Inspection on 18/04/05 for The Pines (Weybridge)

This inspection was carried out on 18th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Pines (Weybridge) 04/10/07

The Pines (Weybridge) 02/11/06

The Pines (Weybridge) 18/08/05

The Pines (Weybridge) 21/10/04

The Pines (Weybridge) 10/06/04

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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 6 Windsor Walk Weybridge Surrey KT13 9AP Lead Inspector John Chivers Unannounced 18th April 2005 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service The Pines Address 6 Windsor Walk Weybridge Surrey KT13 9AP 01932 842954 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sathiavathy Jeyarani Nesarajah Mrs Sathiavathy Jeyarani Nesarajah Care Home 10 Category(ies) of DE(E) - Dementia - over 65 (1) registration, with number D - Learning Disability (10) of places LD(E) - Learning Disability - over 65 (4) PD - Physical Disability (1) PD(E) - Physical Disability - over 65 (1) SI(E) - Sensory Impairment - over 65 (1) The Pines Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 - 4 residents may be in the category LD(E) Older People with Learning Disabilities. (This will be a decreasing number as the home intends to provide care for 30 - 65 year olds). 2 - 1 person with a Learning Disability may have an additional Physical Disability and/or sensory impairment. - LD/SI or LD/PD. 3 - One person of either gender with Physical Disabilities aged over 65 years of age. (This will be a decreasing number as the home intends to provide care for 30 - 65 year olds). 4 - 1 person with a Learning Disability may be over 65 years of age and have in addition a Sensory Impairment and/or Physical Disability. (This will be a decreasing number as the home intends to provide care for 30 - 65 year olds). 5 - 1 named person suffering from Dementia, over the age of 65 years. (This will be a decreasing number as the home intends to provide care for 30 - 65 year olds). 6 - The age/age range of the persons to be accommodated will be 30 to 65 years. Date of last inspection 21st October 2004 Brief Description of the Service: The Pines is registered for a maximum of ten residents who have learning disabilities. The age range of the residents is thirty to sixty five years; however registered provision is also made for one resident over the age of sixty five years. It must be noted that this is a decreasing number as the home will only accommodate the former age range when the older resident leaves the home. The service is privately owned and situated in a quiet residential area close to local facilities and amenities. The Pines Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was ‘unannounced’ and commenced at 11.45am. The duration of the inspection was 3.75 hours. As part of the inspection process one relatively new member of staff was interviewed and discussion / communication held with three residents. A range of policies, procedures and records were also inspected. The findings of the inspection were positive with evidence that the home continues to be managed in a sound manner and affords a very good standard of care to the residents. The homes records were well maintained with evidence of internal monitoring and residents / relatives views being sought. Only a small number of requirements and recommendations are made. What the service does well: The home provides a homely and comfortable environment with adequate private and communal space for the residents. Whilst the home is currently decorated to a good standard, a redecoration programme is scheduled in the near future. Residents have care plans that are monitored, reviewed and updated as appropriate. The resident’s health and medical needs are well catered for and contact with health care professionals is clearly recorded. The home encourages and maintains most of the residents in day centre placements and has regard for the social inclusion of residents in community activities and annual holidays. The home has a commitment to staff training especially in the area of the National Vocational level 2 qualification. The home has regard for the protection of residents and has sound recruitment and vetting procedures. The Pines Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Pines Version 1.10 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 Standards Statutory Requirements Identified During the Inspection The Pines Version 1.10 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 standard(s) 2 The home is meeting the assessed needs of the current residents and this area is monitored and reviewed by staff. EVIDENCE: A sample of residents written needs assessments were inspected. The assessments were comprehensive and covered all key areas. There was evidence of regular reviewing and updating. Future review dates were also set in the reports. The Pines Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Residents have clear and detailed care plans and are allowed to make decisions consistent to their individual level of ability and subject to individual risk assessments. EVIDENCE: Written care plans were available in the sample of residents files inspected. The care plans were detailed and reviewed and updated when necessary. Future reviewing dates are also scheduled for the months of May 05 and July 05 in the sample that was inspected. Residents are allowed to make decisions commensurate to their level of ability and individual risk assessments. Consultation with residents next of kin, relatives, care managers and the court of protection when appropriate is included and evidenced in the decision making process. Residents have choices in meals, activities, holidays and attendance at day centres. One resident recently decided that he would like to spend two weeks at his sisters. Comprehensive written risk assessments were held in the sample of residents files inspected. There was recorded evidence of risk assessments being reviewed and updated when appropriate. The Pines Version 1.10 Page 10 The home’s manager also undertakes a risk assessment of holiday accommodation and venues covering both indoor and outdoor arrangements. The Pines Version 1.10 Page 11 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 standard(s) 12, 13, 15, 16 and 17 The home has regard for the social / vocational inclusion of its residents both inside and outside of the home and the daily routines of the home are that of an ordinary domestic household. The home menu is consistent with requirements and provides for a balanced and varied diet. EVIDENCE: A number of residents attend day centres and take part in activities such as life and social skills. One resident attends a computer course in addition to attending activities such as makaton, self-awareness, music and pottery. Residents without a day centre place have an activity programme at the home. The home has a holiday file, which evidenced a holiday in Brighton in July 04 and a planned holiday in Bognor Regis in September 05. Accommodation is sought in specialist Hotels that cater for people with disabilities. Staff escort residents on shopping expeditions, visits to the library and cinema. Residents also visit local public houses and restaurants. One resident has The Pines Version 1.10 Page 12 recently acquired a set of drums. Another resident plays the electric organ and has one of these instruments in their bedroom. Residents receive visitors in their bedrooms or in communal accommodation if they wish. Visits to the home or visits out of the home are recorded. The home’s routines are that of a ordinary domestic household. Residents indicated in discussion / communication that they were content with the daily round of life in the home. The home’s menu was available and is based on a three-week cycle. The home’s menu provides for a balanced diet and a number of residents were observed to enjoy their meal at lunchtime. Provisions were safely and correctly and safely stored. The temperatures of the refrigerator and freezer was 5 degrees centigrade and – 20 degrees centigrade respectively. The temperature of the refrigerators and freezers are taken and recorded daily. The Pines Version 1.10 Page 13 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 standard(s) 18, 19 and 20 Residents receive close support from their key workers and staff and specialist support is accessed when necessary. Residents health / medical needs are well catered for and medication storage and recording arrangements are consistent with requirements. EVIDENCE: All residents are allocated ‘key’ workers and staff confirmed this during interviews. Staff were observed to provide close and attentive support to the residents and residents indicated in discussion / communication that they were content with staff input. The home has access to a range of specialist support services and this was evidenced by correspondence on resident’s individual files. There was evidence of health care details held on resident’s assessments and care plans. Visits to the Doctor, Dentist and other health care professionals are recorded. Resident’s files also held weight charts and NHS correspondence. The home’s medication administration policy and procedure was updated in January 05. The home also had guidance documentation from The Royal Pharmaceutical Society. Reports from the community pharmacist were available. It was evidenced that such visits occur annually. The Pines Version 1.10 Page 14 A sample of residents medication administered charts was inspected. Entries were clear and evidenced no gaps in recording. Medication is stored in a locked metal cabinet with separate provision for the storage of ‘controlled’ drugs. Recording in the controlled drugs book was clear and evidenced two staff signatures. Old or discarded medication is returned to the Pharmacist for disposal. The record is stamped by the pharmacy. The Pines Version 1.10 Page 15 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 standard(s) 22 and 23 The home has a clear complaint procedure, which has also been prepared in ‘pictorial’ form. Residents are protected from abuse via the home’s protection of vulnerable adult procedures and staff awareness and training in this area. The resident’s personal cash could be more easily audited if individual’s cash is kept separate from the main petty cash system. EVIDENCE: The home’s complaint procedure was available. The procedure was also available in ‘pictorial’ form. The home’s complaint book was available. This evidenced that no complaints had been received. Residents stated / indicated that they had no complaints about the service provided. The home has an internal policy and procedure regarding the protection of vulnerable adults. It was evidenced that staff sign this procedure. In addition the home holds the updated (February 05) Surrey County Council Multi-Agency Adult Protection procedures. Staff interviewed were aware of and clear regarding the home’s adult protection procedure. The manager received the Surrey County Council Multi-Agency training in the protection of vulnerable adults in February 05 and the manager reported that all new staff would receive the same training in June 05. A sample of resident’s personal finances was inspected. Receipts were consistent with the total in the cashbook. It would be sound practice for the home to keep residents cash separately rather than include this in the home’s main petty cash system. This would allow for easier auditing of cash held by residents. An advisory recommendation will be made regarding this. The Pines Version 1.10 Page 16 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The home is situated in a location that is in keeping with its aims and objectives. The home provides a homely and comfortable environment and is decorated and furnished to a good standard. The home is a safe environment, though more diligence is needed regarding checking for loose electrical sockets. EVIDENCE: The home is a large detached property situated in a quiet residential road. Local facilities and amenities are close by. The exterior of the property is well maintained. The home’s garden is well cared for and free from safety hazards. A sample of resident’s bedrooms was inspected. The rooms were decorated and furnished to a good standard and had been personalised to varying degrees by their occupants. It was noted that some residents had quality television sets and sound systems. A loose electrical socket was noted in one of the resident’s bedrooms. This was brought to the attention of the manager The Pines Version 1.10 Page 17 for prompt action. A requirement will be made under Standard 42 of this report regarding this. Bedrooms provide adequate private space for the residents. Communal areas were decorated and furnished to a good standard and provide adequate space. These areas are homely and comfortable. Bathrooms and toilets are of a good standard and afford adequate privacy for the residents. It was noted that the top of one of the bath panels was broken. This needs to be replaced and a requirement will be made regarding this. The home has an electric chair lift attached to the stairs. The homes infection control policy was available. Staff sign the policy. Cleanliness and hygiene were observed to be of a very good standard. Whilst the home is decorated to a good standard all areas are scheduled to be redecorated in 2005 / 6. This was evidenced via the home’s annual development plan. Whilst this work has already been actioned a requirement will not be made. With the exception of the loose electrical socket in one of the resident’s bedrooms no further safety hazards were identified. The Pines Version 1.10 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The home’s recruitment and vetting procedures were evidenced as satisfactory. All details required by Regulation 19, Schedule 2 of the Care Homes Regulations 2001 were held. EVIDENCE: The home has a recruitment policy and procedure. The policy is dated June 2000. One staff file was inspected. The member of staff concerned was a relatively new appointment. The file held an abundance of information including: completed application form and curriculum vita, job description, copy of qualification, copy of birth certificate, photograph, two references, medical history, induction programme, contract, equal opportunities statement, interview notes, copy of staff disciplinary procedure and health & safety information. A Criminal Record Bureau check was also held on file. The manager is currently undertaking NVQ level 4 (management.) At the previous inspection it was evidenced that 50 of the homes staff hold the NVQ level 2 qualification. The manager stated that the remainder of the staff are to commence this training in June 05. There was evidence of staff induction training and staff confirmed their attendance on a ‘moving and handling’ course. The Pines Version 1.10 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 nd 42 The home has a clear regard for health and safety matters and certificated evidence of appropriate tests and checks were held. The home is diligently managed and achieves the required outcomes for the residents. EVIDENCE: The manager monitors the service on a regular basis and countersigns records and reports etc. It was also evidenced that the views of residents and their relatives are sought via questionnaires. The home’s annual development plan for 2005 / 6 was available for inspection. The home’s Certificate of Registration was prominently displayed. The manager of the home is also the service provider and is in the home on a daily basis, therefore Regulation 26 visits are not undertaken. The home’s health & safety policy statement was available. A range of written risk assessments has also been prepared. The Pines Version 1.10 Page 20 The home’s fire risk assessment was evidenced. This was dated 26th February 05. Fire evacuation drills are undertaken on a quarterly basis and weekly alarm and fire equipment tests occur. It would be good practice however if the drills and tests could be recorded separately and include the number of residents and staff taking part in the drill and the time taken to evacuate the premises. An advisory recommendation will be made regarding this. The home had current certificates for the testing of electrical and gas systems and Legionella. Hot water temperatures are taken and recorded on a daily basis. The temperatures are thermostatically set at 43 degrees centigrade. Inspection reports from the Environmental Health Department (health & safety and food hygiene) were available. These were dated 26th October 04 and 23rd 03 respectively. With the exception of one loose electrical socket in one of the resident’s bedrooms no other safety hazards were identified. The Pines Version 1.10 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x The Pines Version 1.10 Page 22 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. 2. Standard 27.1 42 Regulation 23, (2) (b) 13, (4) (a) Requirement Timescale for action 30 / 5 / 05 That the broken bath panel is replaced. That the loose electrical socket in 19 / 4 / 04 bedroom 2 F 4 is secured to the wall. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 23. 6 41 Good Practice Recommendations That residents personal cash is kept separate from the main petty cash system. That fier evacuation drills and alarm tests are recorded separately and that the number of residents and staff evacuated and the time taken to evacuate are recorded. The Pines Version 1.10 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Pines Version 1.10 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!