Inspection on 05/12/05 for The Pines

This inspection was carried out on 5th 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines 06/06/06

The Pines 06/06/05

The Pines 09/12/04

The Pines 28/06/04

The Pines 24/02/04

The Pines 14/04/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 The Pines The Pines Hostel Mayfield Road Orrell Wigan Lancashire WN5 0HZ Lead Inspector Julie Conrad Unannounced Inspection 5th December 2005 08:15 The Pines DS0000032683.V268702.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 The Pines DS0000032683.V268702.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. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Pines Address 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 Pines Hostel Mayfield Road Orrell Wigan Lancashire WN5 0HZ 01942 760015 01942 621320 Wigan Council Social Services Department Mrs Ellen Prescott Care Home 29 Category(ies) of Learning disability (29), Learning disability over registration, with number 65 years of age (6) of places The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. Within the maximum numbers registered there can be up to 29 LD and up to 6 LD(E) Staffing levels are to be calculated in accordance with a Residential Forum Staffing Guidance (Older People) by 1 April 2004. 6th June 2005 Date of last inspection Brief Description of the Service: The Pines is a local authority residential care home, registered to provide care for up to twentynine adult residents of either sex who have a learning disability. Six residents may be over the age of sixty-five years. Of the twenty nine places, five are used to provide short term care. The appropriateness of providing short term care in a care home where the majority of residents live permanently, is regularly discussed by the manager Mrs Ellen Prescott with senior management. The Pines is a two storey building. All residents have a room of their own, there is a large dining room/lounge and a smaller lounge area. There is courtyard, patio with garden furniture surrounded by a lawn area to the rear of the home. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of The Pines took place on 5th December 2005, from 8.15am until 11.25 am. The focus of the inspection was to check previous requirements have been met and to assess a number of standards that were not assessed at the last inspection. The manager was present at the inspection. The inspector spent the first hour of the inspection conversing with the residents before the majority of them went to day care. The inspector conversed with the manager and three members of staff on a one to one basis. Records were checked and an inspection of the building was carried out. What the service does well: What has improved since the last inspection? New sofas and chairs have been purchases for both the main and small lounge areas, making the environment more homely and pleasant for the residents. Three staff are on waking night duty each night, ensuring enough staff are available to attend to residents needs during the night. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 6 An updated medication policy and procedure has been introduced and requirements have been met following the pharmacist inspection, which was carried out prior to this inspection. Assistant accommodation managers have attended a refresher course in medication. A member of staff is in the process of introducing a pictorial menu system, following consultation with residents. This will ensure that residents who are unable to read will know what is being served each day. As required at the last inspection, the manager has a programme of redecoration and renewal for the home from 2005 until 2010. 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 DS0000032683.V268702.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 The Pines DS0000032683.V268702.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): 2, 4 The assessments ensure individual aspirations and needs are assessed and that residents have the opportunity to achieve these. Prospective residents are able to visit the home informally prior to admission, to ensure they make an informed choice. EVIDENCE: The inspector checked three residents’ files which included; a long term resident, a recently admitted resident and a resident preparing for independent living. Each file contains Help Notes which focus on the residents’ health needs, and a personal profile, which includes cultural and communication needs, and individual aspirations are assessed. The manager carries out sixmonth reviews which involve the link worker and the resident, to formally check that aspirations, leisure and social needs are being met. The inspector brought to the manager’s attention that care plans must be reviewed on a monthly basis. Prospective residents are able to visit the home on a trial basis before admission to the home. They are able to visit the home informally with their family or representative and join the residents for a meal or join in the activities. The service user guide informs prospective residents of the service and facilities provided. Following admission to the home, residents are given a service agreement, which is in a pictorial, user-friendly format, with additional information, which includes access to policies and procedures and medication. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 9 The inspector had a conversation with a resident who is to move to independent living. The resident told the inspector that whilst at the Pines she was learning new skills which include; ‘keeping my room tidy, changing my bedding, using the washing machine and dryer and I am to learn how to use an iron. I am going to learn cooking skills at the day centre.’ The resident said ‘I like it here, staff are friendly.’ The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 10 The assessment, care plans and risk assessments focus on promoting independence of the residents, to ensure they live as full a life as possible. The manager must ensure that residents are aware of the homes confidentiality policy, to ensure residents know their confidences are kept. EVIDENCE: The assessments, care plans and risk assessments are formulated with the residents’ involvement, to promote independence and ensure residents are able to make decisions about their life. To ensure residents personal goals are reflected in the care plan, a formal review is carried out every six months by the manager, the review meetings include the resident, the key-worker and any health care professional involved in the provision of care. The inspector has made a requirement that care plans are reviewed each month to ensure the care needs are met. The six month reviews should continue to take place as these include participation of the aforementioned. One resident works at a local supermarket three days a week and told the inspector, ‘I am looking forward to the works Christmas party, as all the managers wear fancy dress.’ The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 11 The inspector brought to the manager’s attention, that the service user guide and the service agreement did not contain information about the home’s confidentiality policy. A requirement has been made at this inspection that information about confidentiality is included in both the guide and the service agreement. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 17 Leisure and social needs are formally assessed and reviewed to ensure the residents’ changing needs continue to be met. Residents are encouraged to maintain and foster new relationships, to ensure they continue to develop personally. EVIDENCE: Each resident’s leisure and social requirements are assessed and incorporated into the plan of care. On the morning of the inspection, residents were observed to be in good spirits and getting along well with each other and staff. Some residents had taken breakfast and were waiting for transport to the day centre. A resident told the inspector that he went to day care each day during the week and that he enjoyed it. Another resident who was taking breakfast, told the inspector he had a friend and pointed to a member of staff, who came to chat with the resident and inspector. One resident asked the inspector to sit and watch her sing on the karaoke machine. Other residents also sat down to watch. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 13 The inspector spoke with a resident who is preparing for independent living. She was enjoying her stay at the Pines and said that staff were good and the other residents were friendly, and that on the whole everyone got along well. The inspector chatted with a resident who gets involved in the gardening at the home during spring and summer. The resident said everything was okay at the Pines and told the inspector that there was a carers coffee morning planned later in the week. Staff and some of the residents have put up the Christmas decorations. There is a large tree with lights in the enclosed courtyard area, a number of small Christmas trees throughout the home, including the lounge and reception area. The windows have icicle lights and decorations, which look very attractive. The atmosphere within the home was happy and friendly, with residents interacting in a relaxed and friendly manner with staff and each other. The consumer meetings take place every three months. Records of the meetings were seen and demonstrate residents are updated on home life issues and their opinions sought on the issues raised. Two senior staff have completed the ‘Professional Development Award’, one of the staff has used the award to focus on developing pictorial menus at the home. She has consulted with residents and the cook. Instead of writing the daily menus on the menu board, pictures of food will be placed on a Velcro board; these will be changed each day. Trips out for some residents prior to Christmas include a Houghton Weavers concert and tinsel and turkey weekend in Blackpool. There will be a Christmas day dinner and gifts for the residents and a boxing day buffet. There will also be a party in between Christmas and New Year with karaoke and on New Years Eve there will be a hot pot supper. The general atmosphere at the home is festive, friendly and happy. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 The home’s medication policy and procedure has recently been revised to ensure the correct information is given to staff and that residents receive their medication in the correct way. EVIDENCE: The staff team deal with residents’ emotional needs on a daily basis. However, neither the assessments nor the care plans specifically address emotional needs. Emotional needs should be included in the assessment and care plan documentation, to ensure the needs are appropriately assessed and met. Staff recently cared for a resident until she passed away. There is another resident who is also very ill being cared for by staff at the home. Staff are being supported by the District Nurse as required. No staff training in death and dying or bereavement has taken place. The inspector has made a requirement that bereavement training is provided for staff. The home’s medication policy and procedure has recently been revised and refresher training in medication is planned throughout the coming year. A member of staff told the inspector that she had attended the refresher medication training and had found it useful. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 15 The inspector checked the medication, which is packaged in the MANREX system and appeared satisfactory. The manager told the inspector that the requirements and recommendations made by the Pharmacist inspector at a previous inspection had been implemented. No controlled drugs are presently kept at the home. The medication policy has a procedure regarding residents who wish to administer their own medication. A risk assessment is carried out to determine whether or not it is safe for the resident to do so. A resident who is considered able to do so will be given a lockable facility in their own room to store the medication. One resident is responsible for her lunchtime medication, but chooses not to keep the medication in a locked facility in her room. It is kept in the home’s locked medication cabinet. Residents are given information on self-administering medication in the service agreement. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a policy and procedure on complaints and the protection of vulnerable adults, to ensure residents are protected. EVIDENCE: The home has a complaints policy and procedure that is explained to residents in the service agreement. The complaints file was checked. No formal complaints have been received at the home since the last inspection. An informal concern was raised by a resident, which was recorded and dealt with appropriately. This demonstrates residents are aware of the complaints procedure and use it. Wigan Local Authority has introduced an updated Protection of Vulnerable Adults policy and procedure. The manager has recently attended refresher training in the protection of vulnerable adults. All staff are to attend the training in the New Year. Wigan Local Authority have introduced a pictorial guide for residents throughout the learning disability service, which explains the different types of abuse that can occur and how the person can get help. Other pictorial guides are being introduced including one on advocacy. The inspector saw both the guides, which are well presented and easy to understand. A guide giving information on ‘how to see information about you’, covers information on data protection and freedom of information and confidentiality. The manager intends to share this information with the residents at the next consumer meetings. The inspector has made a requirement that information on confidentiality is included in the service user guide and the service agreement. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 17 The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 18 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): 25, 27, 30 The standard of décor within the home has improved in part of the home, however, further improvements must take place to ensure residents live in a good environment. EVIDENCE: Since the last inspection the home has devised a programme of redecoration and renewal from 2005 to 2010. Since the last inspection, new sofas and chairs have been purchased in the main and small lounge, which immediately improve the comfort and décor for the residents. The inspector has again made a requirement that the scuffed paintwork on the doors, door surrounds, fire doors and skirting boards be repainted as soon as possible. The programme of renewal and redecoration addresses all areas of the building, however, the paintwork needs to be addressed quickly. Residents spoke positively about the home. They said that they liked their rooms. Two residents said their bedrooms were ‘okay but a bit small’; ‘alright but I wish it was a bit bigger.’ Finance has been secured for the redecoration of a number of bedrooms before March 2006. The remaining bedrooms will be redecorated by the end of 2006, The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 19 along with main lounge, which will be redecorated and re-carpeted. There will be new carpets in the short break part of the building, the downstairs flat and corridor. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 36 All staff receive mandatory and specialist training, to ensure the needs of the residents are met. EVIDENCE: All staff receive mandatory training, for example, food hygiene, moving and handling, fire safety. Refresher training is carried out on an ongoing basis. The majority of staff have achieved NVQ level 2 in care, whilst two senior staff have achieved NVQ level 3. Six new members of staff are currently undertaking training in the Learning Disability Framework, which has a unit on the protection of vulnerable adults. All assistant managers have achieved NVQ level 4 in care and management. A number of staff have had computer training. A course in MRSA is planned for January 2006 from the Public Health Department and mandatory NVQ training is ongoing. The inspector checked two staff files; the individual performance and development reviews are carried out annually, whilst formal one to one supervision is carried out regularly. The last supervision was carried out in October 2005. A member of staff told the inspector that she found supervision beneficial and that she could speak with the manager anytime. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 The home has a management structure of accountability and required policies and procedures, to ensure service users rights and best interests are safeguarded. EVIDENCE: The manager has achieved NVQ level 4 in management and is currently undertaking NVQ level 4 in care. The manager continues to run the home well and encourages residents to get involved in home life by attending consumer meetings and informal discussions. The home has all the required policies and procedures in place, some of which are explained to residents in the service user agreement. The service has introduced user friendly, pictorial guides for residents, explaining abuse, how to recognise the different types of abuse and what to do about it, there is also a booklet about advocacy. These will be used at the consumer meetings to help residents understand more fully what protection and advocacy are about. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 22 Policies and procedures are in place to protect the rights and best interests of residents. The inspector has made a requirement, that the confidentiality policy is included in the service user guide and service agreement. The record keeping at the home is satisfactory, the residents files that contain assessments and care plans are detailed, typed and in good order. A requirement has been made that regulation 26 visits take place by a senior manager each month and that the report be kept on file at the home and be made available at inspections. The Pines DS0000032683.V268702.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x x x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Pines Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 x 2 DS0000032683.V268702.R01.S.doc Version 5.0 Page 24 Yes 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 YA24 Regulation 23 Requirement The scuffed walls and doors and fire doors need redecorating and repainting throughout the upstairs and downstairs corridors. Care plan reviews should take place on a monthly basis. Information on the homes confidentiality policy should be included in the service user guide and service agreement. All care staff should attend a bereavement course. A senior manager should carry out Regulation 26 visits once a month. The assessments and care plans should include specific information on emotional needs. Timescale for action 28/02/06 2. 3. YA6 YA23 15 5 31/12/05 28/02/06 4. 5. 6. YA21 YA43 YA19 18 26 14 31/03/06 31/12/05 31/12/05 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 Standard Good Practice Recommendations The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 25 The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 The Pines DS0000032683.V268702.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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