Care Home: Pinewood & Hollywood

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What the care home does well People have good information so that they can make decisions about whether they would like to live in this service. The service makes sure that they have the right information so that they can look after people properly. People who want to live in the service are able to visit and see what it is like to live there. Each person has their own care plan; these contain most of the information that the staff need to know so that they can care for people properly. The staff help people who use the service to make choices and to maximise their independence and maintain their safety. Individuals are able to lead interesting lives and can make decisions about how they send their time, including going to local events, other community activities and keep in touch with family and friends. The staff help people to plan the menus, shop and cook. They are able to balance the individual food choices and ensure a healthy balanced diet. One person using the service commented that "the dinners are nice here, my favourite is scampi". The staff relate well to all individuals and have a good understanding of their needs. The people who use the service were relaxed, content and well cared for. All aspects of care are managed well. The service makes sure that people have the right information about how to complain if they are unhappy and individual complaints information is available that is suitable for their communication abilities. The service is a safe and comfortable place for people to live. People have their own bedrooms and able to make choices about how the room is decorated and furnished.Pinewood & HollywoodDS0000017910.V375190.R01.S.docVersion 5.2The service is clean and the management make sure that it is a nice place to live. The manager makes sure that there are enough staff to care for the individuals properly and that they have the right checks and training. The manager has the right skills to run the service properly. The service does the right checks to make sure that it runs smoothly and is safe. What has improved since the last inspection? The service is able to identify and plan improvements through out the service ensuring the approach of the service is pro active to the needs of the individuals and environmental issues. The AQAA tells us that the service has now fitted magnetic closures to all doors thus improving fire safety increasing access to areas including bedrooms. A number of these were observed on the day of the inspection. Cleaning of all carpets in both homes occurred professionally in December 2008, this promoting the continued maintenance and appearance of the service. A number of risk assessments have been updated to meet needs of service users in relation health & safety in the home and in the community. A new tenant had their room fully furnished and decorated to their tastes, ensuring that personal preferences and choices have been taken into consideration. The service has increased its` liaising with various professionals to offer support to staff to provide a consistent approach of care to service users e.g. outreach team, social workers and physiotherapists. Service Users who raise concerns are listened to and action taken as required. The service has completed financial risk assessments in line with Mental Capacity Act 2007. The service continues to strive to ensure that the wishes of individuals are met through a person centred approach to Support Planning and Risk Assessment The service has offered individuals a wider range of holiday options this year. One person using the service commented "I am really looking forward to going somewhere different this year on holiday". Individuals Personal Profiles have also been updated and suitable communication books are in place to ensure that all staff are consistent in their approach when communicating and supporting people on a day to day basis.Pinewood & HollywoodDS0000017910.V375190.R01.S.docVersion 5.2 What the care home could do better: A number of areas have been identified where the service must improve in order to ensure better outcomes for the people using the service. Care plans did not on all occasions contain all the information required in order for a persons needs to be met. The care plan was not used as a stand alone document detailing the care and support needs of the individual holistically. The health needs of a person were found to not be in sufficient detail in the care plan and health actions plans had not been fully implemented. Medication balances were not carried forward where a medication had been used from one month to the next, hand written entries on the medication administration record had not been double signed and a number of bottles and box`s did not have the date of opening added. The care plans did not detail a person`s consent to the use of monitoring aids during the night. Key inspection report CARE HOME ADULTS 18-65 Pinewood & Hollywood Smiths Field Colchester Essex CO1 2HP Lead Inspector Louise Bushell Unannounced Inspection 30th April 2009 09:30 Pinewood & Hollywood DS0000017910.V375190.R01.S.doc 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 home adults 18-65 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. Pinewood & Hollywood DS0000017910.V375190.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 Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood & Hollywood Address Smiths Field Colchester Essex CO1 2HP 01206 791455 01206 795971 smithsfield@rchl.org.uk www.rchl.org.uk Redbridge Community Housing Limited [RCHL] 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) Miss Patricia Marie McDonagh Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) 3rd April 2007 Date of last inspection Brief Description of the Service: Pinewood and Hollywood is a care home providing personal care for 8 adults with learning disabilities. The home was opened in 1995, consists of two semidetached bungalows and is situated on a quiet residential development to the south of Colchester town centre close to local amenities. Each property has four single bedrooms, one bathroom, one shower room, a kitchen/dining room and a large communal lounge area. There is an enclosed garden to the rear of the property and ample car parking facilities to the front. The registered manager is Miss Patricia Marie McDonagh and the registered organisation is Redbridge Community Housing Limited (RCHL). Previous inspection reports issued by the Commission for Social Care Inspection were included within the services statement of purpose and service user guide. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star good. This means the people who use the service experience good quality outcomes. This routine unannounced key inspection visit took place on 29th April 2009 between the hours of 09:30 am and 14:30pm. The focus of the visit to the service was to review all of the key standards to ensure that the main outcomes for the people who use the service were being met. The inspection process including planning prior to the visit. This included a full review of the services Annual Quality Assurance Assessment (AQAA), this document is a self assessment completed by the service, highlighting how they feel they meet the national minimum standards, what they do well, evidence to show how they meet the national minimum standards, improvements made over the last twelve months and planned improvements for the next twelve months and what they feel they could do better. The AQAA also provides information in the form of data. This provides valuable information regarding the service, for example how many complaints they have received in the last twelve months, information about polices and procedures and the needs of the people who use the service. The inspection planning also involved reviewing any additional information that we have received from the service regarding incidents and accidents, concerns and complaints. Part of the inspection process involves gathering direct information from the people who use the service, their relatives and or representatives, staff and any significant other person that may be able to provide valuable information regarding the services ability to ensure that the main outcomes for people are being met. On the day of the inspection the inspector was able to meet two of the people who use the service. One person was able to verbally communicate their opinions and direct and indirect observations were made to assess another person’s response and reaction to their environment and surroundings, staff interaction and whether they appeared cared for and well presented. Case tracking is a process that occurred during the inspection, this means identifying two people who use the service and making a full review of all their care needs, including their care plan and any associated documents, meeting with the person where possible, reviewing their medication and assessments. Care tracking enables the inspectors to review holistically the service that a person is receiving and assess, using the key national minimum standards the services ability to meet their individual and changing needs. A limited tour occurred during the inspection to assess the service’s environmental conditions and to ensure that that the service was suitable to meet the needs of the individuals residing there. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 6 Time was also spent with a number of staff members either through direct discussions or direct and indirect observations of practices. The inspector also spent time with the manager of the service, discussing and inspecting medication, care plans, developmental plans and any other issues throughout the inspection. The Annual Quality Assurance Assessment tells us that the fees charged for care and accommodation at Pinewood and Hollywood are £1217.12 per week with a charge made to the people who use the service of £65.20. The fee includes an annual contribution of £150 from RCHL towards holiday costs. The fee excludes all personal items, toiletries, magazines and hairdressing. What the service does well: People have good information so that they can make decisions about whether they would like to live in this service. The service makes sure that they have the right information so that they can look after people properly. People who want to live in the service are able to visit and see what it is like to live there. Each person has their own care plan; these contain most of the information that the staff need to know so that they can care for people properly. The staff help people who use the service to make choices and to maximise their independence and maintain their safety. Individuals are able to lead interesting lives and can make decisions about how they send their time, including going to local events, other community activities and keep in touch with family and friends. The staff help people to plan the menus, shop and cook. They are able to balance the individual food choices and ensure a healthy balanced diet. One person using the service commented that “the dinners are nice here, my favourite is scampi”. The staff relate well to all individuals and have a good understanding of their needs. The people who use the service were relaxed, content and well cared for. All aspects of care are managed well. The service makes sure that people have the right information about how to complain if they are unhappy and individual complaints information is available that is suitable for their communication abilities. The service is a safe and comfortable place for people to live. People have their own bedrooms and able to make choices about how the room is decorated and furnished. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 7 The service is clean and the management make sure that it is a nice place to live. The manager makes sure that there are enough staff to care for the individuals properly and that they have the right checks and training. The manager has the right skills to run the service properly. The service does the right checks to make sure that it runs smoothly and is safe. What has improved since the last inspection? The service is able to identify and plan improvements through out the service ensuring the approach of the service is pro active to the needs of the individuals and environmental issues. The AQAA tells us that the service has now fitted magnetic closures to all doors thus improving fire safety increasing access to areas including bedrooms. A number of these were observed on the day of the inspection. Cleaning of all carpets in both homes occurred professionally in December 2008, this promoting the continued maintenance and appearance of the service. A number of risk assessments have been updated to meet needs of service users in relation health & safety in the home and in the community. A new tenant had their room fully furnished and decorated to their tastes, ensuring that personal preferences and choices have been taken into consideration. The service has increased its’ liaising with various professionals to offer support to staff to provide a consistent approach of care to service users e.g. outreach team, social workers and physiotherapists. Service Users who raise concerns are listened to and action taken as required. The service has completed financial risk assessments in line with Mental Capacity Act 2007. The service continues to strive to ensure that the wishes of individuals are met through a person centred approach to Support Planning and Risk Assessment The service has offered individuals a wider range of holiday options this year. One person using the service commented “I am really looking forward to going somewhere different this year on holiday”. Individuals Personal Profiles have also been updated and suitable communication books are in place to ensure that all staff are consistent in their approach when communicating and supporting people on a day to day basis. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 8 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. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 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. People who use the service can be assured that there needs will be identified through a detailed assessment process, including a visit to the service. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives of the service, and includes a guide, which provides information about the service and the specialist care the service offers. The guide details what the prospective and current individuals can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. All new people are given a copy of the guide and the services makes one available for all to view as they wish. Admissions are not made to the service until a full needs assessment has been undertaken. A skilled and trained person always completes the assessment prior to admission to the service. The assessment was detailed and appropriate to the policy and procedure in place. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 11 The assessment explored areas of diversity including preferences, religious and cultural needs, involvement from family, partners and advocates, race, gender, age and disability. It was evident that the service strives to seek the information and assessment through care management arrangements, prior to admission. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. One person who uses the service commented, “I like it here, all the staff are really nice and helpful too”. The assessment process is conducted annually to ensure that any changes in need are identified and associated support plans are then reviewed and or implemented. Redbridge Community Housing Limited currently has a block contract with Essex County Council. This means that currently the people who use the service are funded through Essex County Council. There are no privately funded placements. Each person had a statement of their individual terms and conditions and these are reviewed and adjustments made annually or as required. A person moved into the service in December 2007 and the AQAA tells us that “His introduction to Pinewood (where he lives) involved initial visits with family and Social Workers. A needs assessment was carried out to ensure that the home would be able to support his needs with input from family and professionals. There were graduated overnight stays to ensure that both he and the other Service Users were happy. The views of existing Services Users were sought and were recorded in the daily summary of his application form”. The AQQA continues to confirm that “Professional input from speech therapy for particular Service User has been on-going but speech therapist has attended staff meeting which has resulted in pictures being displayed to help SU identify individuals and addressing his anxiety by providing additional information for his day service. The Service Users Personal Profile has also been updated so he now has a Communication Book to ensure that all staff are consistent in their approach when communicating to him and supporting him on a day to day basis”. The AQAA also identifies that the service is able to highlight its own developmental areas and is stating that over the next twelve months it is aiming to “Improve range of Service User Friendly documentation including Service User Contract and Moving In pack”. During the inspection evidence was seen of the involvement of specialist services seeking better outcomes for the individuals. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. 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. People can be assured that staff have detailed information available in order to meet their needs, however the information is not always detailed in a care plan which may lead to possible risks for the individual. EVIDENCE: A total of two care plans were case tracked fully. It was established that people who use the service receive personal and healthcare support, which is suitable to meet their needs. Personal healthcare needs including specialist health and dietary requirements are recorded in each person’s care plan. The care plan provides information and a guide for staff to know how to support the person. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 13 The care plan is generated from the pre admission assessment and includes guidelines, risk assessments for the management and control of a range of issues, manual handling and where appropriate behavioural support guidelines. It was observed that the service reviews a detailed needs assessment on an annual basis and this linked with the care plans in place provides adequate information in order for the staff to know who to meet some ones individual need. Discussions occurred with the manager of the service regarding the expansion of the care plans as it was identified in two people’s assessments of need that important information was contained However this had not been transferred onto a care plan. Examples of this included one person having a health condition, epilepsy and autism, but the information contained within the care plan was sparse. It was established that the service relies on the details held within the assessment of need to ensure that a holistic picture of all need is held. A further example identified showed that the assessment of need stated “tends to eat too fast but seems to cause no problems. Needs high fibre diet to avoid renal impairment. Advised to cut out all red meat and foods high in potassium. To drink only water / tea / coffee”. Under this section the assessment then allows the assessor to tick a box stating whether a care plan is needed to be in place. On this occasion the box had been ticked stating that a support plan was not needed. One person using the service commented, “Its nice here and there are always plenty of people to talk to. The staff help care for us, they do a really good job to”. The AQAA states that “Each Service User has their own individual person centred Support Plan which is developed as a result of their assessment of need when they move in. They are developed with the input of the Service Users, staff, other professionals and parents and carers if appropriate. Support Plans are reviewed annually or when there is a recognised change in need. All Service Users Support Plans are accessible and available at all times”. It was identified that some of the care plans were due for a review. The manager agreed that a full review of the care plans would be completed to ensure that they were reviewed, up to date and current. It was observed that personal support is responsive and tailored to meet the individual choices, needs and preferences. Staff were observed to respect the privacy and dignity of all people. The service listens and responds to individual choices and decisions about who delivers their personal care. People are supported and helped to be independent and can take responsibility for their personal care needs. Risk assessment are in place for a number of issues where control measures may be required to be identified and implemented in order for the individual to Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 14 take risks as required. Risk assessments held on the files case tracked included, fire safety, personal hygiene, transport, swimming, community access, road safety and a financial risk assessment. Other risk assessments are in pace as required. The AQAA states that “The service has a positive attitude towards risk and each Service User has comprehensive Risk Assessments in place to reflect their individual life styles and preferences. Risk Assessment policy promotes the Service Users best interest at all times”. The service has also identified areas of improvement in relation to introducing person centred plan (PCP). Staff have recently attended training on person centred planning and the service is aiming to cascade this training to all staff and commence implementing the process. The AQAA states that “Using the resources available through the new funding for the multi-media PCP, to ensure that key staff receives the appropriate training and that the PCPs are fully developed with complete Service User involvement. During the inspection it was directly observed that confidential records were being stored appropriately. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 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. 12, 13, 15, 16 & 17. People who use the service are provided with support to make choices about their lifestyle and to develop their life skills. EVIDENCE: People who use the service are supported to enjoy a full and stimulating lifestyle with a variety of options to choose from. Staff members were able to report that people who use the service were supported to attend various clubs, go to the theatre, Cinema, swimming, trampolining, bowling and many other activities. The people who use the service have opportunities at internal meetings to voice their wishes regarding social events and all other issues they wish to discuss. On the day of the inspection one person confirmed that they were going out shopping and for a coffee, whilst another person was being Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 16 supported to attend an appointment followed by lunch in the community and trampolining in the afternoon. Six of the eight people who use the service were also accessing further activity sessions and day care provisions. Most of the people who use the service had chosen and arranged their annual holidays with the support of the staff team. The manager confirmed that a range of holidays had been booked this year based on the wishes of the individuals. Two people were visiting Keswick on an activity holiday experiencing cannoning and abseiling; two people were also visiting centre parks, whilst other people had chosen to visit the Isle of White and the tea rooms. One person using the service stated that “I am going shopping today to buy a new duvet and to have a cappuccino”. The service sought the views of the people who use the service and their representatives and considered these when planning the routines of daily living and arranging activities. Routines and activities were flexible and focused around individuals changing needs and choices. It was pleasing to observe that a number of people who use the service have been supported to access services through a range of means. For example two people receive direct payments and with support from representatives, they purchase staff to support them in accessing the community when they choose, using a programme of activity that they have been at the centre of devising. Meals were well balanced and nutritional, catering for the varying choices and dietary needs of the people living at the service. Food stocks were of good quality and in appropriate quantities. The people who use the service selected the weekly menu with the aid of picture books. One house had a ‘rise and fall’ sink enabling people who use the service in wheelchairs to participate in food preparation. One person using the service stated that “the dinners are really nice and I especially like scampi”. One person using the service stated that “I like going into the garden, especially when there are flowers in it”. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. 18, 19 & 20 People who use the service can be assured that their health and well being is maintained, however systems for recording health needs could be better, minimising risk. EVIDENCE: Individuals files included information of individuals health needs and how these were to be met, however the information was contained within a variety of sources such as the daily records, the assessment and the care plan. The manager stated that a number of the people who use the service have complex health issues. Whilst it was identified that holistically information was available, it was not presented on all occasions within the care plan which may result in important information being missed. The delivery of personal care was individual and flexible according to changing needs and preferences. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 18 Personal care and support was provided in private and by a person of the same gender where possible. Guidance and support is provided with personal hygiene tasks where required although where people are able to attend to their own personal hygiene needs they were encouraged to do so. External specialist support services are accessed as required. Evidence was held on the individuals file regarding outreach services. The service does not currently have Health Action Plans in place, however at the time of the inspection the manager spoke about the progress being made with their implementation. Medications were stored appropriately in locked cabinets in both houses. Medication administration records viewed at this visit and were satisfactorily maintained. A small number of gaps were identified and brought to the attention of the manager. The manager discussed recent issues that have been occurring at the action that is being taken to resolve these issues. A number of notifications have been received by the Commission in relation to medication errors that have occurred. During the inspection it was noted that a number of staff have been reassessed in medication practices and that external training has been brought forward. The manager confirmed that disciplinary procedures are being implemented for continued failure to follow company policy and procedures. The service operated a system of double-checking the medication administration routines to further protect the health and well being of the residents. A number of bottles and box’s were observed to not have the date of opening added and where a homely remedy had been administered, the Medication Administration Record (MAR) had not been double signed where a hand written entry had been made and the balance of the medication was not carried forward, making it very difficult to complete any audit of the medication. Temperatures of the room were not being recorded to ensure that medication was being stored in the correct environmental conditions, however the manager stated that these were commencing on the 1st May 2009 and presented the inspector with the template forms ready to implement. The service had a reviewed medication administration policy and procedure in place. The AQAA states, “Services Users all have access to health care professionals. All Service Users have their own GP, dentist and domiciliary opticians. Service Users also access chiropodists, physiotherapists, OTs, speech therapists, community nurses as necessary. The service maintains positive contact with these health professionals and staff support Service Users to attend appointments and respect confidentiality”. During the inspection documents were seen of records where people had been supported to attend specialist clinics and relevant health professionals. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 19 A staff member commented that “I love working with the service users, I think it’s an absolute pleasure and a privilege to work with people, it’s a lot of fun and we have a good staff team”. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. 22 & 23 The service has a robust compliments and complaints procedure in place. People who use the service can be assured that their concerns are listened to and acted upon. EVIDENCE: The service has an open culture, which allows people to express their views and concerns through a variety of methods. Feedback gained from one of the people who uses the service confirmed that they are aware of what to do if they are unhappy and wish or wish to make a complaint. The individual stated, “If I was unhappy I would go to the office and talk to the staff, they would mostly always sort it out”. The service has a clear complaints policy and procedure that was available in the hallway of each house. It was reported that the service had not received any complaints. The manager reported that any points raised by the people or their representatives were addressed immediately and therefore never appeared as complaints. A discussion was held regarding the recognition of complaints and the positive way in which they could be used as tools to drive the quality of service provision forward. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 21 The service understood the procedure for safeguarding vulnerable adults. Training in the safeguarding and protection of vulnerable people is scheduled for June 2009. The policies and procedures relating to recruitment promotes the safety of the people who use the service through the completion of an enhanced Criminal Records Bureau (CRB) disclosures and two written references before a new staff member starts work at the service. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. 24, 25, 26, 27, 28, 29 & 30. The service provides a suitable, safe, hygienic and homely environment for people to live in, ensuring that their independence, personal preferences and choices are acted upon at all times. EVIDENCE: The service continues to be of a good standard and it is homely, clean, and safe and truly reflects the individuals’ needs by design and adaptations provided. The people who use the service are fully involved in decisions about the decoration of the service and furniture this includes individual bedrooms and all communal areas. Individuals choose to meet with families or friends in communal settings or privately. They also have access to a payphone where they can make calls confidentially. Individuals have full access to all facilities, enabling their independence to grow. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 23 The AQAA indicates that the service continues to make improvements. It states that the following improvements have been made over the past twelve months. “We have now fitted magnetic closures to all doors thus improving fire safety and increasing access to areas including bedrooms. A number of these were observed during the inspection. Cleaning of all carpets in both homes occurred professionally in December 2008 to maintain appearance and promote infection control. We updated necessary risk assessments to meet needs of Service users in relation to health & safety in the home and in the community. Bedroom was decorated to meet needs of an individual in Hollywood”. One person using the service stated, “I like my room and I always like to keep it tidy, the staff help me”. The outdoor space available is of a good size and enables people to move around freely. The garden is mature, the manager stated that they receive support from the probationary service with the up keep and maintenance of the garden area. On the day of the inspection the garden appeared untidy with large weeds growing and the grounds generally appearing unkempt. The manager stated that they are purchasing new garden furniture soon. One person using the service commented that “I like going in the garden when there are flowers in it”. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): 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. 32, 34, 35 & 36 The service employs robust recruitment procedures and appropriate numbers of inducted and trained staff to ensure that the residents are in safe hands at all times. EVIDENCE: People who use the service appear to have confidence in the staff who care for them. Rota’s show well thought out and creative ways of making sure that the service is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Staff members undertake external qualifications. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 25 There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for individuals and is not led by staff requirements. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people in a person centered way. There is a structured training plan in place and the forth coming training includes, fire safety, health and safety, medication, first aid, mental capacity act, person centered planning, infection control and safeguarding people. The AQAA states that “The service has an experience multi-skilled workforce that strives to provide the best possible quality of service to its Service Users. The service has robust recruitment policies and procedures and Service Users are fully involved in the processes. There is training available for Service Users in recruitment and Service Users have developed a ‘staff criteria’ and their own set of questions, which reflect what Service Users want from their staff. All staff are required to provide satisfactory references and CRB checks before they commence employment. Four staff files were reviewed on the day of the inspection and were seen to hold all the required documentation. There is a robust probationary period to ensure that staff is able to achieve the desired level of competency. A comprehensive training and development program is in place which not only addresses the mandatory training needs for new staff but also provides professional and development opportunities for all staff. The service also accesses external bespoke training for the service when necessary. The training program provides courses that are relevant to staff in their attainment of the LDQ, NVQ qualifications and Common Induction Standards. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Staff recruited confirm that the home was clear about what was involved at all stages and was robust in following its procedure. A random selection of staff files occurred and were complaint with the National Minimum Standards”. One staff member commented that the team is well managed, supported, caring and are genuinely interested in supporting the people who live here. In addition to this the staff member commented that I can’t fault the manager, she is very open and very very good”. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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): 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. 37, 38, 39, & 42 Appropriate leadership, guidance and direction means that the service is managed in the best interests of the residents. EVIDENCE: The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager is able to describe a clear vision of the service based on the organisations values and corporate priorities. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 27 The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of best practice operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centered thinking are given priority by the manager who is able to demonstrate a high level of understanding and demonstrate best practice in these areas. The AQAA received from the service also determines that they are planning to make improvements in the provision of person centred planning and training. The ethos and leadership style of the service supports and enables people to express their diversity needs including their race, gender, sexuality and age. The manager is able to demonstrate through robust operational systems and professional experience that they are knowledgeable and highly competent in a range of areas. The manager ensures that staff follow the policies and procedures of the service. Practice and performance are discussed during supervision, staff training and team meetings. One member of staff commented and confirmed that these areas are explored in these one to one and group sessions. There is strong evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are listened to, and valued. The AQAA contains good information that is fully supported by appropriate evidence. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to the people who use the service. The service demonstrates a high level of self-awareness and recognises the areas that it still needs to improve, and has clearly detailed the innovative ways in which they are planning to do this. The service has efficient systems to ensure effective safeguarding and management of residents’ money and valuables, including record keeping. People are supported to manage their own money where possible. Those who do not currently have the skills are encouraged and supported to develop to become as independent as possible. They have access to their records whenever they wish. Record keeping is of a consistently high standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Risk assessments have recently been introduced regarding financial management and risk for all individuals. The service has a comprehensive range of policies and procedures to promote and protect residents and employees health and safety. There is full and clearly written recording of all safety checks and accidents. The manager, senior team, and staff at all levels have a good understanding of risk assessment processes which is underpinned by promoting independence, choice and autonomy. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 28 These principles are taken into account in all aspects of the running of the service. The manager ensures that all staff are trained in health and safety matters. Individual training records reflect this and regular updates are planned ahead. The AQAA states that The manager has been employed at this project for six years and has continued to develop her experience and skills to effectively run the registered home and meet the aims and objectives organisationally and locally. We develop budgets for the home, which is fit for purpose, reviewed annually and in line with current service users needs. The manager works in partnership with senior management and finance department of RCHL to ensure budgets are planned managed efficiently and provide value for money. We ensure the management of the home is clear to all service users and that best practice occurs adhering to RCHL core values and standards and current legislation. The manager obtains feedback from service users, relatives and day centre to ascertain if service delivery is being met and how improvements can be made through questionnaires and informal discussions. We are internally audited and these reflect the running of the home is service user lead and best practice does occur to meet the diverse needs of service users. They also demonstrate that policies and procedures are adhered too e.g. Regulation 26 visits, quality assurance audits and financial audits. training of staff is focused led on needs of projects aims and objectives and organisationally e.g. equality and diversity, health and safety are two examples. We have ensured service users manage their own monies within their capabilities and financial risk assessments have been reviewed and demonstrate this. We can also demonstrate safeguards by appropriate record keeping e.g. safe book, resident monies book and checking bank statements”. Lockable storage is available for people if they choose. One person using the service commented that “the staff and the manager are very good, and kind to me”. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X X 3 X Version 5.2 Page 30 Pinewood & Hollywood DS0000017910.V375190.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Care plans must be a stand alone working document and be detailed, containing all information relevant to the individual. To ensure that all staff are able to provide care and support as required. Care plans must detail any limitations and or infringements made on the individual. Where monitors are used in a person room, consent must be gained and detailed within the care plan and risk assessment. To ensure that the rights and choices of the people using the service are supported and empowered. A Health Action Plan or suitable care plans must be in place for all people to identify, record and review a person health and possible deterioration in health. Timescale for action 31/07/09 2 YA6 15 31/07/09 3 YA19 12 31/07/09 Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 31 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 3 4 Refer to Standard YA24 YA20 YA20 YA20 Good Practice Recommendations The garden should be maintained. Hand written entries on the Medication Administration Record should be double signed. Balances should be carried forward on all medication used from one month to the next in order to ensure accurate stock balances at all times. Date of opening should be added to all bottles and box’s upon opening. Pinewood & Hollywood DS0000017910.V375190.R01.S.doc Version 5.2 Page 32 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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