Inspection on 18/08/05 for The Pines (Weybridge)

This inspection was carried out on 18th August 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) 18/04/05

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 Announced 18 August 2005 : 11am 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 H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 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 CRH - Care Home 10 Category(ies) of DE(E) - Dementia over 65 (1) registration, with number LD - 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 H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - 4 residents may be in the category LD(E) Learning Disability over 65 (This will be a decreasing number as the home intends to provide care for 30 - 65 year olds). 2 - 1 person with a LD Learning Disability may have an additional PD Physical Disability and/or SI Sensory impairment. LD/SI or LD/PD. 3 - 1 person of either gender with PD(E) Physical Disability 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 LD(E) Learning Disability over 65 and have in addition a SI(E) Sensory Impairment and/or PD(E) Physical Disability. (This will be decreasing in number as the home intends to provide care for 30 - 65 year olds). 5 - 1 named person suffering from DE(E) 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 18 April 2005 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 admit the former age range when the older resident leaves the home. The service is privately owed and is situated in a quiet residential area close to local facilities and amenities. The home provides a caring and supportive service and encourages residents to be as independent as practicable within a risk assessed framework. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was undertaken on 18th August 05. The duration of the inspection was 2.25 hours. As part of the inspection process one resident was interviewed and discussion held with three others. One member of staff was formally interviewed and discussion held with the service provider/manager. A sample of the home’s policies, procedures and records were inspected in addition to the scrutiny of a sample of resident’s individual files. Pre-inspection information supplied by the home to the CSCI was also included in the inspection and written feedback from residents, their relatives and professionals was also evaluated in the process. It must be noted that all of the CSCI ‘core’ Standards were examined at the unannounced inspection on 18th April 05,therefore a random selection of noncore Standards were assessed on this occasion with the exception of core Standards 22 and 23, which were included in this inspection. The findings of the inspection were positive with evidence of good management and practice. Policies and procedures were in place and the sample of records inspected were well maintained. Of particular merit was the organisation and maintenance of the resident’s individual files. There was evidence of staff training in the protection of Vulnerable Adults and staff were aware of the home’s ‘Adult Protection’ procedures. Residents stated in interview and discussion that they had no complaints or concerns about the service provided and their views were consistent with written feedback received from residents relatives and professionals associated with the home. Whilst the premises were not inspected on this occasion it was noted that a large new patio area had been constructed. The patio is attractive, spacious and has been professionally laid. Some of the residents had verbal communication difficulties and communicated via facial expressions and gestures. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that residents, their relatives or representatives sign and date the new contracts/terms and conditions of residency, which have recently been introduced. The home also needs to expand its resident’s pictorial complaints procedure to include the contact address and telephone number of the CSCI Surrey Local Office. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 7 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 H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 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 standard(s) 4 and 5. The home has regard for ensuring written contracts are in place; however residents or their representatives need to sign the documents where individual residents are unable to do so. EVIDENCE: The home has a ‘staged’ admission process, which includes a series of preliminary visits prior to a six-week trail period before permanent residency is agreed. All residents were issued with new contracts/terms of residency agreements on 26th June 05. A sample of the contracts were inspected. The contracts were comprehensive and covered all relevant areas. It would be important for residents, their relatives or advocate to sign the documents where individual residents are unable to do so themselves. A requirement will be made regarding this. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 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 standard(s) 8 and 10. The home takes account of resident’s views and opinions and acts on them as appropriate. The home has regard for the area of confidentiality. EVIDENCE: Resident’s views and opinions are taken into account and this was confirmed in interview with one resident and via discussion with three others. Key workers and staff obtain resident’s views and opinions and act on them as appropriate. Residents attend staff meetings on occasions to put forward their views and this was evidenced in some staff meeting minutes. The home has a policy regarding confidentiality. The policy is dated June 02. It was evidenced that ‘Placing Authorities’ are provided with the home’s written confidentiality statement. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 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) 11 and 14. The home provides a range of activities and maintains resident’s in day centres. EVIDENCE: The resident’s quality of life is enhanced by the activity programmes set at day centres and at the home. The programmes were evidenced in resident’s individual files and in addition each resident has a ‘learning book’. Comprehensive written reports from the day centres were also held. The home provides a range of active and sedentary pastimes within and outside the home. Excursions are arranged and a holiday in ‘Littlehampton’ is planned for September 05. Resident’s stated in discussion that they enjoy the activities provided by the home and the day centres. One resident in particular stated that he “really enjoys sitting on the home’s new patio looking at the flowers and birds in the garden”. Another resident plays the ‘drums’ and this activity could be heard during the inspection. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 12 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) 21. The home has regard for resident’s wishes in regard to funeral arrangements. EVIDENCE: The home has a detailed policy regarding aging and death. Completed funeral wishes and arrangement forms were held in the sample of resident’s files inspected. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 13 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 appropriate procedures in place regarding complaints, however the resident’s pictorial procedure needs to be expanded. The home has regard for the protection of its residents and trains its staff in this area. EVIDENCE: The home’s complaints procedure was available. In addition the home has a complaint procedure in pictorial form for the resident’s. It would be important to include the contact address and telephone number of the CSCI Surrey Local Office within this procedure. A requirement will be made regarding this. The home’s complaint book was available. The book evidenced that no complaints have been received. Written feedback from residents, their relatives and professionals associated with the home were clear that they had no complaints or concerns about the service. This was also the view of resident’s that were interviewed. Staff interviewed were aware of the complaint procedure. The home has an internal policy and procedure regarding the protection of ‘Vulnerable Adults’. In addition the home held the Surrey County Council MultiAgency Adult Protection procedures. The manager has attended the Surrey County Council Multi-Agency training and is due to attend another course in the near future. It was also evidenced by correspondence that two staff are due to attend Multi-Agency training in the protection of Vulnerable Adults on 26th September 05. Samples of the resident’s personal finances were inspected. The cash held was consistent with the balance entered in the resident’s individual account books. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 14 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) 29. The home ensures that residents have any special equipment that they may require. EVIDENCE: Specialist equipment in the form of a stair lift and ‘Parka’ bath was evidenced. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 36. The home has regard for NVQ training and ensuring that staff receive formal supervision. EVIDENCE: It was evidenced that two staff hold the NVQ level 2 qualification and it was further evidenced by correspondence that four staff are currently undertaking NVQ level 3 training. ‘Formal’ staff supervision occurs and written notes of supervision were available in the sample of staff files inspected. Staff also confirmed the frequency of supervision during interviews. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 37 and 41. The home’s management and staffing arrangements enable the home to meet its aims and objectives. The home has regard for ensuring that records are maintained in good order. EVIDENCE: The provider/manager is a qualified nurse and is currently undertaking NVQ level 4 (management) training. She also has substantial experience in the management and provision of residential services for people with learning disabilities. The provider/manager also intends to receive updated training in the protection of Vulnerable Adults and Dementia. Staff interviewed were supportive of the home’s management. The home’s management and staffing arrangements enable the home to meet its aims and objectives. The sample of records inspected were kept to a good standard. In particular the resident’s individual files were organised and maintained to a high standard with information easily accessed. The resident’s files are kept securely in a locked office. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 17 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 x x 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x 3 x Standard No 11 12 13 14 15 16 17 3 x x 3 x x x Standard No 31 32 33 34 35 36 Score x 3 x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Pines Score x x x 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 x x H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 18 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 5.5 Regulation 5, (b) (c ) Requirement That residents, their relatives or advocate signs the contract/terms of residency where residents are unable to do so themselves. That the contact address and telephone number of the CSCI Surrey Local Office is included in the residents pictorial complaints procedure. Timescale for action 30.9.05 2. 22.3 22, (7) (a) 30.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations There are no recommendations as a result of this inspection. The Pines H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 19 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 H58 H09 S13747 The Pines Weybridge V233799 180805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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