Inspection on 01/02/06 for Hornsey Rise Memorial Home

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hornsey Rise Memorial Home 04/12/08

Hornsey Rise Memorial Home 05/12/06

Hornsey Rise Memorial Home 19/07/05

Hornsey Rise Memorial Home 15/02/05

Hornsey Rise Memorial Home 20/09/04

Hornsey Rise Memorial Home 03/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pilgrim Homes (Hornsey Rise Memorial Home) Hornsey Rise Memorial Home Wellsborough Nuneaton Leicestershire CV13 6PA Lead Inspector Diane Butler Unannounced Inspection 10:15 1 February 2006 st X10015.doc Version 1.40 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 Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 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 Older People. 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. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pilgrim Homes (Hornsey Rise Memorial Home) Address Hornsey Rise Memorial Home Wellsborough Nuneaton Leicestershire CV13 6PA 01455 290851 01455 292867 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) Pilgrim Homes Mrs Sally Ann Willis Care Home 38 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (38) Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one falling within category MD(E) may be admitted into the home when there are 10 persons of category MD(E) already accommodated No one falling within category DE(E) may be admitted into the home where there are 14 persons of category DE(E) already accommodated Date of last inspection Brief Description of the Service: Pilgrim Homes (Hornsey Rise Memorial Home) is a care home registered to take thirty eight residents in the categories of dementia, mental disorder (excluding learning disability or dementia) and old age. The home is situated in the rural village of Wellsborough, close to the towns of Nuneaton in Warwickshire and Market Bosworth in Leicestershire. It is owned by Pilgrim Homes, a 200-year-old Christian charity that was founded in 1807 as the Aged Pilgrims Friends Society with a vision to care for elderly, needy Christians. Accommodation can be found on two floors, which is accessed by a shaft lift. There are thirty-two single and three double bedrooms, five of the rooms are en-suite. There is a large lounge and dining room on the ground floor and a further two lounges on the first floor. All the residents rooms are served by a call system. There is also sheltered accommodation for some residents who can access services such as meals from the main body of the home. The rear of the building overlooks magnificent views of open countryside and extensive grounds which are well maintained and accessible to the residents. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three and a quarter hours and commenced at 10.15 am on 1st February 2006. The main method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The registered manager was most helpful during the inspection process. What the service does well: What has improved since the last inspection? The administrator explained that two of the resident’s rooms have been altered to offer ensuite facilities and a further five rooms are due to be altered in the next six months. New non-slip laminate flooring has been laid in the homes dining area and new carpets have been laid in one of the first floor corridors. The inspector was also informed that 50 of the homes windows have been replaced since the last inspection. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 6 A new falls assessment document has been developed. 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. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Prospective residents and/or their relatives are able to visit and assess the quality, facilities and suitability of the home. EVIDENCE: • A Statement of Purpose document is available to all prospective and current residents. This document includes information about the facilities in the home, the services that can be provided and details of the homes complaints procedure. A welcome pack is also given to all new residents. This pack provides further information about the home including ‘the staff team’, ‘life at the home’ and ‘a daily timetable’. Four residents files were checked during the inspection. All four files looked at included an assessment of need completed by the registered manager prior to the resident’s admission into the home. • Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 9 • The administrator explained that all residents are provided with a copy of their Terms and Conditions of residency. This was confirmed on inspection of resident’s files. Residents spoken with during the inspection explained that they had been given the opportunity to look around the home before moving in. This enabled them to see the facilities that were offered within the home and reassure them that their individual needs could be met. • Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents are looked after well in respect of their health and personal care needs and personal support is offered in such a way as to protect the resident’s privacy, dignity and independence. EVIDENCE: • Care plans were in place for all residents’ case tracked. All were thorough in content and relevant to the individual resident. All had been reviewed and evidence of resident input was seen. At the back of the care plan there is a summary sheet, this allows the reader to see at a glance the individual care needs that are required. All four care plans included risk assessments on daily activities, moving and handling, nutritional risk and pressure area risk. Evidence was seen to confirm that residents have full access to health care services. These included local GP’s, community nurses, Opticians and chiropodists. The registered manager explained that the local GP visits the home on a weekly basis to see who ever wishes to be seen. If the residents DS0000001651.V275738.R02.S.doc Version 5.1 Page 11 • • Pilgrim Homes (Hornsey Rise Memorial Home) wish to see a different GP, transport is available to take them to the local surgery. • • The Procedures for the administration of medication were in order with all paperwork checked on this occasion completed appropriately. Discussion with residents and staff and observations during the inspection showed that the staff had a good awareness of how to ensure that a resident’s privacy and dignity are maintained at all times. One resident explained, “We get a great deal of kindness”. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Regular activities and a variety of meals enable residents to make preferred choices on a daily basis. EVIDENCE: • Activities are offered throughout the week. Each resident is given a copy of the activities programme and a copy is displayed on notice boards situated throughout the home. Activities include, music and movement, trips to the local towns of Nuneaton and Market Bosworth, art classes and art activity. Film and video shows are also offered. Comments received from residents included: “We went out last Saturday on the bus, it was lovely, they always take us through the countryside and other different places”. “We have a film or video every Monday, one was about Flamingo’s, it was marvellous. Another was about the Middle East it was really interesting”. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 13 • Pilgrim Home’s Christian ethos provides spiritual support for both the residents and its staff group. There are very close links with the local church and monthly communion, weekly services, bible groups and daily devotional time are offered. Family and friends are strongly encouraged to visit. One resident explained: “The family can visit at any time”. Details of an advocacy service are displayed on the homes notice board and the contact details of a home visitor are also displayed. The Registered manager explained that residents could contact the home visitor at any time for a visit or to be escorted to an appointment. All residents spoken with shared how much they enjoyed the food served at the home. Comments included: “The food is good, there’s always a choice, I like a salad, so, I have a salad”. “The food is quite reasonable and you get a choice”. “No complaints!” • • Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Arrangements for the receiving and responding to complaints are sound and residents are confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: • A complaints procedure is in place and all residents spoken with were aware of who to go to should they have a concern of any kind. Comments received from residents included, “I would talk to xxx and Mrs Willis [Registered Manager], though the little things I would tell the carers and they would sort it out”. “I would speak to xxx if I had a problem”. “xxx would sort any problem out”. • • A copy of the complaints procedure is displayed throughout the home and a copy is also included in the Statement of Purpose document. Care workers spoken with during the inspection confirmed that they had received training in abuse awareness and were aware of what to do should they suspect any act of abuse happening in the home. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,26 The standard of the accommodation within the home is good providing residents with a clean and comfortable place to live. EVIDENCE: • • • The home is safe and well maintained. There is a large dining room and lounge on the ground floor and a further two lounges on the first floor. Decoration in the home is of a good standard and furnishings in the communal areas are domestic in character and in good condition. The extensive gardens to the rear of the home are very well maintained and are accessible to all residents and visitors. Delightful views of the surrounding countryside can be enjoyed from all the communal areas within the home. Resident’s rooms seen during the inspection were clean, comfortable and included the resident’s personal belongings. DS0000001651.V275738.R02.S.doc Version 5.1 Page 16 • Pilgrim Homes (Hornsey Rise Memorial Home) • All areas of the home seen on this occasion were clean and fresh. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 Staff are employed in sufficient numbers to meet the current needs of the residents. EVIDENCE: • On checking the training records it was noted that a number of training courses have been booked for 2006. These include, health and safety and fire safety, moving and handling and understanding aggressive behaviour. The registered manager explained that these courses are to be delivered by Pilgrim Homes Health and Safety officer. Training in Health and Hygiene and Healthy Eating has also been booked for early 2006. Training on Person Centred Care (treating each resident as an individual and a unique person) is also to be delivered throughout the year. Staff spoken with confirmed that they had received induction training when the first started work at the home and on going training is provided. All the residents spoken with on the day of the inspection felt that there were normally enough staff on duty. Two staff members spoken with stated that on the whole they felt that there were currently enough staff on duty to enable them to care properly for the residents, though if someone went off sick then this would obviously have an effect. DS0000001651.V275738.R02.S.doc Version 5.1 Page 18 • • • Pilgrim Homes (Hornsey Rise Memorial Home) • On the day of the inspection a relaxed atmosphere was evident with staff going about their work in an unhurried and professional manner. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,38 The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: • • It was evident during the inspection that the residents benefited from the Christian ethos which was noticeable throughout the home. One resident stated: “We are so well looked after”. A second resident stated: “I’m quite happy, which is just as well, after all I am going to be here for the rest of my life”. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 20 • The home has the facilities to look after small amounts of money on service users behalf. On checking the records and money kept on behalf of one of the resident’s case tracked it was noted that all the appropriate checks were in place, including receipts and two signatures for each transaction carried out. Service users spoken with confirmed that the fire bells are tested on a regular basis. Fire records were in order with the last fire drill being carried out on 29th January 2006. The accident book was seen and was found to correspond with both the resident’s daily records and Regulation 37 notifications received by the Commission for Social Care Inspection. Records seen on this occasion were found to be up to date and accurate. • • • Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 21 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 3 3 3 X 3 X 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X X 3 Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 22 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. x Standard x Regulation x None Requirement Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. x x Refer to Standard None Good Practice Recommendations Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V275738.R02.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 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. 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