Care Home: The Pines

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What the care home does well Prospective people who use this service can expect to have their needs assessed before they move in and will ensure the service can meet their needs. People were provided with a contract and agreements were established. A resident spoken with confirmed they liked the home. The home enables residents to maintain an appropriate lifestyle with individual opportunities and support. All the feedback from residents was positive about this. A relative spoken with said that there were sufficient staff to support her relative appropriately. Residents were aware of how to complain and felt that they were listened to. The Pines was a clean and comfortable home, very spacious with large grounds. The whole home was nicely decorated and well equipped and met the needs of the current resident group. What has improved since the last inspection? What the care home could do better: There are 3 areas that the home needs to develop. The first is evidence of staff identification should be retained and be available for inspection at any time. This is to ensure appropriate staff support the residents through a robust recruitment procedure. Secondly, the kitchen lights in the flat should have shades and the bathroom should have a blind to ensure the comfort and privacy of the residents. And finally policies and procedures should state when they were reviewed, to assure that they contain the best up to date advice for staff. CARE HOME ADULTS 18-65 The Pines 2 Flint Cottages Culford Road Fornham St Martin Suffolk IP28 6TH Lead Inspector Claire Hutton Unannounced Inspection 21st April 2008 11:00 The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Pines Address 2 Flint Cottages Culford Road Fornham St Martin Suffolk IP28 6TH 01284 705062 F/P 01284 705062 pines@consensussupport.com www.concensusupport.com Caring Homes Healthcare Group Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Matthew Philip Dale Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2007 Brief Description of the Service: Flint Cottages is set in a rural position in a small village outside Bury St Edmunds. It comprises of two buildings: Pines House and Pines House Annex. Pines House provides purpose built ground floor accommodation for 6 residents in single bedrooms, one of which has en suite facilities. Communal space comprises of an open plan sitting and dining area. There is also a first floor flat that at present accommodates one resident. The Annex is attached to Pines house and has an interconnecting door, however, this is rarely used and the two facilities are viewed as separate homes. The Annex caters for residents who are relatively independent and provides four single bedrooms all with en-suite. Communal space is a lounge/diner and a large galley kitchen. The garden is well kept and mainly lawn with a mixture of mature and newly planted trees, flowerbeds and patio areas next to the buildings. There is ample parking for staff and visitors in front of the Annex. Fees for this home currently range from £340.00 to £1519.70 per week. Please see the Service Users Guide for what is included in this price. The Pines DS0000067369.V362889.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 the service experience good quality outcomes. This was an unannounced key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday lasting five hours. The inspection process included visiting all areas of the home, discussions with staff and residents, observations of staff and resident interaction, and the examination of a number of documents including residents’ care plans and associated documents, medication records, the staff rota, records relating to health and safety and records relating to staff recruitment. The report has been written using accumulated evidence gathered before and during the inspection. The Commission had received an Annual Quality Assurance Assessment (AQAA) completed by the manager before the inspection. This is a self-assessment document. Six completed surveys were received back from the eleven residents currently at the home. These were all positive. Three completed surveys were also received back from relatives and friends of the residents. One member of staff was interviewed in private during the visit to Pines; three other staff were met and spoken with in passing. Comments received by people who use this service are used throughout this report. On the first day of this inspection an immediate requirement was left as the hot water temperature from a shower was so hot it presented a possible risk of scalding to the resident who used it independently. On 28th April 2008 the manager wrote to us saying that the shower was to be dealt with on 1st May 2008, ‘Meanwhile, I have put in place a risk assessment with an accompanying support plan to ensure the safety of the relevant Service User is preserved as well as maintaining the individual’s independence’. We visited and tested the shower again on 6th May 2008 and found that the shower was within safe limits. What the service does well: Prospective people who use this service can expect to have their needs assessed before they move in and will ensure the service can meet their needs. People were provided with a contract and agreements were established. A resident spoken with confirmed they liked the home. The home enables residents to maintain an appropriate lifestyle with individual opportunities and support. All the feedback from residents was positive about The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 6 this. A relative spoken with said that there were sufficient staff to support her relative appropriately. Residents were aware of how to complain and felt that they were listened to. The Pines was a clean and comfortable home, very spacious with large grounds. The whole home was nicely decorated and well equipped and met the needs of the current resident group. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 7 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 The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people were assessed, which ensured the service could meet their needs. People were provided with a contract and therefore agreements were established. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. The Statement of Purpose sets out the admission criteria for the home including the trial period that is 3 months. The Service Users Guide has been developed using pictures to make it more accessible to residents. This document has recently been updated and given to all the residents in the home. Two files were examined and both were found to have an assessment in place. This was completed before the resident moved into the home. The manager had completed the assessment, he had gained information from family members and had an assessment provided by the Social Worker. The self-assessment (AQAA) told us, ‘We offer any perspective service user the opportunity to “test drive” the home to make sure they feel, as far as possible, that they are making the right choice and decision, which in some circumstances could be a life changing one’. The resident concerned had a lengthy transition period and spent time at the home before a decision was The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 9 made to move in. A relative was visiting at the time and they said they were very happy with the choice of home. The resident was spoken with and confirmed they liked the home. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had access to up to date information so that they could support people appropriately. EVIDENCE: Two care plans were examined. These were well set out and had relevant up to date information clearly communicated. There were personal pen pictures on each individual, an independent life skills assessment had been recently completed and objectives and needs were set out. Examples of these included budgeting own money, maintaining a healthy diet, maintaining personal hygiene and emotional support. To support these objectives there were risk assessments in place. Examples included cooking and ironing, support needed in the community and evacuation in a fire. All the risk assessments had been reviewed in the last 3 months. The self-assessment told us, ‘A comprehensive package of risk assessments and plans are in place for all service users. They all reflect individuality, The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 11 personal goals, and there outcomes’. It also told us ‘All care plans reflect both cultural, sexual and religious preferences of the individual’. Care plans were signed by each staff member to say that they had read them and understood the plan for each individual. The daily notes made by staff were good as they said the support that had been required that day based around what the plan had set out. There was evidence of recent reviews of care plans with relatives and residents participating along with the key worker, manager and social worker. A relative spoken with said that there were sufficient staff to support her relative appropriately. Throughout the day residents were seen to make decisions about what they did for the day and what meals they ate that day. All these decisions were respected and supported by the staff on duty. The 6 surveys completed by residents said that staff always treated them well and that staff always listened and acted on what the resident said. Staff spoken with were clear how they would promote independence by doing activities like cooking/making drinks with residents and not for residents. They also said that shopping purchases were for the residents to decide and therefore the residents decided upon the weekly food budget with those in the annex taking more responsibility for this. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate opportunities for leisure and personal development were offered and met the needs of the resident group. People enjoyed a varied diet. EVIDENCE: There were four residents at home on the day of the visit, but other residents were out doing a variety of activities. Each person had a different plan in place for his or her leisure, education and meaningful activities. One resident had their own day service that spent 4 days a week supporting them in the activities they chose. Another person had no formal day service but attended a number of events each week and had a very varied time. This included attending a cinema club, a sports club and a social club called ‘a place to talk’. This individual also belonged to 2 different clubs that ran in an evening. Other residents had more formal arrangements in place such as paid work, voluntary work in charity shops, sheltered work placements such as ‘wood n stuff’ and Onward Enterprises. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 13 All six surveys completed by the residents said that they always made their own decisions about what they did each day and that there was plenty to do during the day, evening and at a weekend. On the day one resident had a relative visiting for most of the day and a different resident had been taken out for lunch by two visiting relatives. Personal relationships and relationships with family were seen to be supported. One resident was supported to write to a relative and this was documented. Staff spoken with were aware of how they would promote privacy and dignity for individuals and spoke of knocking and waiting for a response before entering a bedroom and aware of ensuring confidentiality when speaking with residents. In relation to meals and meal times residents have helped develop the menu in place and shop at a local supermarket with staff support. The menu had a 2nd option available on each main meal of the day. Food stocks were good and included plenty of fruit and vegetables. Breakfast was usually cereal and toast. The menu had the hot main meal in an evening when all the residents were at home. Choices included turkey casserole, lasagne and liver and bacon. There was a roast at a weekend. All evidence seen demonstrates that residents enjoy the healthy meals on offer. The self-assessment told us, ‘There is a big emphasis on promoting a healthy lifestyle and diet, while still incorporating fun and meaningful activities. Staff are aware that everyone has individual wishes and views’. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported in a manner suited to their personal preference. Medication practices were sufficiently effective to protect people. EVIDENCE: In each of the 2 care plans examined there was a section for staff to follow entitled personal care needs. This gave the level of support required and the preferred type of personal support required. Staff spoken with were aware of who preferred showers and not a bath and how much guidance was needed. Staff were quite clear that they would be guided by the choices of the resident. The daily statements written by staff stated the amount of support given with any activity (such as attending appointments at the dentist, chiropodist and psychiatrist) and also the general well being of an individual including their mood. Care plans set out how an individuals physical and mental health needs would be met with specific individual plans around managing asthma, emotional support and continence. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 15 One resident had been assessed by the occupational therapist and had been supplied with equipment such as a frame, a raised toilet seat and a shower seat. The self-assessment told us, ‘we ensure that all service users are offered the opportunity to attend the ‘well persons’ clinic at their G.P surgeries at regular intervals. We provide good support to all individuals health needs. We have a good and safe medication system in place, which still allows service users to remain independent. There is a sympathetic and dignified approach to assessing and supporting service users that are aging or have declining health needs’. The medication system was examined. Medication was kept secure. Three residents were supported to self medicate. There were risk assessments in place to support this. There was a procedure available for staff to follow. A simple audit of one person’s medication showed that the correct medication was in stock and that person received the correct medication at the time specified. The medication records were in order and each held a photo of the resident. Staff confirmed they had received both medication and first aid training. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected and their views listened to. EVIDENCE: The home had a complaints procedure in place and this was part of the information given to the residents. The complaints procedure had also been developed in a pictorial format to make it more accessible to the residents. This along with the whistle blowing procedure was displayed on the wall in the dining area. In the 6 surveys returned the residents were aware of how to complain. The relative spoken with said, ‘if I had any concerns I would speak to the manager’. Two of the surveys received back from relatives said they did not know how to make a complaint should the need arise. A log of complaints was in place and showed the concerns and what had been done to resolve matters. The self-assessment told us, ‘All complaints and concerns are taken and acted upon with respect and confidence. We offer the opportunity for service users to voice any concerns they have at residents meetings. The procedure is also reminded to them all’. And also ‘As per recommendations from CSCI reports, we have changed the format in which we record any complaints and where evidence is kept of any investigations or findings’. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 17 In relation to safeguarding the home has the local agreed procedure in place and has had cause to use this since our last visit to the home. Those matters have now been resolved and appropriately recorded. Staff were spoken with and one member of staff had received training in safeguarding. The manager confirmed that he was looking at ensuring all staff had received this training and dates for the following month were planned. All the required safety checks such as CRB (criminal records Bureau) and POVA First (protection of vulnerable adults) were in place for staff to safeguard residents. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Pines provided a clean and comfortable place to live and met the needs of the resident group. EVIDENCE: All three areas of the home were visited, the main part, the flat and the annex. A resident said they were ‘very happy and that it was lovely’. The flat is cosy and meets the needs of the one resident there, however the finishing touches should be put in place such as lampshades in the kitchen and window blinds in the bathroom. These additions will make the home more comfortable and ensure privacy. An immediate requirement was left for the shower in the flat as the hot water temperature from a shower was so hot it presented a possible risk of scalding to the resident who used it independently. On 28th April 2008 the manager wrote to us saying that the shower was to be dealt with on 1st May 2008, ‘Meanwhile, I have put in place a risk assessment with an accompanying support plan to ensure the safety of the relevant Service User is preserved as well as maintaining the individual’s independence’. We visited The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 19 and tested the shower again on 6th May 2008 and found that the shower was within safe limits. The annex was comfortable and provided the right equipment to enable the residents there to be more independent. There had been an outside telephone line connected to this part of the house. The main part of the house had a comfortable lounge dinner area and one bedroom was seen with the permission of a resident. This was very individual and had many personal possessions and photographs on display. The whole home was very clean and in good repair. The self-assessment told us, ‘The Pines is always clean and tidy. All the service users are encouraged to ‘do their bit’ when it comes to domestic tasks. All of the service users’ bedrooms are in good decorative order and they are all personalised to each individuals’ choice. We monitor the environment regularly and have a good system for reporting any damages or health and safety issues’. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient well-recruited staff that were appropriately trained, therefore residents were well supported. EVIDENCE: The roster for two weeks was examined. This showed that the plan was to have at least 3 staff on duty during the day and someone sleeping in at night. This was achieved by using some agency staff and was sufficient staff to meet the needs of the resident group. The manager explained that they were currently recruiting more staff. There was 6 care staff employed at the home. Records were examined for 2 care staff. Recruitment records showed that all the required checks and references were in place before someone started work at the home. However there was still a lack of proof of identity available for inspection. This must have been collected to process the criminal records bureau checks that were in place, but was not available on file. This evidence ensures that staff are supported by appropriate staff and should be retained. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 21 Two care staff have an NVQ 3 in care, two staff have NVQ 2 in care and one of these people are doing their NVQ3 currently. One other person is doing the NVQ 3. This is a good proportion of staff that are appropriately trained. The manager had a date next month when all staff would receive safeguarding training. Staff had received manual handling training in March 2008 along with handling and storing chemicals. Fire safety training was also planned for the following month. The company gives all this training to their staff. The following week Boots the chemist were coming to train staff on medication and the manager said he was developing a competency assessment on medication administration as part of staff supervision. One staff member spoken with said they had done an induction and this was the common standards of the skills for care induction. They had also completed an in house induction that enabled them to get to know the residents, home and other staff. The staff member said they had received training in safeguarding, health and safety and emergency 1st aid. The self-assessment told us, ‘we have access to a training provider who can support us to meet are training needs and requirements whenever we require. We realise that there is some specialist training required at times helping us to care for our service users to a higher level’. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Pines was well managed and residents were able to express their views. EVIDENCE: The registered manager had several years experience at a senior level of management in care homes for people with learning disabilities. He had achieved an NVQ level 4 and the registered manager award and we believe he is a suitable person to manage this home. The self-assessment told us that the home seeks the views of the residents in the following way, ‘The Pines holds residents meetings. Issues Service user questionnaires. Some of the Service Users participate in Service User Forums, which are open to all the homes within Consensus. The Service Users at The Pines all participate in putting their support/care plans together’. The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 23 The minutes of the last residents meeting were on display in the dining area for the residents to read. In addition to this consultation the company assures itself of quality by completing an internal audit every six months. This had happened at The Pines in February 2008. The audit was based upon the minimum standards and a document we use called KLORA (key lines of regulatory assessment) This audit had produced an improvement plan. This was available for inspection and each area had been actioned or was in the process of being looked at. Once a month the organisation also visits the home and completes a report that seeks the views of people who use the service. There was a note on the notice board saying ‘have a look’ at this report. In relation to maintaining health and safety the self-assessment told us, ‘There is a walking route which helps to identify any health and safety issues within the home’. This was completed regularly, but interestingly had missed the hot water temperatures in the shower, however this had been promptly rectified as noted earlier in the report. The self-assessment confirms that all the servicing of equipment and utilities were up to date. Also, that all the required policies and procedures are in place, but it did not state when the majority of them were reviewed, therefore we cannot be assured that they contain the best up to date advice for staff. The Pines DS0000067369.V362889.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 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations Evidence of identification should be retained and be available for inspection at any time. This is to ensure appropriate staff support the residents. The kitchen lights in the flat should have shades and the bathroom should have a blind to ensure the comfort and privacy of the residents. Policies and procedures should state when they were reviewed, to assure that they contain the best up to date advice for staff. 2. YA24 3. YA40 The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Pines DS0000067369.V362889.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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