Inspection on 10/07/06 for Toray Pines

This inspection was carried out on 10th July 2006.

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

Toray Pines 06/02/06

Toray Pines 14/09/05

Toray Pines 16/03/05

Toray Pines 01/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Toray Pines School Lane Coningsby Lincs LN4 4SJ Lead Inspector Kathryn Emmons Unannounced Inspection 10th July 2006 09:45 X10015.doc Version 1.40 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 Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Toray Pines Address School Lane Coningsby Lincs LN4 4SJ 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) 01526 344361 01526 343294 Tanglewood (Lincolnshire) Limited Mrs Gillian McLellan Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (8) of places Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Any service users within the category PD will be aged between 50 and 65 years. All of the following rooms may be used to accommodate people within the category PD: numbers 15, 16, 17, 18, 40, 41, 42 & 43. Occupancy When used by service users within the category PD, these rooms will be used on the basis of single occupancy and the overall occupancy will be reduced proportionately. 6th February 2006 Date of last inspection Brief Description of the Service: Toray Pines is a purpose built home situated in the village of Coningsby, which has a range of local services and facilities. It is one of a group of homes operated by the same company, Tanglewood (Lincolnshire) Limited. It is set in its own well-maintained gardens with a patio area. Gardens are accessible for those service users with mobility difficulties or who need wheelchairs. Accommodation is provided on two floors, which can be accessed through a shaft lift or stairs. The majority of rooms are for single occupancy. Lounge and dining areas are located on both floors. There is car parking available to the side of the property. Toray Pines is registered as a care home to provide care and accommodation for up to fifty-two service users in total. The main registration is for older service users who are aged sixty-five years or over. Conditions of registration have been varied to enable the home to cater for up to eight service users with physical disabilities aged between 50 to 64 years of age in designated rooms which, when used for this category are used for single occupancy. Fees range from £335 - £504 per week. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during a weekday and the homes administrator and manager assisted the inspector throughout the inspection. A total of 5 and quarter hours were spent inspecting the home. There were 36 residents living at the home on the day of the inspection. The inspector toured the home and spoke with the 5 staff 2 visitors and 8 residents. Twenty service users comment cards were also received. The main method of inspection used was called “case tracking” which involved selecting residents and tracking the care they receive through checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? Since the last inspection an activities coordinator has been employed at the home. This enables residents to have more opportunities to participate in activities and access the local community. An environment audit has been undertaken and redecoration and refurbishment of some areas of the home is going to be undertaken. The environment is already satisfactory however this maintenance programme further enhances the facilities available. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 6 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. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents experience is that the care team are clear on their needs and have systems in place to meet these needs. Provision of contracts and information regarding the service provides residents with confidence that they can expect a good level of service and control over the service they receive. EVIDENCE: Through case tracking it was evidenced that service users had terms and conditions and contracts in place. This was also indicated on the comment cards and when speaking to residents. Letters confirming assessed needs could be met were in place on files. Preadmission assessments were contained within files. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 9 One resident confirmed that they had been able to visit the home prior to admission to tour the home and ask questions regarding the service provided. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that care plans reflect their assessed needs and aspirations. Risk assessments provide assurance to residents that risk is minimised as much as is possible. Medication arrangements provide residents with a safe administration system. Residents live in a home with an ethos that demonstrates their rights to dignity, privacy and respect. EVIDENCE: Through case tracking care plans and risk assessments were reviewed. Discussion with residents evidenced that the care plans are an accurate assessment of the resident needs and abilities. The key worker who is assigned to the resident reviews these monthly. Residents were satisfied with the health care arrangements. One resident stated they had been taken to the village optician. During the inspection the Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 11 inspector was able to speak to one of the community nursing team. The staff member said the home were very accommodating and helpful and any instructions, which were requested, were carried out by the home care team. Medication arrangements were satisfactory and residents were observered to receive their medication in a dignified and discreet manner. One carer confirmed that they had attended medication training and that all staff who were responsible for administering medication had been enrolled on a medication course at a local college. Observations evidenced that residents were addressed in their chosen form and spoken to in an appropriate and valuing manner. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience evidences that most of their individual preferences are met at the home. Visitors and residents experiences evidence that contact is maintained and promoted. Opportunities to access the community and have social inclusion are in place. Resident’s experience and staff views evidence that residents are encouraged to make choices where they can in all aspects of their care. Resident dietary preferences are catered for. EVIDENCE: Residents spoken with said the were able to carry on with their hobbies following their admission to the home. One resident said “I am able to do something every day if I chose to”. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 13 Since the last inspection an activities coordinator has been employed for 20 hours a week. A record is to be maintained of all activities provided and which residents participated. This enables the activities coordinator to identify which residents have not participated group activity and may chose to have some one to one time instead. Another resident said they had been able to continue to follow their belief and that they had be offered the opportunity to attend church or have a minister visit. Residents made very positive comments regarding the food, such as “I really enjoy my food”, “ Its always warm and I got a cake for my birthday”. Lunchtime was observered and the lunchtime meal was viewed. Residents have a choice at all meal times. Drinks are provided on a regular basis and all rooms viewed had a jug of juice in place. Residents have the choice of biscuits or fresh fruit with their drinks. Two of the kitchen staff were spoken with during the inspection. Both were clear on their job roles and what the homes expectations of them were. Specialised diets such as gluten free diabetic and pureed diets are catered for. Those resident who require assistance to take their meals were supported in a dignified manner. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their concerns will be listened to and investigated. Residents are protected from potential abuse by the homes safeguarding adults procedure and staff training. EVIDENCE: Residents said they were satisfied that if they had any concerns these would be addressed. Residents said they could speak to any of the staff and were not concerned about raising issues. Information regarding how to make a complaint is on display in the main reception of the home. Residents spoke with staff on a daily basis and residents meetings are also held and minutes are maintained. One visitor said they had been able to raise an issue with the homes manager and this had been responded to. Staff training records evidenced that all staff had been trained in Safeguarding Adults training. Three members of staff spoken to were given a scenario regarding adult abuse prevention. All staff responded appropriately. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment. The standards of decoration and furnishing are good, providing residents with a comfortable and homely place to live. There are aids and adaptations to ensure the needs of residents with a physical disability can be met. EVIDENCE: A tour of the premises evidenced a clean and homely environment. Domestic staff are employed on a daily basis and no adverse odours were noted through out the home. The home is set in landscaped gardens, which residents can assess easily. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 16 Residents who gave permission for their rooms to be viewed made positive comment regarding their rooms. One resident said “I have all I need and the room is big enough for me to use my wheelchair easily.” Those residents who use the hoist to move from bed to chair had bed-raising blocks on the bed to enable safe manoeuvring of the hoist. Residents are able to personalise their bedrooms. A callbell was tested in one of the bedrooms and was responded to promptly. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not always satisfactory to meet resident’s needs. A motivated and enthusiastic care staff team supports residents. Ongoing training and supervision sessions provide a trained and skilled workforce. Residents are protected by the homes robust recruitment procedures. EVIDENCE: One visitor, 3 comment cards and 2 residents spoken to during the inspection said that sometimes there were not enough staff on duty at busy times of the day. Examples were given such as one resident saying “I can only have one bath a week”, another resident said “The staff don’t have a lot of time to sit with me”. One visitor said that they had noted that their relative had to wait on occasion to use the lavatory. This was discussed with the manager who said that staff levels are reviewed on a regular basis. One staff spoken to said, “We are busy but its not too bad”. The home is proposing to admit nursing care residents in the near future. It is suggested that staffing levels need to be reviewed in view of this and the comments made during this inspection. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 18 During the inspection call bells were answered promptly and staff were noted to be busy, however on at least two occasions staff were seen briefly sitting and speaking with residents. Three staff files were inspected. These evidenced that staff have been recruited safely with all necessary checks in place. Staff receive an induction and those staff spoken with were able to describe their induction and what training they had received. The home employs a training coordinator for 9 hours a week. Training records are in place and the training plan for all staff is reviewed regularly. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s benefit and have confidence in the fair and inclusive leadership style of the manager. Residents are kept safe by the homes health and safety polices. A quality assurance system provides residents with evidence of an improving and evolving service. EVIDENCE: The homes registered manager is Mrs Gill McLellan. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 20 Mrs McLellan has many years experience of caring for older people. Staff and residents all made very positive comments regarding Mrs McLellan management style. Residents said they felt relaxed living at the home and that they were kept safe and secure. One resident said “I can go to bed at night and not worry”. The responsible individual undertakes monthly Regulation 26 visits to the home in addition to visiting a couple of times a week. The home has a quality assurance programme in place and the results are fed back via the resident meeting minutes. The home produces a newsletter to inform residents and relatives of the homes arrangements and any changes in the staff team. The home polices and procedures are updated regularly to reflect any changes in the homes service. Staff spoken to were able to discuss fire safety arrangements and confirmed that fire drills had taken place. Those residents who have money held by the home for safekeeping are protected by the administrator’s recordkeeping. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP27 Good Practice Recommendations It is strongly recommended that staffing levels are continually reviewed to ensure they provide residents with sufficient time to have their needs met. Toray Pines DS0000002558.V302387.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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