Inspection on 27/11/06 for The Pines

This inspection was carried out on 27th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines 20/12/05

The Pines 11/08/05

The Pines 26/07/04

The Pines 27/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 29th November 2006 10:00 Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 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.V322572.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 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.V322572.R01.S.doc Version 5.2 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 and Borders Partnership NHS Trust Mrs Khatijah Joosub Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 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. Cost of Care: £78,884.42 per year. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Due to the retirement of the Manager, Senior Support Worker and staff representing the establishment assisted Regulation Inspector Damian Griffiths throughout the inspection. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire and notifications of significant events known as Regulation 37’s compiled by the home. Any comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page of this Inspection report. The inspector was with staff and service users at The Pines for a period of 6 hrs. The inspector ensured that time was spent sampling resident’s care need assessments, care plans, talking to service users and observing interaction between service users and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, training and the distribution of staff skills compiled in the daily rota. Completed CSCI surveys were received from service users, relatives and social and health care practitioners. The inspector would like to extend thanks to the residents, their relatives and staff at The Pines for their time and hospitality. What the service does well: The home provided service users with spacious surroundings with choice of communal or private room space. Staff had taken care to promote hygiene and cleanliness without affecting the homely atmosphere of the premises. Assessments of care need were all in order with care plans that show how assessed needs were to benefit the service users. There had been no new service users to the home since the last inspection. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 6 Service users care needs were carefully recorded in the care plans to allow them to experience the benefits of local services and community activities with a limited amount to risk. A fulfilling lifestyle was ensured both inside and outside of the home and service users benefit from staff support to ensure their needs were met in a manner they preferred. Contact with family, friends and the local community were encouraged and supported to maintain and promote relationships. Staff had a very good understanding of the service users care needs and detailed daily records were in place. The home had a good complaints policy for family and representatives to use and residents were safeguarded by the staff’s knowledge of the Surrey MultiAgency procedures that were in place at the home. The recruitment practices in this home were good and service users and their representatives had the opportunity to contribute to the running of the home and health and safety issues were promoted. What has improved since the last inspection? What they could do better: This was a very good inspection, and the Inspector was confident that one requirement and three recommendations would be actioned by the Surrey and Borders Partnership NHS Trust. The registered provider must appoint a new manager and to inform CSCI of the outcome. It was recommended that each risk assessment is considered for inclusion in the daily care plan folder, in order of importance and in a clearer printed form. That the homes replace the Welsh-dresser and arrange for the carpet to be cleaned. The home assess staff training need in the following areas: Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 7 Protection of vulnerable adults, first aid, disability awareness and medication administration. 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. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 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 Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users received a thorough assessment of their care needs. EVIDENCE: Assessments of care need were all in order with care plans that showed how assessed needs were to be met in a way that was beneficial to the service user. There had been no new service users to the home since the last inspection however all assessments had been subject to regular review. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Specialised and individual care was delivered to service users as identified in their comprehensive care assessment. Each service user had the best opportunity to indicate their preferences and care was taken to ensure the independence of services users was promoted. EVIDENCE: Care plans were comprehensive and contained full details of each service users care needs: A photograph of each service user, details of main contact persons, GP and regular daily notes in each folder. Each care plan contained detailed account of service users likes and dislikes. One service user disliked her hair being brushed but does like loud music and socialising. Risk assessments could be found in a separate file with the exception of assessments about safe manual handling contained in the care plan. The only criticism was about the format of the assessment as this was often to be found printed on a photocopied background and poorly visible. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 11 It was recommended that each risk assessment is considered for inclusion in the daily care plan folder, in order of importance and in a clearer printed form. Please see the recommendations section of this report. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A fulfilling lifestyle was ensured both inside and outside of the home and service users benefit from staff support to ensure their needs were met in a manner they preferred. Family, friends and the local community are encouraged and supported to maintain contact and promote relationships. EVIDENCE: The level of educational developments were appropriate for the needs of the service users at the home. Regular opportunities to attend classes such as cooking were available and during the inspection the service users were observed serving the meal that had been prepared at the class. The home had recently staged a ‘diversity day’ that included an invitation to the neighbours of the whole street of the home for an ‘open-day’. Service users have the opportunity to visit the local shops and restaurants and try a variety of Asian and European foods. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 13 Daily activities were supported by the Surrey and Borders Partnership outreach team and day care workers were escorting the service users to the swimming/hydro-therapy and for walks to the park during the inspection. At home, a service user who been to her cookery class was able to share the meal with fellow service users and later on in the day there was a lively music session. Service users follow a tried and tested daily routine that had been recorded on each care plan with details of how each service user preferred to be assisted at the start of the day. The Trusts dietician had assessed one of the service users and was advised staff of meals to prepare. The service user was weighed and his overall dietary needs regularly reviewed. A turkey mince pie and cranberry sauce was available for dinner prepared by one of the service users. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18.19 and 20. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Staff had a very good understanding of the service users care needs and good detailed daily record were evidenced however the Inspector witnessed a degree of complacency in the way some staff addressed the service users and in the way that medication was administered indicating a training need for review. EVIDENCE: Care plans included clear guidelines of support each resident required with personal and health care showing work that had been done with the service user and their ‘key-worker’. The residents’ emotional needs were also detailed in the care plans and daily records, which included visits to the doctor, dietician, dentist and reviews of care. The service users received excellent health care support each being monitored closely for weight loss and temperature change. Staff ensured that any health care information was discussed at each staff hand-over at the end of each shift. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 15 Service users privacy was respected, staff were aware of the individuals need for discretion with regard to personal care and emotional need. Some staff members had to be informed of the habit of referring to service users as: ‘him’, ‘her’ and ‘them’ while in the service users presence, however, staff were observed to directly address each service user by their first name when wishing to instruct or inform and to demonstrate a good knowledge of each service users care needs. It is recommended that this is addressed through staff training. Medical Administration Records (MAR) were arranged in an easily manageable folder for each service user, photographs and protocols in place, CD cupboard separate and reasonably secured but on a plasterboard wall and behind a locked door of the storage COSHH cupboard. The drugs return book had been stamped by the pharmacist who had recently completed the homes second Medicines audit of the year, no returned drugs kept at the home. There were no anomalies to the records. A staff member administering the drugs was informed by the inspector to serve each service user in turn and not to dispense two or more at time. It is recommended that staff training be reviewed. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a good complaints policy for family and representatives to use and residents were safeguarded by the staff’s knowledge of the Surrey MultiAgency procedures that were in place. EVIDENCE: The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the residents. CSCI have received no complaints about this home since the last inspection. There were no complaints documented in the home’s complaints folder. Staff consulted were aware of adult protection issues and the manager had attended the Surrey multi agency procedures for the prevention of adult abuse training. Staff were aware of safeguarding vulnerable adults issues and training was being received. There had been no reported adult protection instances reported since the last inspection. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided service users with a spacious yet homely environment with choice of communal or private room space. The home was clean tidy and the appropriate care had been taken to promote hygiene and cleanliness. EVIDENCE: All requirements met from previous inspection had been implemented and the home was clean tidy and had plenty of room for personal choices such as television in one room and a radio in another. Carpets were in need of cleaning and the home had maintainence programme in place to accommodate regular cleaning. The lounge areas had comfortable seating that service users were take advantage of some choosing to stretch out and relax others had their own particular furniture that allowed them to sit in comfort and to continue to be a part of the group. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 18 The homes ‘Welsh-dresser’ situated in the living room was in need of replacement as it had sustained damage and general wear and tear. Service users bedrooms reflected the personality of the owner and staff support was in evidence in the way items of importance to the service user was respected. The laundry area had been fitted with paper towel dispenser and liquid soap as had the kitchen but neither had paper towels inside. It was recommended that the home replace the Welsh-dresser and arrange for the carpet to be cleaned. Please see the recommendations section of this report. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was in need of a new manager. Staff were well trained and capable of delivering service user care however it was recommended that a review of training need be considered. The recruitment practices in this home were good. EVIDENCE: Staff roles were well defined however there had been changes in management roles since the retirement of the Manager. The deputy manager ‘acting-up’ while arrangements to recruit a new manager was put into effect. It is required that the home must have a permanent manager in post and that CSCI is kept informed of the outcome. A sample of staff files of those on duty were inspected and evidence of skills attained by the staff team met the needs of the service users. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 20 Staff files inspected contained adequate job descriptions and staff were aware of the main roles and policies of the home and sought to achieve the goals set out in the service users care plans. The key worker system was operated in this home and staff had responded by ensuring that the service users needs were well recorded so that agency and bank staff were well informed. Staff were observed communicating with the service users in a manner they understood and were aware of their care needs. Staff training met the service users care needs which included: epilepsy, medication administration and communication however much of the training was in need of revisiting such as protection of vulnerable adults, first aid, disability awareness and medication administration. It is recommended that the home review training needs. Three staff files were sampled for details of the homes recruitment practice and policy. There were no irregularities to be found and staff in the home were mainly long-term employees who were ‘happy at work’. Please see the requirement section of this report. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives had the opportunity to contribute to the running of the home and health and safety issues were promoted. EVIDENCE: The home was in good order and staff and the deputy manager were working well and was knowledgeable and aware of the service users needs. Regular reports, Regulation 26, were being sent to CSCI. There is a need however for a permanent manager to be employed. Parents attended their own support meetings and participate with the care planning and were welcomed and encouraged at the home. Service users also had the opportunity to attend regular monthly house meetings. Comments received from the CSCI survey confirmed that relatives were satisfied with the quality of care at the home. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 22 Promotion of health and safety issues was good. The home was clean and tidy all potentially hazardous materials were under lock and key, water temperatures, fridge temperature, foodstuffs and policy and practice documentation was checked and in place and staff had received health and safety training. Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 X 5 X 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 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 24 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 YA32 Regulation 8(a)(b)(2) Requirement The registered provider must appoint a new manager and inform CSCI of the outcome. Timescale for action 27/01/07 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 YA9 Good Practice Recommendations It was recommended that each risk assessment is considered for inclusion in the daily care plan folder, in order of importance and in a clearer printed form. It was recommended that the home replace the Welshdresser and arrange for the carpet to be cleaned. It is recommended that the home assess staff need to receive training updates for: Protection of vulnerable adults, first aid, disability awareness and medication administration. 2. 3. YA24 YA34 Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Pines (The) (Redhill) DS0000013748.V322572.R01.S.doc Version 5.2 Page 26 - 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. 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