Inspection on 20/12/05 for The Pines

This inspection was carried out on 20th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines 27/11/06

The Pines 11/08/05

The Pines 26/07/04

The Pines 27/04/04

Similar services:

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Pines (The) (Redhill) 2 College Crescent Redhill Surrey RH1 2HP Lead Inspector Damian Griffiths Unannounced Inspection 20th December 2005 10:00 Pines (The) (Redhill) DS0000013748.V271916.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) (Redhill) DS0000013748.V271916.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) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pines (The) (Redhill) Address 2 College Crescent Redhill Surrey RH1 2HP 01737 277716 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) Surrey Oaklands NHS Trust Mrs Khatijah Joosub Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-64 Years 26th July 2004 Date of last inspection Brief Description of the Service: The Pines is a care home, which opened in 1997 and is run by Surrey Borders Partnership NHS Trust. The service provides care and accommodation for six younger adults of both sexes with a learning disability. The premises are owned and maintained by the metropolitan housing association. The home is a detached purpose built bungalow and consists of 6 single bedrooms, a comfortable sitting room, dining room, and adequate toilet and bathing facilities. The internal decorations and furniture are in a satisfactory condition. There is a patio and garden to the rear of the property and parking space at the front of the property. Pines (The) (Redhill) DS0000013748.V271916.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 inspection of two, to be undertaken by the Commission for Social Care Inspection (CSCI) year beginning April 2005. It was an unannounced inspection and took place over a period of 4 ½ hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by the Senior Support Worker Ms Rookes and in the afternoon Jeannette Campbell Service Manager representing the establishment. The registered manager was on leave. The service users have extremely complex needs and use mostly non-verbal communication, they also become anxious and uncomfortable with people they do not know. In order to minimise any distress caused, the inspector did not feel it appropriate to carry out in-depth interviews with the service users and used observations of interactions and service user response to evaluate the home’s success at meeting the outcomes for the standards. The Inspector met six service users and four members of staff who were happy to contribute to the inspection report. A selection of documents and reports were sampled relating to service user information, care needs and quality of life issues. Staff files were inspected for information about their recruitment process, skill mix, and training. The inspector would like to extend thanks to the residents, their relatives, management and staff at The Pines for their time and hospitality. What the service does well: What has improved since the last inspection? Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 6 Documentation inspected contained the organisations new name. The Surrey Borders Partnership (formerly the Oakland’s NHS Trust) is due to complete the reorganisation of its services this year. Continence aids and towels were stored in resident’s bedrooms and not in the bathrooms. Hazardous substances were stored according to COSHH regulations and alternative storage had been found for individual service users toiletries. Samples of resident’s personal financial records were checked and there were no obvious discrepancies. 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) (Redhill) DS0000013748.V271916.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) (Redhill) DS0000013748.V271916.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): 1 and 5. The Statement of Purpose provided clear and helpful information and service users contracts were available and in evidence. EVIDENCE: The statement of Purpose provided useful information that would help any prospected service user considering a new home. Information relating to the premises, staff training and the complaints system were presented well. The home has a full complement of service users at present however inspection showed that prospective new service users would receive a full assessment of needs and be allowed to visits the home whenever convenient. Six care plans were inspected and showed that all aspects of daily living had been assessed and implemented. Information was comprehensive detailing health plans, risk assessments and contracts. Pines (The) (Redhill) DS0000013748.V271916.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): Not assessed EVIDENCE: Not assessed Pines (The) (Redhill) DS0000013748.V271916.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): 11. Service users benefit from specialised and full activities programme available at the home. EVIDENCE: Specialised equipment designed to alert and stimulate the senses, touch; sight and sound had been installed to provide the service users the opportunity of increasing their experience in these areas. Aromatherapy and hand massage was used with care and enjoyed by the service users and staff alike. The aromatherapist was visiting at the time of the inspection and service users were observed enjoying these sessions. The service users are also supported to maintain family and community links and regular holidays. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 11 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): 19 and 20. Care and assistance was well planned and seen to be provided, where needed, in a respectful and sensitive manner. Sound policies and practices were in place for the administration and management of medicines. EVIDENCE: The care plans sampled provided evidence that service users’ healthcare needs are being met. Service users are all registered with a local GP and referrals to other health care professionals were available, and included: Dentists, doctors and dietician. Health care plans had been regularly reviewed and updated and records showed good relationships with these practitioners benefited the service users. There were no service users able to self-medicate however staff were observed to be proficient with the task of administration service users medication. The home’s medication policy and procedures were all in place and Medical Administration Charts had been completed correctly. The quantity of tablets was accurately recorded, daily medication recorded correctly and signatures of the persons administering this were recorded. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 12 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): 22. The home had satisfactory policies and procedures in place for dealing with complaints and there was some evidence of service users feeling their views were listened too and acted upon. EVIDENCE: There were no complainants recorded or reported at the time of the inspection. The home has complaints procedures in place. The inspector was shown a pictorial format that has been supplied to service users. This version details that service users can complain to a member of staff of their choice and gives simple information on the complaints process. During this inspection the service users were seen to be making clear choices about their daily lives and staff attending to their needs. Service users were seen to be choosing where they went and what they did in the home with confidence and support when needed such as help to sit more comfortably and help to drink from a cup. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 13 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): 24,27,28,29 and 30 The location and layout of the home was suitable for it’s stated purpose. It was accessible, safe and reasonably well maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: A tour of the premises revealed a well maintained home that was clean, tidy and homely offering the services users a comfortable and safe environment to enjoy and to celebrate Christmas. Service users rooms were personalised and computer generated paper prints identified the occupants. The rooms were each different and reflected the service users preferences of colour design and personal possessions and each room had been adapted to meet the physical needs of each person. The living room contained comfortable sofas and was graced by a Christmas tree and decorations. The furniture was being updated but was comfortable and clean. One service user and had recently benefited from a new piece of furniture, electrically operated and enabled them to sit from a standing position with relative ease and adjusted to a comfortable suitable position. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 14 The kitchen area was all in order, clean and hygienic however the fridge was subject to a health and safety requirement being made. Please see the requirements and recommendations section of this report. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 15 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): 33. All interactions observed between staff and service users evidenced a high degree of respect and skill in working with individual service users at the home. EVIDENCE: Staff rotas for the three-day shift system were inspected and compared with staff training programmes. Staff had the necessary skill mix that would ensure the wellbeing of the service users on all shifts. Training included: health and safety, first aid, safe manual handling, administration of medication and infection control. Any further information was curtailed due to difficulty accessing the staff files due to a problematic lock. Please see the requirements and recommendations section of this report. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 16 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): 40 and 42 The overall level of health and safety was good all the required areas of safety were in good order appropriate from one small but important area of concern. EVIDENCE: The fridge was found to contain several items of food that was beyond the sell by date as recommended by the manufacturers and staff had neglected to label other food items to indicate when they had been opened. Bathrooms, toilets and laundry areas were in need of soap and towel dispensers. Water temperatures were checked and within the permitted range. Staff had completed Health and Safety and Food Hygiene training however it was apparent that refresher courses might need to be considered Certificates for Gas, insurance and electrical appliances were all up to date. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 17 Hazardous substances were placed in COSHH cupboards that were locked and staff were aware of the COSHH safety requirements. Resident’s toiletries were stored in their own room appropriately. Accidents were recorded in the preferred method of the NHS that included copies from the original record that were hard to decipher. An alternative method of recording accidents that would be easier for staff (RIDDOR) would be beneficial. Staff had completed Health and Safety and Food Hygiene training however it was apparent that refresher courses might need to be considered again. Health and Safety Policies and Practices were amongst a range of information available to staff. Three service user financial accounts were inspected and all information was in place, receipt books and transactions were all in order containing staff and witness signatures, although these were not consistently recorded. To ensure safety to service users accounts it is recommended that each entry in the service user account book be witnessed. Please see the requirements and recommendations section of this report. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 18 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 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pines (The) (Redhill) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X 3 X 2 X DS0000013748.V271916.R01.S.doc Version 5.0 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 YA42 Regulation 13(3) Requirement The registered person must ensure that arrangements are made to prevent infection by providing appropriate soap and paper towel dispensers. The registered person must ensure that foodstuffs are stored in compliance with Food Safety Regulations. The registered person(s) must ensure that the garden, patio and pathways are appropriately maintained. This was not inspected due to inclement weather conditions therefore a new timescale for action has been agreed. Timescale for action 20/02/06 2. YA42 12(1)(a) 20/02/06 3. YA42 23(2)(o) 20/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000013748.V271916.R01.S.doc Version 5.0 Page 20 Pines (The) (Redhill) 1. 2. 3. 4. 5. Standard YA41 YA41 YA42 YA42 YA42 It was recommended that each entry in the service user financial account book be signed by a staff witnessing the transaction It was recommended that the homes filing cabinets be regularly maintained. It was recommended that a simpler and clearer form of accident recording be used. It was recommended that consideration be given for staff to receive refresher course for Health and Safety and Food Hygiene. It was recommended consider an alternative method of accident recording. Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pines (The) (Redhill) DS0000013748.V271916.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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