Care Home: Pinfold Lodge Nursing Home

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What the care home does well People have very detailed care plans in place which helps them receive the care they want. Health care professionals are asked for their input and specialist equipment is available to make sure that people’s health care needs are fully met. Activities are provided that are suitable to meet people’s preferred needs so they have a more interesting and fulfilling life. People’s social needs are assessed thoroughly using a specific auditing tool to make sure that people receive the social stimulation they need. Robust recruitment procedures are in place so that people are looked after by members of staff who are suitable to work with vulnerable people. The management team have implemented thorough ways of running the home and have put into place excellent audits to make sure that the services being delivered are of a consistently high standard to meet people’s needs. People spoken with and people who were surveyed said: ‘The home is always clean. I am well looked after. If I need anything there is always someone there. I like playing the games and activities.’ ‘The staff look after me and they care.’ ‘The staff are good they are involved. I feel as though they build up friendships with you, the carers care for me and it feels lovely.’ ‘The girls are very good, the staff are here when you need them, and on the whole I am very happy.’ What has improved since the last inspection? Full pre admission assessments are carried out before people are offered a place in the home. Where necessary care plans are gained from Care Managers to make sure people’s needs are known and can be met. The home’s care plans have been redeveloped to make sure they reflect people’s needs. People or their chosen representatives are asked to take part in this process so that all parties agree the information in the care plans and are kept well informed. Risk assessments are kept up to date and specialist equipment is provided to help maintain people’s health and well being. People’s privacy and dignity is maintained when personal care is being delivered.Pinfold Lodge Nursing HomeDS0000028007.V377035.R01.S.docVersion 5.2Medication procedures have been developed and items are stored appropriately to make sure that medication procedures protect people’s health and wellbeing. Documentation about the complaints received has been developed so that it is robust. People are informed about the outcome of all complaint investigations so that all parties are kept well informed. The environmental issue about flies being found around the home has been rectified and continues to be monitored to make sure the home remains pest free. Gaps in potential staffs employment histories are fully investigated to make sure that people are protected from staff who may not be suitable to work in the care industry. What the care home could do better: Menus should be displayed so people know what variety of food available to them. Staff should receive formal supervision at least six times per year to make sure that they continue to develop their skills. Key inspection report CARE HOMES FOR OLDER PEOPLE Pinfold Lodge Nursing Home 6 Sheepdyke Lane Hunmanby Filey North Yorkshire YO14 0PS Lead Inspector Denise Rouse Key Unannounced Inspection 30th July 2009 09:00 DS0000028007.V377035.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. Pinfold Lodge Nursing Home DS0000028007.V377035.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 Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinfold Lodge Nursing Home Address 6 Sheepdyke Lane Hunmanby Filey North Yorkshire YO14 0PS 01723 891069 01723 892575 denisemedd@btconnect.com 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) Complete Care Homes Ltd Vacant post Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 34 The maximum number of service users who can be accommodated is: 34 6th August 2008 2. Date of last inspection Brief Description of the Service: Pinfold Lodge provides personal and general nursing care and accommodation for up to 34 people over 60 years of age. It is in Hunmanby village and is within walking distance of the local amenities. It is a detached house situated in its own grounds with parking facilities for visitors and staff. The accommodation is provided in both single and double bedrooms over two floors. Double rooms are normally used for single occupancy. There are two passenger lifts and level access to and around the home, which provides a large communal sitting area and separate dining room. There is an assisted bathroom on each floor. The service user guide, statement of purpose and last inspection report is available for people to read so that they can make an informed decision about if the home can meet their needs before they are admitted. On 30 July 2009 the weekly fees charged ranged from £525.00 to £527.55 plus Funded Nursing Care. Extra costs include private hairdressing and chiropody. Pinfold Lodge Nursing Home DS0000028007.V377035.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. This means the people who use this service experience Good quality outcomes. This is what was used to write this report. • • • Information about the home kept by the Care Quality Commission. Information received in the homes Annual Quality Assurance Assessment (AQAA).This is information the manager provides about the home. A visit to the home undertaken by one inspector, which lasted from 9:15am until 15:15pm. This included talking to people who live at the home and to some relatives who visited. The inspectors spoke with staff from all departments, to the manager and general manager. Some policies and procedures were inspected as well as care profiles, staff files, complaints information and some personal allowance accounts. The inspector undertook a tour of all areas of the home and spent time watching the general activity to get an idea about what it was like to live at Pinfold Nursing Home. Mealtimes were observed. Information from 9 surveys received from people living in the home, from 4 staff and 2 health care professionals. • • At the last inspection on 6 August 2008 Denise Medd who was the deputy manager was overseeing the day to day management of the home with the support of the general manager. Ms Medd has now been appointed as the home manager. Feedback about what was found during the inspection was given to the manager and general manager of the company at the end of the inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 6 What the service does well: People have very detailed care plans in place which helps them receive the care they want. Health care professionals are asked for their input and specialist equipment is available to make sure that people’s health care needs are fully met. Activities are provided that are suitable to meet people’s preferred needs so they have a more interesting and fulfilling life. People’s social needs are assessed thoroughly using a specific auditing tool to make sure that people receive the social stimulation they need. Robust recruitment procedures are in place so that people are looked after by members of staff who are suitable to work with vulnerable people. The management team have implemented thorough ways of running the home and have put into place excellent audits to make sure that the services being delivered are of a consistently high standard to meet people’s needs. People spoken with and people who were surveyed said: ‘The home is always clean. I am well looked after. If I need anything there is always someone there. I like playing the games and activities.’ ‘The staff look after me and they care.’ ‘The staff are good they are involved. I feel as though they build up friendships with you, the carers care for me and it feels lovely.’ ‘The girls are very good, the staff are here when you need them, and on the whole I am very happy.’ What has improved since the last inspection? Full pre admission assessments are carried out before people are offered a place in the home. Where necessary care plans are gained from Care Managers to make sure people’s needs are known and can be met. The home’s care plans have been redeveloped to make sure they reflect people’s needs. People or their chosen representatives are asked to take part in this process so that all parties agree the information in the care plans and are kept well informed. Risk assessments are kept up to date and specialist equipment is provided to help maintain people’s health and well being. People’s privacy and dignity is maintained when personal care is being delivered. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 7 Medication procedures have been developed and items are stored appropriately to make sure that medication procedures protect people’s health and wellbeing. Documentation about the complaints received has been developed so that it is robust. People are informed about the outcome of all complaint investigations so that all parties are kept well informed. The environmental issue about flies being found around the home has been rectified and continues to be monitored to make sure the home remains pest free. Gaps in potential staffs employment histories are fully investigated to make sure that people are protected from staff who may not be suitable to work in the care industry. 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. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 8 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 Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 9 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): Standard 3 (6 not applicable) 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 have benefited from the better admission procedures and documentation in place. People have their needs fully assessed and considered by the home before a place is offered to them. EVIDENCE: Before an admission is agreed the manager considers the needs assessmant for the prospective person and the capacity of the home to meet their needs. Information is gathered from discharging hospitals and care managers to make sure that people’s needs are fully understood. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 10 The manager spends a lot of time with people who are considering moving into the home to answer any questions they may have. People are invited with their family to look round and are invited to spend some time in the home before reaching their decision. If the person cannot visit the home an appropriately trained member of staff goes to see them to carry out the assessment and answer any questions they may have. Information is available in the service user guide, statement of purpose, last report and home brochure. This helps people understand what services the home can offer them so that they can decide if this is the right home for them. A named nurse is allocated to the new admissions to help them settle into the home. Contracts are issued and signed by all parties to make sure people understand the terms and conditions of residency. Where necessary advocates are used to make sure that people’s rights are protected. Relatives spoken with praised the staff for making them so welcome and providing them with all the information they needed to make an informed choice that this home was the right home for their relative. They said ‘ We did visit other homes, we chose this place as it was friendly and clean. Not having experienced looking for a care home before, we looked at the last inspection report.We then decided to just drop into the home unannounced. We were made very welcome. We were given enough information about the home and were shown round. We knew as soon as we walked in this was the right place. Staff cared about people and the rooms were spacious. We cannot speak highly enough about this home.’ Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 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 have very detailed highly personalised care plans in place which helps to make sure that their health care needs are well met. Medication systems are robust and this helps to protect people’s health and wellbeing. EVIDENCE: Care plans are very detailed and are personalised to each individual’s needs this helps to make sure that people’s needs are fully understood and are met. The care plans are living descriptions of what each person feels is important to them, they are created in consultation with the person receiving care by the persons named nurse. Care plans are reviewed with the person or their chosen representative each month or their need’s change to ensure people feel involved and to make sure people’s independence is protected. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 12 More detailed reviews take place after a period of time to see if the home is still meeting people’ s needs and providing their long term goals. People are asked if they wish to take part in these reviews. A student social worker has been involved in this process and has gained consent from people to carry out these reviews which are very detailed. Family members have been sent questionnaires so if they are not able to attend the review they can still give their input providing extra information and helping all parties to feel valued and listened to. All staff including laundry, domestic and kitchen staff attend shift handover reports so that all the staff are aware of everyone’s needs so the people can be fully supported. Night care plans are in place so that staff are aware of how people like to be cared for during this time. Time is taken to match the home’s resources to each persons needs. Special equipment is provided where necessary to make sure that people’s health is protected. Very detailed special assessments are undertaken to help protect people who may be at risk from falls or may have skin care issues. All relevant health care professionals are contacted to make sure that each person receives the best support to resolve issues positively, and make sure that people’s health care needs are met. Some health care professionals have given further training to staff and this helps to make sure that that good practice is developed within the home. Health care professionals visit the home, or staff accompany people to appointments where necessary to make sure that people see the specialists who can help them. Two health care professionals completed surveys, comments received included: ‘Communication with staff in the home and the visiting health care professional is good. The home endeavours to provide a real “homely” yet professionally supported atmosphere. Pinfold Lodge’s staff are all able to give a good account of patients’ present problems and issues. It is a good home.’ Risk assessments are individualised and are in place for risk of falls and the use of bed rails. Where there is supporting documentation i.e. referrals to fall clinics, the referral document is on file next to the risk assessment. This makes sure that the information is easy to read and staff can see what has taken place to help protect people’s health and well being. No one presently living in the home looks after their own medication. However, locked facilities are provided if anyone wanted to in the future, and it was agreed that it was safe for them to do so. Trained staff handle people’s medication, which is kept safely locked away. Medication balances are recorded thoroughly and all items are stored correctly. The supplying pharmacy undertakes an audit and the management of the home also regularly audits their systems. Any shortfalls found are addressed this helps to make sure that the medication systems in operation in the home are robust. Pinfold Lodge Nursing Home DS0000028007.V377035.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): Standards 12, 13, 14 and 15. 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. Care continues to be taken to meet people’s social needs in a range of ways, and choice and individuality are seen as important in their lives. EVIDENCE: People are supported to make decisions about how they want to live their life. They follow their own chosen routine and activities are made available to them which are varied and match their preferred activities. There are televisions in the communal areas and music is available in the lounges and dining areas for people to enjoy. Everyone has a social care plan which gives information about their preferred routines and social activities. There is an activities co-ordinator in place. She is keen and enthusiastic about her role she spends time to get to know people’s needs well and then produces activities which are suitable for people to take part in; this makes sure that people’s social needs are known and can be developed. A special assessment tool is used when planning activities so that the activities better suit people’s Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 14 different levels of ability. Management are now working on providing more joint activities with the other homes in the group. A student social worker is creating individual activity programmes for people who are less able to join in group activities to make sure people gain social stimulation. An activities programme is available and there are group sessions held for people as well as one to one activities undertaken. There have been local outings to take people to the shops or local pubs. Special occasions such as birthdays are celebrated and Valentines Day and Easter were celebrated with decorations and special food. Entertainers visit the home and there is a summer fayre being organised for August. Relatives spoken with said ‘The activities are good, they get XXX to play snakes and ladders and do different things, which helps to stimulate the mind and body. Staff includes everyone in activities if they want to take part.’ People who prefer to stay in their bedrooms are visited by the activities coordinator and all activities are recorded so that there is a record of the activities that are undertaken. People who are frail and who cannot communicate have one to one activities which can include a hand massage, so that they gain the stimulation they need. People are encouraged to maintain contact wherever possible with their family and friends and the local community. Visiting is open and people are made welcome at any time. Visitors spoken with said ‘We are delighted with the home; we can come in to see our relative any time we wish. Staff always makes us feel welcome.’ One relative has provided a flower arranging activity which was enjoyed by all people who took part. Members of staff are keen to continue to improve on the social activities in the home and one member of staff said in their survey ‘If we had more money for social activities we could get more people in to entertain the residents or even take them out more often. We have to make our own money at events such as the summer fayre to pay for all activities and craft equipment.’ The management team may wish to consider how they could address this issue. People’s religious needs are known and provided for by local clergy who visit the home on request and a service is held at the home every 6 weeks by a lay preacher and congregation. A chiropodist and hairdresser also visit to provide their services to people for their convenience. Resident and relative meetings are scheduled to be held. However no relatives attended the last meeting. Staff ask visitors for their views when they visit the home so that informal information is gained to see if people are happy with the service being provided. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 15 The kitchen was inspected. The food looked appetising and nutritious. Special diets are catered for and supper is available. However currently the menu is not displayed and this should be so that people know what food is available to them. Three people who live at the home who completed surveys said that they ‘sometimes’ liked the food. This was discussed with the management team. A new menu is being created to help resolve this issue and this will be displayed after being created. Special crockery and cutlery equipment is provided for people who need this to help them eat independently. People who need assistance are fed by patient staff in an unhurried manner so that their nutritional needs are met. Meals can be taken in the dining areas or in people’s own bedrooms, whatever people prefer. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 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. People are confident that their complaints will be listened to and acted upon. EVIDENCE: The complaints procedure is available to people living in the home. People spoken with said that they would be happy to speak to the manager or to staff if they had a complaint; they said they felt safe and supported. Nine people living at the home who completed a survey said they knew how to make a complaint and felt that issues would be addressed. Staff have received safeguarding training. Those spoken with all had an understanding of the different types of abuse and the action they must take should they suspect abuse had taken place. The manager is familiar with the local procedures and understands how to report a safeguarding incident. This helps to protect people from harm. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 17 People have information available to them about Advocacy and the home actively assists people to gain independent representatives to help support them where necessary. Every person living in the home has had a completed Deprivation of Liberties assessment undertaken. These have been looked at by the local authority and have helped to make sure that people’s independence and rights are protected. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26. 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 live in a well maintained home, which meets their needs. Infection control measures are in place to help protect people. EVIDENCE: The home is warm homely and inviting. There is a secure door entry system in operation to help protect people. There is an ongoing maintenance programme operating in the home which helps to make sure that the home is safe and well presented for people to live in. Since the last inspection a new patio has been created which has disabled access and there is garden furniture so that people can enjoy sitting outside. New light fittings have been fitted to bathrooms and bedrooms and eleven bedrooms have been redecorated this year including Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 19 upgrading the en suites to 6 bedrooms in the old wing. The bedrooms are re decorated when they fall vacant and people can personalise their room to make them feel at home. There is a variety of communal lounges and dining areas which people can use. Passenger lifts are available to allow people to access all areas of the home. Hand wash facilities are available throughout all areas of the home this helps to maintain infection control. The laundry was inspected some areas of the laundry walls required filling and skirting boards were required to be fitted as some machinery had just been replaced. This work was due to be completed. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. 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 are looked after by a competent, well trained staff team. EVIDENCE: Management consider the skill mix and deployment of staff within the home to make sure that people receive the care they want when they need it. Recently more staff have been recruited to help make sure that people were provided with continuity of care. One member of staff said ‘Things are more settled, we are at the tail end of recruiting, we have managed to meet people’s needs, and the carers really put themselves out.’ People spoken with said staff were available when they needed them. Staff spoken with said ‘I love it here, everyone works as a team, the staff are cheerful and this rubs off on to the residents.’ The home carry out robust pre employment checks and this helps to make sure that only staff who are suitable to work with vulnerable people are Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 21 employed. Gaps in employment histories are checked out. If necessary third references are gained to make sure that the applicants are suitable. An equal opportunities policy is in place to make sure that the recruitment process is thorough and non discriminatory. Induction training for new staff includes information about how to protect people from abuse, which helps to keep people safe. Currently 50 of care staff have achieved a National Vocational Qualification in Care at Level 2 or 3. The home continues to support staff to work towards achieving this award to develop their skills and knowledge. Staff have received training in moving and handling, safeguarding adults, infection control, fire safety and dementia awareness. This helps to make sure that staff have the skills they need to support people. Staff meetings are held so that staff have an opportunity to voice their opinions. Their views are listened to and acted upon. Staff are encouraged to identify their own learning needs. They said there was always plenty of training being provided to help keep their skills up to date. However staff supervision was not up to date for all staff and this was discussed with the management team, who were aware of this and were beginning to address this issue Staff said in surveys they completed: ‘Training for the staff has been improved, and efforts have been made to include the night staff to a greater extent. The home is changing and many new improvements are being made. At this moment in time I feel we are actively trying to improve the home and all grades of staff are being asked to contribute.’ And ‘At Pinfold Lodge we do take advantage of courses to improve our knowledge and skills. We do try our best to provide a good service to people in our care.’ Also ‘Management keep us informed as to what is going on, they inform the staff and the residents and relatives as well. New things come in all the time and are rolled out to us as soon as possible. I enjoy working in this home.’ Health care professionals are invited to the home to deliver training on specialist subjects to help develop the knowledge and skills of the staff, this is good practice. People living in the home said ‘The staff are good they are involved. I feel as though they build up friendships with us, the carers care for me and it feels lovely.’ And ‘The girls are very good, the staff are here when you need them, on the whole I am very happy.’ Relatives spoken with said ‘We cannot speak highly enough of the care, staff interaction is very good, staff show an interest and understand each person’s personality, and this is reassuring. The staff are lovely; we could not have made a better choice of home. If you have trust in the staff you can sleep at night.’ Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 and 38. 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 benefit from a well maintained and well managed home that improves its services by asking for people’s views, and acts upon them. EVIDENCE: At the last inspection on 6 August 2008 Denise Medd the deputy manager was responsible for the day to day management of the home with the support of the general manager. Arrangements were not seen to be detrimental to the service that people were getting. Denise Medd has now been appointed as the home manager. She is aware that she needs to apply to be registered with the commission and we have been advised by the general manager that she has Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 23 started this process. People spoken with who live at the home, staff and relatives were all positive about the new manager and said she was friendly and approachable and keen to improve how the home ran. The management team have introduced extremely thorough audits to monitor how well the home is running. The management team have a good understanding of the needs of people using the service and they have prioritised improvements for people who live there. Every three months surveys are sent to people living in the home, or to healthcare professionals, staff or family members to ask for their opinion about how the service is operating. The results are summarised and are available for people to look at. Relatives and residents meetings are scheduled to make sure that people have an opportunity to put their views forward. There is information made available to people in the home about deprivation of liberties, advocacy and local health care provision. Information leaflets are also available about the Care Quality Commission and the work that we undertake. This helps to keep people informed. The management team are always looking for new ideas to improve the service for example: all staff, including ancillary staff attend shift handovers so that they are kept up to date about people’s current needs. Personal allowance accounts were inspected. Receipts are kept of transactions and all balances checked were correct. Health and safety checks are undertaken to make sure that hot water temperatures supplied to people’s bedrooms are suitable to protect people from the risk of scalding. Regular checks are undertaken of the fire alarm system to make sure that it is working effectively. Fire drills are undertaken to make sure that staff are very proficient in the actions they must take to help protect people in the event of a fire. The home is maintained and a rolling programme of improvements are undertaken to make sure that the home remains pleasant for people to live in. Pinfold Lodge Nursing Home DS0000028007.V377035.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 2 X 3 Pinfold Lodge Nursing Home DS0000028007.V377035.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 2 Refer to Standard OP15 OP36 Good Practice Recommendations The menus should be made available to people once they have been updated to make sure people are aware of the variety of food available to them. Staff should receive formal supervision at least six times per year to make sure that they continue to develop their skills. Pinfold Lodge Nursing Home DS0000028007.V377035.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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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