Inspection on 25/05/06 for The Pines

This inspection was carried out on 25th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 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 25/10/05

The Pines 23/05/05

The Pines 27/01/05

The Pines 14/05/04

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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 The Pines Sherwood Park Pembury Road Tunbridge Wells Kent TN2 3QE Lead Inspector Lynnette Gajjar Key Unannounced Inspection 25th May 2006 09:30 The Pines DS0000026197.V293570.R01.S.doc Version 5.1 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 DS0000026197.V293570.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Pines Address Sherwood Park Pembury Road Tunbridge Wells Kent TN2 3QE 01892 526274 01892 615800 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) The Avenues Trust Limited Mrs Sharon Forrest Care Home 24 Category(ies) of Learning disability (24) registration, with number of places The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is restricted to provide care for one service user who is over 65 years of age whose date of birth is 19th August 1939. 25th October 2005 Date of last inspection Brief Description of the Service: The Avenues Trust Limited manages the Pines. It is a care home registered for twenty-four service users with a learning disability but some double bedrooms are now used for single occupancy only. The Pines comprises of four detached bungalows set in partly secluded wooded area next to a resource centre run jointly with the Local Authority Social Services and the Health Authority. The bungalows were purpose built in late 1970’s and are designed to support individuals with physical and learning disabilities. Accommodation comprises of fourteen single rooms and two double rooms. There is an open planned lounge/dining room and separate kitchen in each bungalow. There are separate fenced communal gardens around the bungalows. The property is located off the main Pembury Road in Tunbridge Wells, Kent. There is a large driveway with some parking adjacent to the building. All staff work on a shift roster, which includes waking night staff. The homes current fees range from £1275.84 to £1600.74. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, the first in the year running from April 1st 2006 to March 31st 2007. The visit lasted from 09:30 to 17:25pm. Due to the service manager being on annual leave, a further visit and feedback meeting was held a week later on 2nd June 2006. The home currently has 17 service users and is running with one vacancy. Currently there are only two double rooms in use, as others are being used for single occupancy only, on assessed need. The organisation is looking to reduce registered numbers due to this. The home’s registered manager is taking maternity leave (May to Oct 2006). The interim management arrangements are, a service manager covering home, Tuesday mornings, Thursday and Friday and weekends if required. With each unit manager undertaking shared management administration on a daily basis. The visit was spent talking directly with service users, both privately and collectively, with staff, and the service manager. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of service users in the report. Some judgements about quality of life and choices were taken from direct conversation with service users, and direct observation followed by discussion with care staff and evidencing records held at the home. A tour of the premises was undertaken, with time spent assessing various records and case tracking. Information was also gathered through a pre inspection questionnaire completed by the manager and comment cards returned to the Commission. A number of CSCI “comment cards” (completed questionnaires) were received from 8 service users, 4 relatives/visitors; x1 Health professional. Feedback included: What is good about living in your home? “Go out” “ I can go in and out of the houses as I please” “The long sofa in the lounge, I like to spread myself on it and listen to the good music” “Going out places” “ I feel safe around people and environment I know” What’s not so good? “I don’t always have access to the kitchen to help myself to food” “Would like to go out more” When I can’t go out when I want to because not enough staff” The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? Through the refurbishment of bungalow one bathroom, service users are guaranteed a safer and more comfortable bathing facility, which will be enhance further with the installation of new flooring currently on order. Numbers of white goods have been purchased for kitchens, with new curtains and comfortable seating in others and all guttering has been cleared. Good progress is being made in developing person centred care plans in bungalows, particularly with more stable key working. Safer access to the gardens has been achieved through fencing off individual bungalow gardens offering more secluded and personal garden space. Bungalow 1 & 3 have recently benefited from a more stable staff team. Staff have lockable storage to place personal items. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 7 Quotes have been obtained to install doors to offices in each bungalow and budget approved, awaiting contractors to confirm fitting dates. Following the changes in a service users’ care needs reassessment of their bedrooms suitability has been undertaken to ensure that necessary equipment and facilities could be accommodated. The registered manager is no longer unit manager to a bungalow, through the appointment of a new unit manager. Releasing them to be more effective in their role as registered manager. 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. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 8 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 The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 9 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): 1,2,3,5 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service Users and representatives have access to the information needed in making a decision if the home can best meet their needs. EVIDENCE: Service user guides seen today were in both clearly written and pictorial formats. Some bungalows had more personal information included than others. It was acknowledged by the manager that minor adjustments to staff details were in hand. Staff talked though a very comprehensive pre admission process including any new service users being required have a tea, day visit and over night stays in a transition period of approximately 3 month, before making a final decision to choose to live at the home permanently. This included assessments from health and social professionals and Avenues Trust own assessment formats. A service user moved from one bungalow to another and good practice of reviewing and following new admission procedures and reviews has been implemented. A visit was taking place by representatives of prospective new service user today. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 10 The manager acknowledged and was acting upon records and direct observation today, that a current service users’ care needs had changed sufficiently to require a review and move into the vacant larger room to safely meet their current care needs. The service manager demonstrated a clear understanding regarding the category and needs of the service users that the home could meet. Her knowledge and experience of the homes capacity to meet individual needs is good. Care plans seen today contained a written tenancy agreement/contract, which gives the persons’ security and rights of residency to the Pines but does not give details of the actual private room assessed as best meeting their care needs. The Service manager stated this will be addressed through contract reviews and room plans. This document clearly lays out the tenants and landlord’s rights and responsibilities. Representatives had signed some contacts and staff detailed where others had declined. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 11 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): 6,7,8,9,10 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Person centred care plans, risk assessments and guidelines continue to develop offering more detailed information to ensure consistent support by staff to meet the individual health and social care needs of service users and to track the care provided. EVIDENCE: Through discussion with a staff and assessing three current care plans, it is clear that service users are given full support and encouragement to maintain personal contact with health and social care professionals, to maintain good standards of health and social care. Guidelines and risk assessments enable staff to access information that is most important and to maintain individual and collective safety. Photographic and pictorial formats are used to aid communication and better understanding by service users. Daily write ups were discussed with some good entries that really gave the reader a good understanding of how the day had gone for the service user, how they felt, what they had done and needed help with. There were others that required more detail. It is evident in bungalows where there is a stable key working team the person centred care planning and records have been implemented The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 12 well. Staff evidenced a clear and practical understanding of service users needs. Records seen had some minor gaps in recording and an area easily addressed by staff and picked up by regular monitoring and auditing of records by the Service manager. In house care reviews take place regularly. Interaction between service users and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Often with appropriate two way banter and fun. Records are stored securely today and staff were observed to seek service users agreement for these to be share with others. Office doors have been quoted and approved on 18th May 2006 but no installation date has been agreed. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 13 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): 12,13,14,15,16,17 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are given encouragement and support to make choices about a range of local social and recreational interests at a pace suitable to them. Service Users feel that menus and food provided offers the quality, nutritional value and healthy fresh products. Thus leaving them feeling the right to exercise choice and control over their diet. EVIDENCE: Service users are able and encouraged to follow hobbies and interests of their choosing and the staffs knows individual personal preferences. Care records reflect that a steady, though flexible routine occurs on a day - to -day basis and individual service users feel safe with this. This however has been restricted by limited numbers of staff that can drive and staffing numbers. Outings happen daily, both planned structured sessions at local day centres, as wells as more leisure opportunities such as the local pub as a particular favourite, having ‘lunch out’ and walks to then park. Many trips to theatre, shows, daytrips to the coast and Disneyland were discussed. As well as more The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 14 relaxing watching personal videos, TV, and listening to music. Due to personal experiences some service users participation in local activities and outings can be restricted but this is being encouraged and supported to increase opportunities at a pace suitable to the individual, including holidays. Contact with families and relatives are promoted on an individual basis, through visits, telephone calls and letters. Interaction between service users and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Often with appropriate two way banter and fun. Each bungalows menu offers a varied and wholesome variety of meals, with ample fresh fruit and vegetables. These are tailored to the specific service users likes and dislikes. With very obvious different tastes and preferences in the chosen foods in the different bungalows. Specialist diets are catered for, with specially adapted crockery and cutlery to assist those as required. Clear support and guidelines for assisting service users are in place, that are personal, respectful of preferences and special support needs to make mealtimes an enjoyable time. Direct observation showed mealtimes to be at a pace comfortable to the service user. Each bungalow has there food budget and service users are supported to write shopping lists, purchase foods locally and be involved in the preparation and cooking of foods to the best of their ability. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 15 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): 18,19,20,21 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health, social and personal care needs of service users are well supported with regular contact with specialists and external professionals. Service users are treated with genuine respect and dignity by care staff. Robust monitoring and recording of medication administration are being implemented to ensure Service users are protected in safe handling of their medicines. EVIDENCE: Staff are clearly aware as to the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing. More female staff is required to implement gender preferences in personal care. Service users with visual impairments have not had the benefit of specialist assessment and support from visual impairment advisors regarding environmental and personal independence/lifestyle needs but staff was keen to explore this further. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 16 The home has made some improvements to good practice in relation to medication management; each medication storage area has daily temperature checks. MAR Sheets have photos of service users and the medication they are on and why. Not all units have PRN guidelines of administration. One staff member tends to take lead in the ordering and returning of medication in each bungalow. Due to the open and vigilant recording of errors since the last inspection, one bungalow has had a very high ratio of medication errors (mainly around failure to sign the MAR sheet when medication given). The unit manager has taken appropriate action through additional supervision, verbal or written warnings and retraining being explored. The unit and service manager to ensure the strategies are working, are closely monitoring this. Due to an incident, accountable checking of expiry dates, reordering and receiving PRN medication has been instigated. Good practice recommendations were made in line with Royal Pharmaceutical Society Guidelines. The wishes of service users and their families, in respect of death, are detailed in a document called “When I die”. One bungalow has recently lost two older and well respected service users, staff have supported their relatives and friends through this difficult time, but having their ‘when I die’ wishes recorded these were managed with in-depth respect and dignity. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 17 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): 22,23 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse is promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. It is evident for a number, they would be heavily reliant on a relative/ advocate/staff to identify concerns and raise them on their behalf. The pre inspection questionnaire completed by the service manager indicates two formal complaints have been received, investigated and substantiated with appropriate action taken to resolve the issues. Two relative feedback questionnaires indicated that they were not aware of the complaint procedure. Staff who have been spoken with evidenced a good understanding of how to protect and prevent abuse, including reporting under local procedures. One adult protection was raised recently but local social services were satisfied with the investigation and action taken by the home that this was closed immediately. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 18 There are no current adult protection alerts relating to this home. A number of service users due to personal safety have restraint guidelines in place such as use of lap belts in wheelchairs and uses of bedsides. Full risk assessments are in place including agreement of all relevant stakeholders as in the best interest of the service user. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 19 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): 24,25,26,27,28,29,30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a generally comfortable and homely environment, which would be enhanced further by the refurbishment and replacement of kitchens to make safe access and meet the assessed needs of service users, the completion of redecoration of communal areas and personal bedrooms. Including the consideration of further communal space that can be used in private. EVIDENCE: All four bungalows are of the same design and layout, however each bungalow clearly reflects the personalities and individuals in residence. The bungalows have open planned lounges and dining area, which does not give private communal space other than returning to their rooms. This can cause difficulties in meeting preferred social preferences in activities and private time. Service users can access the office and day service where private rooms are available but this requires leaving their home in all weathers. The units continue to be presented to good standard cleanliness. The exterior of the buildings maintenance has been undertaken. Some redecoration of the homes has taken place but there are still areas that require The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 20 urgent attention. Bathrooms have been retiled but consideration to exposed piping should be risk assessed and appropriate action taken. Bungalows detailed replacement three-piece suites, assisted bath, white goods and requests for new flooring and curtains have been approved. Further improvements to infection control management can be made through ensuring seals around toilets are effective, reviewing current kitchen units, shelving, door handles and work surfaces are compatible to good infection control practice. Kitchens are not compatible to meet service users needs due to the height of surfaces and cupboards and so not promoting personal involvement and development of skills. This should be reviewed with professional guidance from OT/Physiotherapists and visual impairment advisors. Two service users do not have a bedroom that meets their needs; the Service Manager detail action currently in hand to address this; in that they are in the process off reviewing current bedroom plans and through consultation with service users and representatives moving rooms to met their assessed need would take place before new service users are admitted. Bedrooms were adequately furnished and decorated to the preferences of service users and personal possessions were displayed reflecting the personalities and lifestyles of service users. Specialist equipment in the form of assisted baths, hoists etc are serviced annually. Some safety precautions were discussed with staff regarding accessing visual impairment assessment regarding a specialist advice and guidance to aide independence and freedom of movement around the home and garden areas, and moving and handling of heavier service users over ramps to conservatory doors. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 21 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): 31,32,34,35,36 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service A staff team that receives good training and on-going support and supervision supports service users in meeting individual needs. Service users would benefit by stabilizing the staff team through positive recruitment to the vacant positions currently experienced. EVIDENCE: The home has 54.4 whole time equivalent (WTE) staff hours allocated; there is currently 36.5 WTE in post. The home is currently running with 17.9 unfilled permanent posts. The majority of bank and agency staff used is regular and therefore familiar with the service users. Efforts to recruit permanent members of staff is ongoing and it is a recommended that these efforts continue. Female staff are required to ensure gender preferences for personal care can be implemented effectively. Two feedback received from comment cards did indicate that relatives/professionals did not always feel there was adequate numbers of staff on duty. Staff are currently working towards NVQ Level 2. Ten staff have achieved NVQ 2 or above. Staff spoken with all indicated through discussion that good and regular training is provided by the organisation. Thorough training matrix’s The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 22 are monitored by head office to ensure all core training is completed and updated as required. One comment cards was received and expressed: “The only concern I have is the current high level of carers for whom English is not their first language and their capacity to understand (Named) training, particularly how and why to administer emergency medication” Staff files are held at head office and a sample of these were assessed on the return visit. Three staff files were assessed. A new staff file was tracked evidencing good recruitment processes, checks and formal records. References and CRB disclosures are now undertaken prior to employment, longer serving staff had CRBs transferred from previous employers as within 12 months of date. Good induction programmes are followed complying with Skills Sector recommendations. New staff to Learning disability undertakes BILD LDAF training with certificates seen on file. Recommendations were made to develop improving monitoring and auditing of files to ensure accurate records are in the correct place, dated and signed. Files tracked evidenced appropriate disciplinary action has been undertaken when required. Staff on duty today evidenced a good understanding of service users care needs through the positive relationships formed between them. Rosters are covered by all staff on 24-hour basis including waking night. The home does employ designated waking night staff. Staff confirmed they receive regular formal supervision. Auditing records showed at least 6 supervisions and appraisal in the past 12 months. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 23 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): 37,39,42 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users personal preferences support and care needs are encouraged through the service managers open approach to running the units and the promotion of a safe home and working environment. EVIDENCE: The registered manager is currently on maternity leave until October 2006. Interim arrangements are the service manager in over-all day-to-day management but who works part-time hours. Each unit manager has an additional administration day to assist in management administration. From observation seen today this appears to be working effectively with good communication between senior staff. Relatives and staff expressed a high regard for the management approach to the units. Service users felt the unit manager and service manager were The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 24 approachable from direct observations and interaction during the visits. Staff also felt comfortable to approach and discuss issues with the manager directly. Staff meetings occurred at least monthly with minutes taken for reference. The service manager demonstrated through discussion, a good understanding of the needs of current service users and current issues they require support in. Monitoring health and safety in the home is to a good standard. Equipment is serviced as required to maintain a safe home and facilities. Fire system testing is undertaken monthly and fire risk assessments approved by the fire officer. Fire drills have been undertaken and recorded. All food records of temperatures are maintained to a satisfactory standard. Staff training in moving and handling should be reviewed to ensure compliance with Manual Handling Operations Regulations 1992 for renewal and updates. Risk assessments continue to develop for individuals and staff activities in the home and care duties; those seen were being regularly reviewed. Staff and the manager evidenced a clear understanding of accident/incident recording and reporting under regulation 37 to the commission. However records were not maintained to comply with data protection and alternative arrangements are being implemented from this visit. Head office monitors all accident incidences with monthly graphs and printouts provided for action. Records on the whole at the home are completed to a satisfactory standard, with minor gaps identified. The service manager acknowledged these and will explore monitoring systems and reviewing current practice to assist staff in reflecting care and support given but also dating and signing these. The Service Manager undertakes individual regulation 26 visits to each bungalow monthly. Many areas identified today had been recognised in the last visit. The homes insurance cover is current. The homes registration certificate is incorrect due to two service users passing way and registered number being reduced due to the withdrawal of double rooms. Application of a minor variation is in hand to correct this. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 25 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 Standard No Score 1 2 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 3 28 2 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 4 3 X 3 3 2 2 3 The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 26 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 YA10 Regulation 17 Requirement Records 17 (1) (b) Personal records should be stored securely. In that offices should be fitted with doors, which can be locked. This remains a requirement from previous inspection. It is acknowledge these have been order. Completion date to be no later than 31/08/2006 In that accident /incident records are filed to comply with data protection and freedom of information Acts. Full action plan with proposed completion dates to be submitted by 15/07/2006 Fitness of Premises 23 (2) (b) & (d) The home should be well decorated and maintained internally with furniture, fixings and fittings in good repair and The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 27 Timescale for action 31/08/06 2 YA24 23 31/08/06 suitable for purpose. In that: 1) Identified bungalow hallways, communal areas and bedrooms are redecorated. This remains a requirement from previous inspection records. Full completion of work is to be achieved by the 31/08/2006. 2) Cracking and plaster damaged to fire door exits is investigated and rectified. Full action plan with proposed completion dates to be submitted by 15/07/2006 Fitness of premises 23(2)(f) In that bedrooms for two service users identified are reviewed and reassessed to ensure the size, layout is suitable to meet their individual needs safely. Full action plan with proposed completion dates to be submitted by 15/07/2006 Fitness of premises & Facilities and services. 23(2)(a) 16(2)(h) A full review of each kitchen is undertaken to reassess and ensure they provide adequate and accessible facilities to assist service users to prepare and cook their own food and safe for use. 3 YA25 23(2)(f) 15/07/06 4 YA24 23(2)(a) 16(2)(h) 15/07/06 The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 28 In that kitchen units/surfaces and equipment is at a height and in good state of repair for safe use by service users. Due to broken drawers and inappropriate heights of units and surfaces for service users. Full action plan with proposed completion dates to be submitted by 15/07/2006 5 YA30 13(3) Health and Welfare 13(3) The registered manager shall make suitable arrangements to prevent infection and spread of infection at the care home. In that: 1) Advised is sought from infection control unit regarding infection control management of each unit and recommendations action taken. 2) Kitchen wooden doors, handles, work surfaces and damaged shelving are replaced to ensure effective infection control management and cleaning. Full action plan with proposed completion dates to be submitted by 15/07/2006 Staffing18. – The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users - (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for DS0000026197.V293570.R01.S.doc 15/07/06 6 YA33 18 15/07/06 The Pines Version 5.1 Page 29 the health and welfare of service users;(b) ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs; In that proactive action is taken to recruit permanent female staff required for gender preference during personal care. Full action plan with proposed completion dates to be submitted by 15/07/2006. 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 YA1 Good Practice Recommendations It is recommended amendments required to the service user guide and statement of purpose are implemented and a copy supplied to the Commission and Service users within 28 days of revision. It is recommended that contracts are reviewed to ensure they include the room to be occupied and that this room meets their assessed needs. Where representatives are not willing to sign these documents on service users behalf this is recorded as such. It is recommended that audit and review sheet is set up in each section of care plan to aide staff in record management. It is recommended that permanent staff continue to develop person centre care plans to hold all the information required to offer consistent and appropriate personal care. It is strongly advised professional visual impairment assessments are undertaken (as identified) to ensure all DS0000026197.V293570.R01.S.doc Version 5.1 Page 30 2 YA5 3 4 YA6 YA6 5 YA19 The Pines 6 7 8 9 YA20 YA20 YA24 YA35 10 11 YA41 YA42 equipment, environmental factors are implemented to meet personal needs, safety and aspirations. It is recommended the site obtains a BNF that is renewed and in date of the last six months. Details of where this is held are stored with each medication file. It is strongly recommended that the manager reviews alternative measure as necessary and closely monitors medication strategies implemented to reduce errors. It is recommended that the organisation continue to work with the local authority to maintain the entrance grounds are maintained appropriately. It is recommended human resources introduce monitoring and auditing system to staff files to ensure information is filed in the correct file and gaps of signatures and dates are completed correctly. It is recommended that any original and reviewed documents are dated and signed by the author, to ensure that the latest and most up to date version is followed It is recommended that staff training in moving and handling should be reviewed to ensure compliance with Manual Handling Operations Regulations 1992 for renewal and updates at least yearly. The Pines DS0000026197.V293570.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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