Archived: Pinehurst Care Home

our inspection, some of whom lived with diagnosed dementia. All of the people living in the service were able to converse with us.

This inspection was carried out over two days by four inspectors on 04 and 05 April 2016. It was an unannounced inspection. As part of our comprehensive inspection, we checked that remedial action had been taken to address shortfalls identified at our last inspection in December 2014, in regard to staffing levels and documentation relevant to the administration of medicines. All remedial action had been taken to achieve compliance with relevant regulations.

There was a manager in post who was registered with the Care Quality Commission (CQC) since 2010. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

People, relatives and staff told us there was a sufficient number of staff deployed to consistently meet people’s needs. Staffing levels had been calculated taking into account people’s specific needs.There were thorough recruitment procedures in place which included the checking of references.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

Staff knew each person well and understood how to meet their support and communication needs. Staff communicated effectively with people and treated them with kindness and respect.

Staff had received all essential training and were scheduled for refresher courses. All members of care and nursing staff received regular one to one supervision sessions. Staff reported feeling well supported in their roles.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options had been considered.

Staff sought and obtained people’s consent before they helped them. People’s mental capacity was assessed when necessary about particular decisions. Meetings with appropriate parties were held and recorded to make decisions in people’s best interest, as per the requirements of the Mental Capacity Act 2005.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences and restrictions.

People’s individual assessments and care plans were reviewed monthly or when their needs changed.

Clear information about the service, the facilities, and how to complain was provided to people and visitors.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People were involved in the planning of activities that responded to their individual needs. People’s feedback was actively sought at relatives and residents meetings.

Staff told us they felt valued by the registered manager and they had full confidence in her leadership. The registered manager was open and transparent in their approach. They placed emphasis on continuous improvement of the service.

There was a system of monitoring checks and audits to identify the improvements that needed to be made. The registered manager acted on the results of these checks to improve the quality of the service and care.

We made a recommendation about the storage of cleaning equipment and about suitable décor for people living with dementia.

People who used the service also told us they liked the home and their rooms, their rooms were warm enough and their taps worked properly.

People who used the service said they had no complaints but knew how to make one if they did.

We spoke to relatives of the people who use the service, who told us they felt their relative was well looked after, their room seemed warm enough, the food was good but was not perfect, the chef always offered alternatives if wanted and they felt listened to when they raised any issues.

A relative of person who used the service also told us that they found it difficult to identify staff sometimes and we saw another relative had commented to the home about this. The manager agreed to remind people to wear name badges and was in the process of making a pictorial staff rota.

We saw people were supported to be able to eat and drink sufficient amounts to meet their needs.

We found that people who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We saw that people were given support to make a comment or complaint where they needed assistance, and people had their comments or complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint.