Inspection on 04/10/07 for The Pines (Weybridge)

This inspection was carried out on 4th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines (Weybridge) 02/11/06

The Pines (Weybridge) 18/08/05

The Pines (Weybridge) 18/04/05

The Pines (Weybridge) 21/10/04

The Pines (Weybridge) 10/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Pines (The) (Weybridge) The Pines 6 Windsor Walk Weybridge Surrey KT13 9AP Lead Inspector Chris Woolf Unannounced Inspection 4th October 2007 09:20 Pines (The) (Weybridge) DS0000013747.V346768.R02.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) (Weybridge) DS0000013747.V346768.R02.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 Older People and 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) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pines (The) (Weybridge) Address The Pines 6 Windsor Walk Weybridge Surrey KT13 9AP 01932 842954 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) s.nesarajah@btopenworld.com Sathiavathy Jeyarani Nesarajah Sathiavathy Jeyarani Nesarajah Care Home 10 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (10), Learning disability over 65 years of places of age (4), Physical disability (1), Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 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) 1 person with a learning disability may have an addiitonal physical disability and/or sensory impairment - LD/SI or LD/PD 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 to 65 year olds) 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 decreasing number as the home intends to provide care for 30-65 year olds.) One 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). The age/age range of the persons to be accomodated will be 30 to 65 years 2nd November 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: The Pines is registered for a maximum of ten residents who have learning disabilities. There are eight single and one double bedroom. At the time of the inspection there were 7 residents living in the home. The current age range of the residents is sixty two to seventy three years. The service is privately owned and is situated in a quiet residential area close to local facilities and amenities. There is one parking space on the premises and on street parking nearby. The home provides a caring and supportive service and encourages residents to be as independent as practicable within a risk-assessed framework. The current fees for the service at the time of the visit range from £800 to £950 per week. Information on the Homes’ services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is s.nesarajah@btopenworld.com. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information for this report is based on an Annual Quality Assurance Assessment completed by the company and an inspection site visit. The site visit, which took six hours, was unannounced; this means that neither the provider nor the residents knew that it was going to take place. During the site visit the inspector talked with the residents who were able to communicate verbally and also observed a good rapport between the staff and all residents. Discussions were held with the staff on duty, one visiting professional, and the manager. A full tour of the premises was undertaken. Observations were made of a meal being served, and medication storage and administration. A selection of records were inspected including care plans, staff files, menus, training matrix, and a variety of policies. The people who live in this service prefer to be called residents and this is the term used to describe them throughout the report. Where the word AQAA is used in the report this refers to the homes Annual Quality Assurance Assessment. What the service does well: The home is managed in the best interests of the residents, and there is a friendly and positive atmosphere. The staff team are all trained to NVQ Level 2 or 3. A comprehensive pre admission assessment is carried out for all prospective residents and they have the opportunity to ‘test drive’ the home prior to any final decision being made about admission. Care plans are detailed and informative. Resident’s varying health care needs are met by the home. The information produced for residents’ reviews is very comprehensive and gives a good picture of what has been happening with the resident since the last review. Residents are treated with respect at all times. They are given appropriate choices in all aspects of their daily lives and their views are continually sought to improve the service the home provides. The meals in the home are wholesome, nutritious and attractively served. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 6 The garden is very pleasant and nicely kept. A letter observed in the home’s compliments file sums up the good things in the home. It states, ‘I’m very happy to be at The Pines and all the staff are very helpful and I really feel like I am being with my own family. They do feed us very well. … I am happy with all the care I’m being given’. A visiting professional commented, “As a home its pretty O.K.”. 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 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) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, & 5 (Adults 18-65) and 2, 3, 4 & 5 (Older People). Standard 6 (Older People) is not applicable in this home. Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Prospective resident’s needs and wishes are fully assessed and documented prior to admission to ensure that the home can meet their needs. Residents are able to ‘test drive’ the home before making a decision about admission and each resident is issued with a contract/statement of terms and conditions with the home. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 9 EVIDENCE: The home has not had any new residents admitted since the last inspection. However, they do have a comprehensive assessment form available and ready for use. In addition to information on physical and mental health, personal care needs, wishes, and likes and dislikes, it also explores any equality and diversity needs of the prospective resident. Fees are agreed with the funding authority based on the level of care required and the fee range given by the home. Evidence was seen of a pre-assessment that has been carried out for a prospective new resident. The manager has been to see the prospective resident and met with her existing manager and key worker. A psychology report and a joint review report have also been obtained. The prospective resident has visited the home for ½ a day and a further visit is booked. Following this the resident will be monitored and a full review will be carried out before any decision is made about admission. Assessments are used to ensure the homes capacity to meet the assessed needs of prospective residents and no resident will be admitted unless the home are confident that they can meet these needs. The home encourages trial visits as it gives the prospective resident time to see if they like the home and get on with the existing residents. It also gives the existing residents time to see if they accept the new person and if they relate to them. Before a decision is made the existing residents’ views will be taken into consideration. Each resident is issued with a contract/statement of terms and conditions that is signed by the home and the resident or their representative. The contract includes the fee payable and whom; and any additional charges that are the responsibility of the resident. It is made clear in the contract that holidays are not included in the fee charged. This home does not offer intermediate care (Older People Standard 6) which is a specific service aimed at short term rehabilitation with a view to residents being able to return to their own home. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 (Adults 18-65) and 7, & 14 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents’ needs and goals are recorded in clear and comprehensive individual plans of care. They are supported to take responsible risks and are given choices in all aspects of their daily lives. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 11 EVIDENCE: A comprehensive care plan is produced and agreed with each resident. These care plans are based on the information gained during the pre-admission assessment and include details of all physical and mental health needs, religious, spiritual and diversity needs, and contact with family and friends. All care plans are updated whenever a change in need occurs, and at least once every six months. A daily report is kept for each resident and the home is in the process of changing these to a format that complies with Data Protection. Reviews with care managers take place once a year. Review files seen were comprehensive. A visiting Care Manager confirmed that she makes a yearly visit to review her resident. She commented, “They are very well prepared, the layout of their reviews is good, and whatever I have asked for has been there” Staff spoken to on the site visit confirmed that a key worker system is in place. The homes AQAA states, ‘The Key Workers are appropriately trained to understand the needs and requirements of the residents’. Residents are able to make decisions about all aspects of their daily lives. The homes AQAA stated, ‘Each resident has their own appointed Key Worker who encourages their independent choices in lifestyle, for example what they would like to wear and where they would like to go on outings’. A resident said, “I want to go to town to get a new suit and a Mac before we go on holiday. When I want to go to town they will organise to take me”. A staff member commented, “Yes, they get enough choices, they make choices in everything”. Although the home does not hold specific meetings for the residents, one of the residents chooses to join the staff meeting and to make his views known. The homes AQAA indicates, ‘By listening to the requests of residents we are now planning more adventurous holidays by going abroad with the residents who choose to do so’. If a resident wishes to make use of an advocacy service the home will arrange this for them. However the majority of residents have their affairs dealt with by their Enduring Powers of Attorney or the Court of Protection. Residents are supported to take responsible risks. Assessments are undertaken to identify any risks and to put into place strategies to minimise the risk. Resident risk assessments are kept with their care plan. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 13 11, 12, 13, 14, 15, 16, & 17 (Adults 18-65) and 10, 12, 13, & 15 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities both in the home and in the local community. They are supported to maintain and develop appropriate personal and family relationships. Their rights are respected; and they receive a wholesome and nutritious diet. EVIDENCE: Residents’ have the opportunity to maintain and develop social skills through attending a day centre, and a local centre in the evenings. There is a variety of training on offer including computer skills, gardening, pottery, sign language, drama, and pottery. They also sing, and meet their friends. A resident said, “I go to the centre, we do lots of different things. I have a work plan but it’s not always the same. I did computers. I made these things in pottery, I have been making pottery for years.” A visiting professional commented, “Perhaps they could do more day care stimulation for some clients”. A staff member said, “They like dancing and colouring”. Residents’ spiritual and cultural needs are supported by the home according to their personal wishes. These needs are documented in their plan of care. Some residents choose to go to church occasionally. Currently the home does not have any residents with any other cultural needs. Staff support residents to take part in community activities such as shopping, walking, visits to Hampton Court, visiting the library, bowling, church, flower exhibitions, picnics, trips to see the Christmas lights in London, visits to the pub, and a regular weekly trip to eat out. A resident said, “We go to eat out on a Friday”. Staff said, “I am always taking them out”, and “We take them for a drive”. Residents are encouraged to maintain contacts with family and friends. A resident said, “I go to see my sister every holiday. One of the staff, usually my key worker, takes me to Victoria and my sister meets me at the other end”. The home makes arrangements to take the residents who are interested away on holiday. Four residents and four staff are going by Euro tunnel to Paris. A resident said, “We are waiting for my passport to arrive and then we Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 14 are going to Paris on holiday for a week”. A staff member said, “They go on holiday”. Several of the residents choose to help with tasks in the home. Each resident has an activity profile in his or her room. One commented, “I peel the veg, I help them out on days when I am not at the day centre”. A staff member said, “xxx goes to the day centre and still wants to help here when he comes home”. Residents who wish can have a key to their own room, one said, “I’ve got a key to my room but I don’t need one to the front door as the staff are always here to open it for me”. A nicely balanced menu is available for the residents with choices always available when wanted. The homes AQAA states, ‘Healthy meals of their choice are provided with organic and healthy foods. Residents who have a favourite food can request this and it will be provided’. A cooked breakfast is served two mornings a week. The majority of residents require their meals to be pureed because of swallowing difficulties. Their meal is served to them at the table from separate dishes. The meal observed was well presented and colourful, and the staff explained to the residents what was being served. Meal times are flexible to meet the needs of the residents and this was observed on the day of the site visit. A resident said, “The meals are lovely, you can have a choice if you want. They steam the vegetables and they really taste good”. Staff said, “The food is good”, and “Always fresh food and vegetables”. A visiting professional commented, “Food is of a reasonable quality”. Each residents weight is recorded regularly and any significant variations are explored. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 (Adults 18-65) and 8, 9, & 10 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare support and assistance is planned and provided, where needed, in a respectful and sensitive manner. Health care needs are met by the home, supported by a team of health care professionals. EVIDENCE: Residents have choices in the way they receive personal support. The homes AQAA states, ‘We encourage residents to have their own choice concerning Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 16 when they go to bed and when they get up, their own choice of clothing, hairstyling and personal grooming’. Residents’ privacy, dignity, and independence are promoted by the home. Where guidance and support for personal hygiene tasks is needed this is carried out in accordance with their personal and cultural needs and wishes and is documented in the individual residents daily notes. The home is currently considering introducing a more comprehensive recording system for personal care. Residents’ health care needs are met by the home supported by a multidisciplinary team of health care professionals. All contact is recorded in the resident’s individual care plan and evidence was seen of contact with G.P., District Nurse, Dentist, Chiropodist, Continence Advisor, Eye clinic, and hospitals. The aroma therapist also visits the home every week. All residents have an annual health check at the very minimum, and more often wherever necessary. A resident said, “Mrs Nesarajah took me to the hospital when I was ill on a Sunday, she has also encouraged me to give up smoking and sweets”. The same resident also said, “I used to have fits but they are under control now”, and, “I see the doctor for my flu jab in November”. The homes policies and procedures for the recording of medication are sufficient to allow an audit trail. Medication storage is satisfactory. A photograph of each resident is provided with the Medication Administration Record sheets as a safeguard and to guide staff to the correct resident. A medication information sheet gives details of the medications for each resident. The home has appropriate guidelines in place for ‘as required’ medication and this is signed by the G.P. Risk assessments are in place for any resident who wishes to self medicate. Policies for Home Remedies are signed by the G.P. All staff who administer medication have been trained; and the administration of medication witnessed was handled sensitively Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 (Adults 18-65) and 16, 18, & 35 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents concerns and complaints are listened to and acted upon and they are protected from abuse EVIDENCE: A copy of the homes complaints policy is on display in each resident’s bedroom. Since the last inspection the complaints policy has been updated, as required, to include details of the current link inspector. The home has had no recorded complaints since the last inspection. One complaint was raised directly with CSCI, the home was contacted and a staff-training programme was requested. The home had a book available in the hallway for the recording of any complaints, however, following discussion at the site visit about Data Protection, this is to be reviewed and separate sheets are to be made available. Completed sheets will be stored in a file in the office. The homes own quality assurance includes keeping records of compliments as well as complaints. A resident commented, “I have been here for 2 years, its nice”. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 18 Residents are protected from abuse. The home has an adult protection and a whistleblowing policy. All staff been trained in Adult Protection. No new member of staff is employed until an Enhanced Disclosure has been submitted to the Criminal Records Bureau, a satisfactory check has been received against the Protection of Vulnerable Adults register, and two satisfactory references have been received. Staff spoken to confirmed that they have received training in adult protection and that they understand the whistleblowing policy. Where the home looks after any residents monies this is handled satisfactorily Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, & 30 (Adults 18-65) and 19, 20, 24, 25, & 26 (Older People) Quality in this outcome are is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a home that is accessible, comfortable, and suitable for it’s stated purpose. Some improvements are needed in infection control procedures and practices to fully protect residents. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 20 EVIDENCE: The home is located in a quiet cul-de-sac, close to local facilities and amenities. There are 2-3 steps for access but the current resident group can all manage these steps. The house is set out over 3 floors with stair lift access to the 1st and 2nd floors. The home is reasonably well maintained although some of the décor in the hallways is now looking a little ‘tired’ and needs painting and freshening up. The provider indicated that repainting was to take place in the autumn and a recommendation has been made that this goes ahead. The CCTV cameras that were in the home have been removed to comply with the requirement on the last report. The home has a very attractive and well-kept garden. Resident’s bedrooms are decorated and personalised to meet their individual needs and choices. The homes AQAA states, ‘Bedrooms are individually decorated to their choice of colour scheme and preferences and have been made personal with pictures, posters, television, music and radio facilities and with individual bedding and soft furnishings of good quality’. Shared space is made up of a lounge at the front of the house, and a separate dining room which leads directly into the kitchen at the rear. This gives easy access for residents who wish to assist with the cooking. Cleanliness in the home is satisfactory and there are no unpleasant odours. A resident said, “Its always spotless”. Although the home has an infection control policy and gloves and aprons are readily available, there were some infection control issues. There was no liquid soap and paper hand towels in the toilet although it has since been explained that these are put away because of problems with one resident eating the paper towels, therefore the home may need to investigate other methods for hand drying within this area. Towelling, rather than paper hand towels were in use in the kitchen. The washing machine does not have a specified programming ability to meet disinfection standards and although there is a sink in the laundry area this is used for laundry and there is not a separate sink available for hand-washing. A requirement has been made regarding these issues Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, & 36 (Adults 18-65) and 27, 28, 29, 30 & 36 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Residents are cared for by a team of properly recruited staff, who are trained to meet their needs and who show them a high degree of respect at all times. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 22 EVIDENCE: All staff working at the home have achieved NVQ at either Level 2 or Level 3 and one is currently doing Level 4. During the site visit it was observed that staff show respect to the residents and relate well to them. A resident said, “The staff are alright, no trouble”. There are sufficient staff on duty to meet the needs of the residents. Overnight there is one waking and one sleep-in staff on duty. Additional staff are brought in for outings and other events that require more help and the planned holiday to Paris will involve 1:1 staff/resident ratio. The homes recruitment procedures safeguard the residents. No new member of staff is employed until a satisfactory check has been made of the Protection of Vulnerable Adults register. Where a new member of staff starts work prior to receipt of the Enhanced Disclosure they work under supervision. The home is now updating all of their staff files to comply with the revised Schedule 2 of the regulations. Statements of Terms and conditions of employment, and equal opportunities monitoring are retained on the staff files. The home did employ some staff brought over specifically from overseas, but this practice has now ceased. The home has a training and development programme. All new staff have induction training to Skills for Care specifications. Some gaps were observed in the training matrix but the appropriate training is already planned to ensure that staff are up to date with mandatory training. A recommendation is made that the training should go ahead as planned. Staff receive fairly regular formal supervision, and in addition the manager is constantly monitoring their practice and discussing performance with them. One member of staff commented “She is always here seeing that we are doing things right”. Staff meetings are also held every month. General comments from staff included, “I like working here”, and “I can see the difference here from my last place, they are most happy”. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 24 37, 38, 39, & 42 (Adults 18-65) and 31, 32, 33, & 38 (Older People) Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the residents. The health, safety and welfare of residents and staff are protected. EVIDENCE: The registered manager is also the owner of the home. She is also the owner of two other homes one in the same area and one in Devon. The manager holds a Diploma of Nursing, the NVQ 4 Registered Managers Award, and is a member of the Institute of Management. She is experienced and competent to manage the home. Staff and residents confirmed that the manager promotes an open, positive and inclusive atmosphere in the home. This includes a commitment to equal opportunities. The homes AQAA states, ‘We continually evaluate systems to promote the rights, responsibilities and diversity of people and ensure structures and frameworks are in place to achieve this. These structures are in place for the benefit of all residents, individuals, families and colleagues. There are appropriate Policies and Procedures and a Code of Conduct is in place which all staff study and we ensure they understand and review these policies regularly according to the needs and changes’. Staff commented, “The manager is very flexible”, “She is very supportive”, “We are always free to go and get things for the residents if they want things”, and “The manager is always here”. A resident said, “The manager is wonderful”. The home has developed its quality assurance systems. Questionnaires are sent to residents, family, visiting professionals and staff and an analysis is produced of the results. Staff meetings are held monthly and residents who wish also join this meeting. Regular audits are undertaken of medication, premises, Health & Safety, clothing, food and nutrition, care plans, staff files, and staff training. Where the home looks after any residents monies this is handled satisfactorily and protects the resident from abuse. The manager has recently persuaded one resident to give up smoking. As well as improving his health his bank balance has also increased significantly enabling him to purchase more new Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 25 clothes and other items that he would like, and to pay for him to go to Paris on holiday. The home promotes the health, safety and welfare of service users and staff. Risk assessments are carried out for safe working practices. Any accidents are recorded. Requirements of statutory bodies are all actioned. The safety testing of all equipment is up to date. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 3 3 3 4 3 5 3 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 X 26 3 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 3 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pines (The) (Weybridge) Score 3 3 3 x DS0000013747.V346768.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA30 Regulation 16 (2) (j) Requirement The home must review and update their infection control policies and procedures. In particular the provision of liquid soap and paper hand towels in all areas where infected material and/or clinical waste are being handled; and the procedures for the laundering of soiled clothing. Timescale for action 31/01/08 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 YA24 YA35 Good Practice Recommendations The re-painting in the hallways should continue as planned. The home should continue with its planned training to ensure that all staff are up to date in the mandatory training subjects. Pines (The) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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) (Weybridge) DS0000013747.V346768.R02.S.doc Version 5.2 Page 29 - 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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