Care Home: Pinehurst House Nursing Home

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What has improved since the last inspection? The home has met previous requirements and recommendations given at the last inspection. Ongoing refurbishment of the premises has been carried out; and this includes refurbishment of the fountain in the central courtyard, and other improvements to the gardens. There has been improved care planning and documentation. What the care home could do better: No requirements have been given as a result of this inspection. One recommendation is given, to ensure that the statement of purpose is brought up to date. Key inspection report CARE HOMES FOR OLDER PEOPLE Pinehurst House Nursing Home Pinehurst Off Filmer Lane Sevenoaks Kent TN14 5AQ Lead Inspector Mrs Susan Hall Unannounced Inspection 29th April 2009 08:45 DS0000026196.V374764.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinehurst House Nursing Home Address Pinehurst Off Filmer Lane Sevenoaks Kent TN14 5AQ 01732 762871 01732 763922 coetzeeh@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd 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) Helena Coetzee Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 30. Date of last inspection 30th April 2007 Brief Description of the Service: Pinehurst House is a care home providing nursing care for 30 Older People. It is owned by BUPA Care Homes, who are a well known provider of care homes. Pinehurst House is a purpose built establishment, which was first registered in 1986. The home is situated in a quiet residential area, and is surrounded by well maintained gardens. Resident accommodation is all on the ground floor, and is divided into three bays of ten beds; each bay has it’s own communal areas. The bedrooms do not have en-suite toilet facilities, but there are a sufficient number of toilets and bathrooms in each area. The home has a central inner courtyard, which is a very pleasant sitting area, with a fountain and sensory garden. There is plenty of car parking at the front of the building. The home is easily accessible via the main A25 road, and is approximately two miles from Sevenoaks Town Centre. Sevenoaks is well served by public transport, and has all the usual town amenities. The current fees range from £675.00 to £1100 per week; depending on the assessed needs of individual residents. Additional charges are payable for hairdressing, chiropody and private taxi hire. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was assessed as having a rating of three stars, excellent. This means that the Commission is confident that residents receive excellent standards of care in this home. Everyone contacted speaks highly of this home and the standards of care. A key inspection was carried out, and this involves assessing all information obtained about the home since the last inspection, as well as a visit to the home. Information is received from formal notifications, letters and telephone calls, and the home’s Annual Quality Assurance Assessment (AQAA). This is a self-assessment document, which each home is required to complete and return to the Commission at a specified time. The AQAA was well completed, and provided to the Commission when requested. We (i.e. the Commission) sent out survey forms to residents, staff, and health professionals, and received fourteen completed forms. These were all very positive in content, with comments such as “The carers are marvellous here” from a resident; and “Everything is done well, and nothing is too much trouble for the staff” (from another resident). Health professionals’ comments included: “Very high standards of care, and care staff have a high standard of skills. This is an excellent nursing home. It provides excellent care and quality of life”; and “There is a caring, homely and attentive environment. There is excellent end of life care, with an established senior staff team. I cannot think how this home could be improved.” The visit was carried out by one inspector over six hours. During this time, we viewed all areas of the home; read documentation such as care plans, staff files, medication records and servicing records; and chatted with a total of twelve residents, three visiting health professionals, and seven staff, as well as the manager. What the service does well: Every aspect of this home was found to be in good order and running well. This includes: • • • • Good management of pre-admission information and the information process; Well written and informative care plans; A suitable range of daily activities; Well cooked home food; DS0000026196.V374764.R01.S.doc Version 5.2 Page 6 Pinehurst House Nursing Home • • • • A well maintained environment, both inside and outside the home. Good staffing levels, and a good range of training; Excellent management by the registered manager; Lots of opportunity for residents to share their ideas and feelings about how the home is running, and to suggest changes. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Pinehurst House Nursing Home DS0000026196.V374764.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 Pinehurst House Nursing Home DS0000026196.V374764.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides good information for prospective residents, and assists them through the admission process. EVIDENCE: The home provides good information for enquirers, in the form of a home profile, which is kept in the reception area. This includes a mixture of the statement of purpose and the service users guide. The manager is in the process of updating the statement of purpose, having noticed that some of the information was out of date. The service users guide includes relevant information such as the management of catering, laundry, and housekeeping; hairdressing arrangements; activities available; and the terms and conditions of residency. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 9 The guide clearly states that some items are excluded from the fees, such as visitors meals and private treatments. However, a daily newspaper of the resident’s choice is included in the fees. All residents have a comprehensive pre-admission assessment prior to moving into the home. We viewed four of these assessments and they were all well completed. The manager tries to minimise the difficulties for residents moving into a care home, by arranging for the same nurse who carried out the preadmission assessment to be available on the day of admission, and welcome the newcomer into the home. The same nurse then carries out admission procedures. All residents are provided with a contract, and have a four week trial period prior to making a decision as to whether to stay permanently. Pinehurst House Nursing Home DS0000026196.V374764.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care is excellently managed in this home. Residents are completely confident in the ability and competence of the staff, in ensuring that they will be given high standards of care. EVIDENCE: The care home is divided into three bays, and individual care plans are appropriately stored in these three areas. This ensures that nursing and care staff can access them easily. We examined four care plans, and found them to be suitably detailed and informative. They are set out in indexed folders, so that it is easy to find the information required. Residents and/or their representatives, are involved in the preparation and ongoing discussions about their care plans. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 11 The home uses BUPAs Quest documentation, which is BUPAs own system for care planning, and follows clear procedures for delivering individual care. All aspects of daily living are included, such as personal hygiene needs, nutrition, moving and handling, medication, social activities and lifestyle. Detailed assessments include items such as the risk of falls, and show the action to be taken in order to prevent these. The home has profiling beds, which can be lowered; this reduces the risk of injury for residents. Moving and handling assessments state if the resident needs a hoist for transfers, and note which hoist and sling should be used. All hoist transfers are carried out with two nursing or care staff. Individual likes and dislikes are recorded, such as preferred times for getting up and going to bed; if the resident prefers to stay in their own room for meals; and if they like to take part in group activities. For example, one care plan states likes breakfast in bed; prefers lunch in own room. Wound care plans show how a wound has been sustained, and the action taken to treat the wound and prevent further wounds. There are good directions for the type of dressing to be applied, and a separate account for each change of dressing. This means that nursing staff can track the progress of healing for individual wounds. All documentation in care plans is completed to a high standard, and demonstrates the care which is being given. Care plan audits are delegated to one of the nurses, and the manager also audits three care plans per month. The care plans include communication sheets showing the content of discussions with relatives; and input from health professionals such as GPs, physiotherapy, and psychogeriatrician. We met three doctors during the course of the inspection, and each of these spoke very highly of the nursing care given by the home. Two of them had also completed survey forms which included the following comments: this home excels at providing care; providing holistic caring with twenty-four hour nursing. And this home provides excellent nursing care. There is good communication with me, and my practice. It is a pleasure to visit and attend my patients in this home. Their management of medication is of a high standard. Medication is stored in a clinical room, which has sufficient storage space, and two medication trolleys for administration. There are two nurses on duty in the mornings, with each nurse responsible for half of the home. This ensures that residents receive their medication on time during the busy morning period. One of the nurses manages the oversight of medication; and checks storage, and administration charts, each month. Medication trolleys were seen to be in good order. There are good procedures in place, such as dating bottles of medication on opening; and two nurses signing for all medication checked into the home. All Medication Administration Records (MAR charts) were viewed, and no errors were found. There is correct storage and recording for controlled drugs, and a weekly audit to check these. Homely remedies are properly Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 12 administered and recorded, and each resident has a signed agreement from their GP for giving any of these. Staff were observed interacting with residents, and treating them with dignity and gentle affection. One of the doctors noted that staff are very good in respect of maintaining privacy and dignity, and always knock on doors, ask their permission etc. Care plans show that residents are asked for the name by which they prefer to be addressed, and staff abide by this. Residents said that the carers are marvellous here; and nothing is too much trouble, they give 110 per cent. The home has good systems in place for managing end of life care, enabling residents to stay in the home if this is their wish, and ensuring that specific individual preferences are adhered to. The nursing staff obtain advice from a local hospice where needed, e.g. for pain relief and palliative care; and use a system called the Liverpool Care Pathway which monitors residents preferences at the end of life. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are provided in accordance with residents preferences and choices. Food is very well cooked, and provides residents with good standards of choice and nutrition. EVIDENCE: The monthly activities programme is displayed in several areas around the home, and shows that a good variety is available. The home employs an activities co-ordinator four days per week; and a carer is allocated to carry out activities on another day. Activities are carried out from 10a.m. – 4p.m, and include one to one time as well as group activities. One to one time includes walks in the gardens; games such as scrabble or crosswords; and reading daily newspapers. These are provided for each resident at no extra cost, and enable them to follow current affairs as they wish. A manicurist visits the home on a regular basis, and the hairdresser visits every week. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 14 Group activities include items such as armchair exercises, quizzes, art class, reminiscence, tea parties and film shows. Special days are always celebrated, such as St. Georges Day and Mothers Day. Entertainers are invited to visit the home for items such as piano playing and singing. The home is able to access suitable transport for taking out small groups of resident for outings, and they visit local places such as Knowle Park for picnics, and can have shopping outings. Residents spiritual needs are discussed on admission, and the manager will ensure that individual ministers or priests are able to visit according to residents wishes. A Christian church service is held in the home on a monthly basis for those who wish to attend. Visitors are always made welcome in the home, and are valued as residents guests. They can stay for lunch if they wish, and will be given a three course meal with wine for a small charge. Residents said that the food is excellent, and that there is plenty of choice. The head chef draws up the menus, and he ensures that they are of good nutritional value. He discusses the menus with the residents, and enables them to have their own choices included. There is a different choice of cooked breakfast each day; a different starter for lunch; and two choices of meat or fish dishes as well as vegetarian options. The chefs provide a choice of four desserts each day, and a resident said that these are mouth-watering. Both chefs are on duty together for one day per week, so that they can discuss changes and work together. The chefs work from 7.30a.m until 6p.m., and are assisted by a kitchen assistant throughout the day. The kitchen was seen to be extremely clean, well organised and well equipped. The Environmental Health Officer has awarded the home a score of five stars for cleanliness and hygiene. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure is easily accessible, enabling residents and visitors to share any concerns. Residents are confident that their views will be listened to, and that appropriate action will be taken in the event of complaints. EVIDENCE: The complaints procedure is clearly on display in the reception area of the home, where it can be easily accessed by residents, or anyone visiting. It includes the contact details for the regional manager and the managing director, for anyone who wishes to take the complaints procedure beyond the manager. There is also a suggestions box, which can be used for anonymous ideas or concerns. All complaints are acknowledged within three days, and will be responded to within twenty-eight days. We have been informed that BUPA are currently reviewing their complaints policy. The manager records all concerns and complaints, and the documentation shows that these are taken seriously and dealt with appropriately. Day to day concerns are usually voiced to staff or the manager, and dealt with immediately. The home carries out residents meetings and surveys, which provides other avenues for residents to make their feelings known. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 16 The homes training matrix shows that staff are trained in the protection of vulnerable adults, and are aware of the different types of abuse. All staff are given initial training in this as part of the induction process; and have yearly updates. The manager is conversant with the correct procedures for contacting the Social Services Safeguarding team if needed. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19-22 and 24-26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are well maintained, and provide a comfortable, clean, and homely environment for residents. EVIDENCE: The home is situated in a quiet residential area, and is surrounded by very pleasant and well maintained gardens. It is divided into three bays, with ten beds in each, and each bay has its own sitting area. One of these has been made into the main dining area, and one is the main lounge used mostly for joint activities and special occasions. A new loop system has been fitted in here, to assist residents with hearing impairment. A vacant bedroom was currently being reorganised to use as an extra quiet lounge, suitable for Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 18 relatives to meet with residents in private. All areas are attractively presented, and have good quality furniture and soft furnishings. The building is kept very clean by a team of cleaning staff overseen by a housekeeper; and usually comprises three cleaning staff as well as a laundry assistant. Ongoing maintenance is carried out by a full time maintenance man, who carries out routine safety checks and ongoing repairs; and also redecorates bedrooms every time they become vacant. All bedrooms are for single use, and each room has a patio door leading out to the residents own outdoor area. Some of these have been personalised with flower tubs and baskets. There are other areas in the gardens for walking or sitting, which have different features; and the home also has an attractive central courtyard for sitting out in good weather. This has been re-planted during the past year, and has extra hanging baskets in place; there is a also a fountain which has been refurbished. The bedrooms do not have en-suite facilities, but there are a sufficient number of toilets and bathrooms. Each bay has its own bathroom; and there are two additional bathrooms. All bathrooms are fitted with appropriately adapted baths and hoisting facilities. The home has profiling beds in all rooms, and these are suitable for providing nursing care. Each bay has a hoist and a stand aid; and other equipment such as weighing scales, raised toilet seats and grab rails, are available throughout the building. The laundry is divided into two separate rooms, one for washing and drying, and one for ironing and managing clean laundry. There are two washing machines and two tumble dryers. A laundry assistant is on duty each day to ensure good management of residents clothing and all other laundry items. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff are dedicated to giving good care to the residents, and are well trained in their different roles. EVIDENCE: Staffing levels are well managed, ensuring there are always sufficient numbers of staff on duty. Two nurses are employed in the mornings, and each takes responsibility for half the number of residents. One nurse is on duty for all other shifts. There are five of six care staff in the mornings; four care staff in the afternoons and evenings, and two care staff at night. Nursing and care staff are supported by a good ancillary team of catering, housekeeping, laundry, maintenance and administrative staff. The home is committed to training staff for NVQ levels 2 and 3. The percentage of care staff with this training has recently dropped, as several staff have retired and been replaced with new staff. The percentage is currently just under fifty per cent, but another five care staff are commencing this training; and when they have completed it, the percentage will be up to approximately sixty per cent. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 20 Recruitment practices are well managed. We examined three staff recruitment files, and these contained all the required documentation. Applicants are required to provide a full employment history, complete a medical questionnaire, provide ID checks, and attend an interview. An interview record is retained, and a POVA first and Criminal Record Bureau checks are carried out. Applicants must provide confirmation of their eligibility to work in the UK. The company obtain two written references; and check nurses NMC PIN numbers. All new staff are given a job description, and a booklet called The working guide to BUPA care services. This includes the terms and conditions, and details of information such as disciplinary and grievance procedures. New staff have a comprehensive induction, which includes all mandatory training; and there is a three month probationary period. The training matrix confirms there is ongoing staff training in safe working practices such as fire awareness, moving and handling, first aid, and basic food hygiene. Additional training courses are provided for subjects such as understanding dementia and dealing with challenging behaviour. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31-33 and 35-38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provides clear leadership to the staff team, and ensures that the home runs smoothly and efficiently. EVIDENCE: The manager has been in post in this home for over three years, is a trained nurse, and has many years of experience in caring for older people. She has completed the Registered Managers Award. She provides excellent leadership to the staff, and manages the day to day running of the home. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 22 Staff at all levels work well as teams, and know that they are valued for the work they do. We received five survey forms back from staff, and they all spoke positively about their experience of working in this home. Comments included: Training has been fantastic. There are always people on hand if you need to know anything; The staff and morale are great, and everyone knows how to do their jobs properly, and are always willing to learn more. And the manager is very supportive, and gives good advice when needed. It is a great home. There are regular staff meetings organised by the manager, and these provide a venue for discussions. There are monthly staff meetings, and weekly meetings for heads of departments. Nursing staff have specific, assigned roles (such as overseeing care planning or medication), and this enables them to take ownership of specific tasks, and develop their skills and training. The manager speaks to residents on a day to day basis; and takes her part in working alongside nursing and care staff to help them with practical skills. Residents take part in regular meetings, and know that they can share ideas and opinions. The manager has an open door policy, and residents know that they can talk with her at any time. BUPA carries out a quality assurance system that includes yearly questionnaires, and the results of these are amalgamated, published, and acted on. A regional manager visits the home every month to carry out compliance checks, auditing processes and support for the manager. Residents are encouraged to maintain their own finances if they are still able to do so. Small amounts of pocket monies can be stored on their behalf, and records are kept of all transactions. These records are available for viewing at any time by the resident or their authorised representative; and are checked every month by the regional manager. All staff have ongoing one to one supervision, with at least six sessions per year, and often more, depending on how their role is developing. This includes clinical on the job supervision, checking staffs practical skills, as well as academic discussions. Supervision is delegated to different heads of department, to be appropriate for each staff member. There is a also a BUPA Personal Best programme, which is an incentive for staff to work to the highest level, and provides recognition for their hard work and achievements. Policies and procedures are reviewed every year, and staff are informed of any changes during that time. All documentation seen was well maintained, up to date, and neatly organised. BUPA has dedicated Health and Safety staff within the region, supported by a National Quality and Compliance team. This includes Health and Safety and Fire Management Leadership. The maintenance man carries out ongoing checks for items such as wheelchair checks, hot water temperatures, Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 23 thermostat checks, fire alarm tests, fire drills and PAT testing. The documentation for these checks is excellent. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 X 3 3 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 4 3 3 Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 25 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 OP1 Good Practice Recommendations To ensure that the statement of purpose is amended to reflect the current management and running of the home. Pinehurst House Nursing Home DS0000026196.V374764.R01.S.doc Version 5.2 Page 26 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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