager is however aware of many areas to address to provide a good quality care home. The manager and her deputy have had meetings with staff and residents to enable them to have an input in the direction of care. They have allocated key workers to provide more personal care and have reviewed the training of staff to ensure it meets the needs of the residents. Care plans are being reviewed to ensure they accurately reflect the needs of each resident and systems in the home are being reviewed to ensure the home is both safe and clean. The kitchen is in the process of being refurbished, new dining tables and chairs have been purchased and some decoration is taking place. An activities room has been provided in a spare room and a weekly exercise class has been introduced to provide light exercise for residents. What they could do better: Information about residents is not comprehensive and does not provide clear direction to staff as to how appropriate care should be provided. This is necessary to ensure residents’ needs are met and that independence is maintained for as long as is possible. A lack of suitable weigh scales means residents health cannot be fully monitored. The storage of medicines and the systems of administration are not good and do not ensure residents are safe. Risk assessments in the home have not identified how risks are minimised to promote independence. The home’s activities do not ensure that residents’ are well stimulated. No one is directly responsible for ensuring activities are provided daily and the proprietor has not provided and activities budget to promote this area of care. Kitchen benches and tiling were replaced several weeks ago but the kitchen has not been finished and still poses a hazard to health. A programme of improvement works should be produced and be available to the manager to demonstrate the serious intentions of the proprietor to improve the standards in the home for the benefit of residents. The staffing levels in the home are not good and do not ensure residents are well supported in a clean, safe home. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 7 Many of the management systems in the home should be reviewed and updated. It is accepted that the manager is new and that it takes times to quality review systems to ensure a good standard of appropriate care is provided. The proprietor must ensure that, as stated in regulation 26 of The Care Homes Regulations 2001, he makes an unannounced visit each month and forms an opinion on the standards of care provided. He must also ensure an appropriate system of quality assessment is in place to ensure that residents are well cared for and their expectations are considered. 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. The summary of this inspection report can be made available in other formats on request. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 8 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 The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is readily available to prospective service users to inform them about the home. Pre admission assessments are conducted by senior staff to limit the possibility of admitting someone whose needs cannot be met in the home. The home does not provide intermediate care but respite breaks are available. EVIDENCE: Prospective residents are provided with up to date information about the home. Recent inspection reports are available from management. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 10 The acting manager has recently changed the details in the home’s service user guide following the resignation of the registered manager. This provides up to date information to prospective residents. Two visitors in the home stated that their relative moved into the home recently and every care was taken by staff to make this trouble free. Although initially the move was temporary pending a vacancy in another home their relative has been made so welcome that she has decided to stay. Prior to admission senior staff meet with prospective residents to ensure their needs can be met in the home. Four care plans reviewed all contained appropriate information gained from meeting the resident prior to admission and from care managers. A record of medicines prescribed is not recorded in the information obtained before admission. This information is useful in determining the care to be provided. The home does not provide intermediate care to rehabilitate people to return to independent living, but respite care is provided. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about residents is recently updated but is not comprehensive and does not provide clear guidance to staff regarding residents’ needs. Residents health is assessed but equipment necessary for assessing health is not available therefore residents may be at risk. The medication processes in the home do not ensure residents are safe. Residents are respected and treat with dignity by the staff team. EVIDENCE: The case records of four residents were examined. The acting manager and her deputy have worked hard to improve the records since their appointment. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 12 However one file did not contain a personal profile. This would show staff the current lifestyle of the resident. Although one resident’s health has deteriorated recently the file contained no information regarding last wishes. It is beneficial to obtain this information in advance to enable complex requests to be handled sensitively. Care plans were in place but the information was insufficient to demonstrate to staff the actual support needed. Good care plans help maintain a person’s independence. Risk assessments are in place for supported bathing, however no risks are identified to demonstrate the need for this invasion on privacy. A risk assessment should identify the risk and review the various solutions that may reduce the risk and maintain a person’s independence. A resident whose needs included regular weight monitoring to ensure good health is maintained has not been weighed recently as the home has no suitable weigh scales. Many of the care plans reviewed were produced in April 2005 and have had no alterations. Care plans that are regularly reviewed ensure up to date care is provided. Each of the care plans demonstrated that residents have regular healthcare appointments to maintain good health. The medication system was reviewed to assess if it met the needs of residents. The temperature of the medication room during the inspection was uncomfortable. An electric fan was on to move the air around while staff work there. The temperature of the room is not recorded, however it was assessed that the temperature exceeded the maximum level at which medicines should be stored. The temperature of the medication fridge is not recorded to ensure it is within the appropriate temperature range. As stated previously medicine usage of prospective residents is not recorded. The home has a set of policies and procedures related to medication but no policy was found for providing homely remedies or for handling alerts sent by the MHRA. The actual practice before providing any homely medicines includes obtaining approval from the GP and this is deemed to be good practice. The medical administration records contained handwritten entries that were unsigned or countersigned to ensure the description is correct. Not all medicines received into the home were recorded. An audit of medication had not identified an accounting error. Senior staff are provided with medication training together with any other member of staff who requests this training. Residents were seen to be dressed well in age appropriate clothing. Throughout the inspection staff were observed treating residents with respect The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 13 and dealing with any issues in a dignified way. Care records identify residents preferred names. The relatives of a resident recently admitted into the home said they were impressed with the actual care provided and with the commitment of the staff team. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s activities programme does not provided sufficient stimulation to meet the needs of the resident group. Visitors are welcomed into the home. Residents are provided with wholesome foods but the kitchen is not maintained to an acceptable standard. EVIDENCE: Residents’ individual needs relating to activities have not been assessed. Staff were observed talking with residents but little in the way of structured activity was seen. One member of staff stated that she has little time to be involved in activities as residents are quite dependent and her time is spent addressing personal care needs. When asked she could not remember taking a resident out of the home in the last three months other than to a healthcare appointment. The acting manager is aware that activities need to be improved The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 15 and has obtained the services of Mind Active who visit periodically to provide entertainment, a chairobics session has started to provide light exercise for residents and a room is now dedicated for arts and crafts. The proprietor does not provide an activities budget to enable the manager to obtain appropriate games and reminiscence materials. The home has a visitors policy welcoming residents into the home at any time. Two visitors spoken to said they are always made welcome when they visit and can see their relative in private. Residents and their families are encouraged to handle their own finances. But for those who require it the home maintain monies for residents and a system of recording is in place. The home has a set of menus that contain appropriate amounts of fruit and vegetables. The meals provided to residents during the inspection were wholesome and those residents who commented said they enjoyed them. The cook stated he is aware of residents’ preferences and provides meals on different sized plates depending upon each resident’s appetite. The kitchen is being replaced with some new units and tiled walls, but this process is taking an excessive time to complete. Ceilings and walls have not been finished to avoid flaking paint landing on work benches. The fly screen to one window was holed and a door used to maintain ventilation had no fly screen fitted. Some cleaning of the kitchen takes place but the cook has been without support for several months and some cooking equipment is not adequately cleaned. To maintain residents health it is expected that a high standard of cleanliness is maintained in areas where food is prepared and cooked. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good complaints process supports residents and they are protected from abuse by a staff team that are aware of vulnerable adult procedures. Some information to support staff is not available in the home. EVIDENCE: The home provides a copy of the complaints procedure to new residents in the Service User Guide and a copy is on the wall near the entrance for the benefit of visitors to the home. No complaints have been received since the last inspection, however a log is maintained to record any matters of this nature. Two visitors to the home had not made a complaint but felt happy to talk to the manager with any concerns. Staff have been trained in how to be aware of issues that affect vulnerable people and the staff spoken to were confident they would always support the rights of residents in the home. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 17 The home has policies and procedures to protect residents but the manager was unaware of the Department of Health guidance (NO SECRETS) dealing with the protection of vulnerable adults. This guidance should be available to all staff to promote abuse awareness. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some work has been done to improve the home to provide residents with a homely place to live. A number of safety related issues that are of concern were identified. The domestic arrangements do not ensure residents’ dignity is promoted. EVIDENCE: The proprietor has a twelve-month plan to improve the home. To date a section of the outside fence has been replaced, the kitchen is being refurbished, some redecoration has taken place and dining room furniture has been replaced. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 19 During a tour of the premises the following issues were identified; Door locks that cannot be operated from the inside were fitted to bedroom doors. These should be removed or disabled to avoid the possibility of residents being inadvertently locked in their bedrooms. Intumescent strips in fire doors were painted, thereby reducing their effectiveness in the event of a fire. Coloured tags identifying the degree of care required by residents should be removed from bedroom doors and a more appropriate method of identifying needs should be developed. Strong odours were identified in some bedrooms. This may affect the dignity of residents using these bedrooms. A cupboard in the dining room that contained flammable materials was unlocked, creating a fire hazard. The front door that is a fire exit is locked by staff to reduce the risk to residents who may wander. This would be a hazard and an immediate requirement was made to change this procedure. The rear yard has been made into a pleasant place to sit in fine weather. This has raised the problem of cleaning materials being stored in open view in the laundry area causing a potential hazard to residents. The kitchen as mentioned earlier requires urgent completion and a ‘deep clean’ to ensure a good standard of hygiene is provided. Residents’ bedrooms were generally pleasantly decorated and filled with personal ornaments and wall hangings. Two visitors commented the home is not new but is comfortable. Comments in the two visitors questionnaires were; good friendly atmosphere and provides a homely atmosphere. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although a good standard of trained staff are employed they are not in the home in sufficient numbers to ensure residents needs and wishes are met. A good proportion of the staff team have achieved a qualification in social care provision. Staff recruitment ensures that residents are protected but this does not extend to some contractors who work in the home frequently. A staff training and development programme is in place for staff but a National Training Organisation induction programme is not available for new starters without a knowledge of care practices. EVIDENCE: Staff spoken to in the home felt well supported by management and other staff but they also felt under pressure in meeting the needs of the resident group. Activities are not regular as the staff team only have time to meet the basic needs of residents. One care worker spoken with had not taken any resident outside of the home socially for three months. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 21 The cook has been working alone in the kitchen as the kitchen assistant has been on long-term sick leave. He therefore has not been able to maintain the kitchen cleanliness at the appropriate level. On a tour of the building odours were noted in several areas. Although these odours cannot always be eliminated, they can be minimised with appropriate cleaning and airing routines. Domestic staff are assisted with some internal cleaning tasks. A risk assessment is not in place to ensure residents are safe and well protected when this work is performed. During the inspection the number of care staff on duty for 24 residents was 3. This included an agency worker. The last time four care staff were on duty together was over one month previous. Care and domestic staff need to be employed in sufficient numbers to ensure residents’ needs are met. The manager and six staff have left the home since the last inspection and have mostly been replaced. The acting manager can and does use agency staff to ensure minimal support for residents is provided. The acting manager has a training plan in place to ensure an appropriate standard of qualified staff are employed. Currently 75 of care staff have a National Vocational Qualification (NVQ) in care. This provides a good basis for the provision of care. Staff spoken to stated that training requests that benefit residents are supported. The records showed the majority of staff have received training in all those areas expected in a care home providing care for older people. Some staff have been trained in dementia awareness and challenging behaviour to meet the needs of a section of the current residents. A recruitment process is in place to ensure appropriate people are employed to work in the home. Two care plans of staff recently employed showed that appropriate checks are made and references are obtained. All new staff are provided with a staff handbook and given an induction into the home by management. Should new staff be recruited without any care experience the home do not have the necessary induction package in place to train them and ensure the residents are safe and well supported. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has left the home and a new management team that are working hard to improve the standards for the residents is in place. No substantial systems to monitor the standards of care provided are in place. A system is in place to record monies held on behalf of residents but the audit system is poor and does not ensure residents’ monies are safe. The systems to ensure residents are safe and protected are adequate. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 23 EVIDENCE: The acting manager is working towards the recognised qualification that demonstrates she is competent to care for vulnerable people. She and her deputy are working hard to improve the standard of care provided. They both spoke at length about the improvements they intend to put in place. Two visitors to the home stated that the management were providing a safe homely place to live. Staff feel well supported by the management team. The acting manager and her deputy completed an assessment document prior to the inspection and have identified several areas of care they intend to improve. The proprietor has not introduced a quality assurance system to monitor the standards of care provided. There was no evidence that he visits the home on a monthly basis to monitor the standards as required by regulation to ensure the management is providing appropriate care. The home has not developed its own questionnaire to enable residents, their visitors or professional visitors to comment about the home. This style of self-regulation must be in place to ensure the expectations of residents and their supporters are achieved. Residents and their families are encouraged to manage their own monies. However a system is in place to hold monies for residents should this be their choice. Two people countersign each transaction, receipts are kept and management does a regular audit. A check done during the inspection of the accounts for one resident could not be reconciled as insufficient information was available. The management team is working towards ensuring residents are safe at all times. Staff training related to health and safety is provided. The acting manager is working with the proprietor on a plan of improvement, although as with the improvements to the kitchen these are not being done efficiently. A full programme of improvement is not yet in place to enable the acting manager to confidently state when actions will be completed. The storage of substances hazardous to health are not secure as the storage room has open access from the rear garden and fire precautions may not ensure residents are safe as door seals are painted over and the front door is locked with a key. Regular maintenance is carried out and certificates are available for inspection that demonstrate this is done. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 24 The home does not have a current certificate of registration on display. This may be due to the previous manager taking down the certificate that included her name with no request being made for a replacement. The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 X X 2 The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP8 Regulation 12(1)(a) Requirement The manager must ensure that provision is made to enable residents to be weighed. This is especially important when a need to weigh is identified to monitor physical health. The manager must ensure that good systems for storage, handling and recording of medicines is in place. • The temperature at which medicines are stored must be below 25°c. The medication room should have its temperature checked and if necessary appropriate actions taken to maintain a suitable temperature for storage. • The temperature of the medication fridge must be recorded regularly to ensure it operates within the correct temperature range. • A record of medicine usage by prospective residents should be recorded. • The medication policies and procedures should be DS0000065947.V346254.R01.S.doc Timescale for action 30/09/07 2. OP9 13(2) 30/09/07 The Pines Version 5.2 Page 27 3. OP15 16(2)(g) 4. OP19 12(1)(a) reviewed to ensure they are appropriate for the home. New procedures for handling medical alerts sent to the home and before providing homely medicines should be produced. • Hand written entries in medical administration records should be signed by the transcribers and countersigned by a checker. • All medicines brought into the home should be recorded. • Audits of medication conducted by senior staff must be thorough. The kitchen refurbishment 30/09/07 started several weeks ago should be completed to a good standard. The kitchen should be clean and thereafter maintained in a clean condition. Windows and doors should have working fly screens and equipment should be in good working order. The following issues regarding 30/09/07 health and safety must be attended to; • Bedroom door bolts that can only be operated from outside of the room must be removed or disabled. • Paint must be removed fron the intumescent door seals to ensure their effectiveness. • Coloured tags on the outside of residents bedroom doors identifying the degree of need should be removed and a more appropriate method of informing staff about the individual should be found. DS0000065947.V346254.R01.S.doc Version 5.2 Page 28 The Pines 5. OP26 16(2)(j) Cupboards containing combustible materials must be locked when not in use. • The practice of locking the front entrance door that is a fire exit must cease immediately and a system introduced that maintains residents in a safe environment be introduced. An immediate requirement was made to ensure residents are not locked in. • Cleaning materials must be locked away. The manager must ensure a 30/09/07 good standard of hygiene is maintained in the home. Systems should be developed and sufficient staff made available to minimise the strong odours in the home. • The kitchen requires a ‘deep clean’ and a system introduced and sufficient staff made available to maintain a good standard of hygiene. The manager must ensure that staff are employed in sufficient numbers to ensure the care provided meets the needs of residents, that appropriate regular activities take place and that the expected standards of hygiene can be maintained. Any contractors working in the home must be appropriately supervised to ensure that vulnerable people are safe. An application should be made to register a manager for the home. The proprietor must introduce a system to review the quality of DS0000065947.V346254.R01.S.doc • • 6. OP27 18(1)(a) 30/09/07 7. OP29 18(2) 30/09/07 8. 9. The Pines OP31 OP33 8(1)(a) 24 and 26 31/10/07 30/09/07 Page 29 Version 5.2 10 OP38 Care Standards Act 2000 care provided. The proprietor must also produce a monthly report of his findings following unannounced visits to the home. The manager must ensure an Immediate appropriate certificate of registration is displayed in the home. 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 OP3 OP7 Good Practice Recommendations A record of the medication prospective residents are prescribed should be obtained and recorded before an admission is made. The care plan for each resident should be reviewed and any information to staff in how to provide specific care should be detailed. Risk assessment forms are used to identify staff working practices but not to identify the risk and record how the risk is minimised to maintain the independence of the individual. Activities designed to stimulate and exercise residents should be developed. Consideration should be given to providing an activity coordinator and an activities budget to enable staff to plan future activities. Activities should meet the needs of both individuals and groups in the home. The manager should obtain a copy of the Department of Health guidance ‘NO SECRETS’ and this should be made available to the staff team. The manager should have a training package in place that meets National Training Organisation standards for any new staff recruited without experience in care practices. Ensure sufficient information is provided to be able to fully audit residents monies held in the home. 3. OP12 4. 5. 6. OP18 OP30 OP35 The Pines DS0000065947.V346254.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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