CARE HOMES FOR OLDER PEOPLE
Pilgrim Homes Hornsey Rise Memorial Home Wellsborough Nuneaton CV13 6PA Lead Inspector
Mrs Janet Browning Unannounced 19 July 2005, 09:00 am
th 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 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 C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Pilgrim Homes Hornsey Rise Memorial Home Wellesborough Nuneaton CV13 6PA Address Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01455 290851 01455 292867 wellsborough@pilgrimhomes.org.uk Pilgrim Homes Mrs Sally Ann Willis Care Home (CRH) 38 Category(ies) of Dementia - over 65 years of age (DE(E)) 14 registration, with number both, Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (MD(E)) 10 both, Old age, not falling within any other category (OP) 38 both. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: No one falling within the category MD(E) may be admitted into the home when there are 10 persons of category MD(E) already accomodated. No one falling within category DE(E) may be admitted into the home when there are 14 persons of category DE(E) already accommodated. Date of last inspection 15th February 2005 Brief Description of the Service: Pilgrim Homes (Hornsey Rise Memorial Home) is 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 town of Nuneaton in Warwickshire and Market Bosworth in Leicestershire. It is owned by Pilgrim Homes, a 200 year old Christian charity which 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, of which one is ensuite. There is a large lounge and dining room on the ground floor and a further two lounges throughout the home. 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. Security gates are in place to ensure the safety of the residents as there is a considerable amount of traffic that uses the road outside of the home.
Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 19th July 2005. The inspection commenced at 9.00am and finished at 1.55pm. When undertaking inspections, the Commission for Social Care Inspection (CSCI) focuses on the outcomes for clients living in a home. To support this, three residents living at Pilgrim Home were ‘case tracked’. This means that the care records of three clients were checked; the clients themselves were spoken with where possible, as well as two members of staff supporting their care. Opportunity was taken to speak nine other residents in the home and a relative visiting the home at the time of the inspection and some of the home’s documentation was also examined. The inspector received 4 resident comment cards and one relative comment card. The home also completed a pre-inspection questionnaire, which was received prior to the inspection. The recommendations and requirements arising from this inspection are a direct result of case tracking, comment cards and other observations made by the inspector during the inspection. What the service does well:
The home promotes a Christian ethos, which is evident throughout the home with bible readings, hymn singing and services being part of the activities programme. Residents who choose to live here do so because of this aspect of the home. The home has a mini bus, which is used for outings and there is a large conference hall, which is used for varied events such as visiting choirs, and video shows on a large screen. The extensive gardens are well maintained and accessed by residents and are thoroughly enjoyed, with croquet being played in the summer months and football nets for residents’ younger family to use. There are magnificent views over the surrounding countryside, which are very much appreciated by all residents giving the home a peaceful air. The care plans are of a general good quality with detailed assessments and records kept of the residents’ day-to-day events. The communal atmosphere in the home is relaxed and peaceful with residents being able to choose their own preferences of lifestyle. All residents spoken to gave many positive comments about the home and feel that they are included in deciding how the home is run, with regular residents meetings being held. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better:
Although the care plans are of a good quality, improvements could be made with the documentation and risk assessments of residents’ challenging behaviours. Some staff had only received limited training on how to handle challenging behaviour and were using a form of restraint without a resident being fully risk assessed or having details care plans for physical violence being in place. The home must address this issue. Training of staff was detailed in the pre-inspection questionnaire, and although the staff spoken too had awareness of adult protection, not all staff had received formal training on this. The medication procedure and recruitment procedures were adequate but the documentation of “as required” medication and exploration of gaps in employment histories could be improved making these procedures more robust. Because of the Christian ethos of the home, residents choose to live in the home from all over the country; so it can be difficult for family and friends to visit. The home could ensure that all attempts are made for relatives and visitors to attend reviews of residents’ care needs if the resident so wishes. The home provides sheltered accommodation for some people, which is within the premises of the home. People living there are self-caring of all aspects of their care, but use facilities within the home. As such their accommodation is unlocked leaving it and their medication accessible to the residents. This is a potential risk, especially for those residents who have dementia care needs and must be addressed. The manager of the home who is registered by the CSCI has an administrator acting as a “joint manager”. There is confusion amongst both residents, and the relative spoken to, over who actually has ultimate responsibility within the home for issues such as complaints, with some seeing the administrator as the manager. The lines of accountability must be formally addressed by the home.
Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 7 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 C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 6 The assessment process and services provided by the home are sufficient to ensure that all needs are met. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 10 EVIDENCE: The case notes examined during case tracking had sufficient detail of all aspects care explored in the assessment process. Details of information gathering from relatives and, in one instance from a previous care home, were evident. The process covered aspects of care both physical and psychological, with life histories within the notes. Risk assessments for nutrition, moving and handling and pressure sores were detailed. The home provides care for people with dementia and the training for staff is based on the “Person centred care” model, which puts the resident at the centre of the care. The home maintains links with community psychiatric services and call upon them if they require advice on care. The home’s Christian ethos means that the home provides a comprehensive service to meet this religious group needs. The home does not provide intermediate care services. Resident’s stated; • “I love living here.” • “It fits into my Christian beliefs.” A relative stated: • “Very welcoming, caring place, far better than others.” Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Care plans indicate that staff have sufficient information to meet residents’ needs, with the medication procedure being generally sound enough to protect residents from harm. The approach of the staff is such that residents are assured that they are treated with dignity and respect EVIDENCE: The care plans evidenced during the inspection indicated a good standard with sufficient detail for staff to provide the care. Staff spoken to stated that they read the care plans for information. One care plan for a resident with challenging behaviour, who had been recently admitted, had details of her behaviour and the techniques required to calm the situation. What it did lack was details of what triggered this behaviour, and a risk assessment of violent actions. Staff had stated that the resident could hit out when receiving personal care. The Registered Manager stated that the resident was still under the assessment process and this was going to be addressed. The daily records were very good with care staff relating entries to the care plans enabling the reader to see exactly what care the resident had received that day and if care needs had changed. Where this could be improved is in the recording of pain control. For example, one resident required analgesia (pain killers) at 2:30 am. The daily record did not give details of where the pain was, the strength of pain and if the analgesia was effective.
Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 12 The residents had access to health services with the local GP visiting weekly with a clinic for six residents, but residents stated that they could see a GP for emergencies out of this time. A chiropodist, optician and district nurse also visited regularly and visits to a dentist could be arranged. The home also had links with community mental health teams. There was evidence of care plans being reviewed monthly with family involvement on admission. One relative spoken to stated that she had not been involved in any review of her relative’s care since admission 18 months ago and that her relative had some short-term memory problems. This had not been mentioned to the home. The registered manager stated that relatives were involved but many did not live close to the home so this was not always possible. Indications are that the home provides a safe medication procedure, but details of maximum dosage and frequency of medication given as required (PRN) were detailed on the drug chart which is best practice and the recording of PRN medication given was not always clear. Staff were observed talking respectively with residents and residents spoken to stated; • “Carers always knock before they come into my room.” • “I was asked how I wanted to be addressed.” • “We get listened to, and can choose when we want to do things.” There has been an issue of a staff member speaking to residents a little curtly, which was highlighted in the complaints records. The administrator stated that this was being addressed by Pilgrim Homes personnel and by the home itself, with meetings and communication training for staff. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 The home’s philosophy regarding activities satisfies the residents’ expectations and preferences with residents having the ability to exercise choice over their preferred lifestyle. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 14 EVIDENCE: The majority of residents choose to live at Pilgrim Home because of the Christian ethos with many of the activities having a Christian leaning. A full activities programme is pinned up in each resident’s room, with details of outings, bible readings, music and movement to name a few, which are organised by activities organiser and visiting organisations. Residents spoken to stated: • “I love the art class each week.” • “There are lots of outings in the mini-bus and quizzes.” • “We went to the flower festival in Market Bosworth, which was lovely.” • “I chose to live here because of the Christian readings in the home.” The home has a large conference hall which is used for a variety of functions such as funerals, video shows, choirs, chapel services in winter to name a few. Outside there is a summerhouse which is used for serving cream teas. Visitors can visit any time and residents are aware of advocacy services with posters evident in reception. Many residents have moved to the home from differing parts of the country so visits from relatives can be scarce. There is a person who can visit residents who have no regular visitors. Residents spoke about being able to read and be involved in their care plans and one resident showed the tapestries and drawings she had done in art class on the bedroom wall. The room had many personal items, which the resident felt gave her memories of times past. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16 and 18 The home’s complaints procedure is such to ensure that resident’s can be confident that any concerns are listened to. Adult protection awareness is generally good, however more robust procedures in care of residents with dementia would ensure that all residents are protected from harm. EVIDENCE: Indications from the complaints records are that complaints are dealt with efficiently and effectively. Residents spoken to state; • “I would go to the boss if I had any complaints, and if I wasn’t satisfied I would take it higher.” • “The complaints procedure is pinned up outside the lift.” • “You feel listened to here.” • “I feel safe here.” Two members of staff were spoken to and gave indications that they were aware of the correct procedures for adult protection. One resident case tracked had challenging behaviour and the indications were that the resident could be physically violent towards staff during certain procedures. One staff member stated that this sometimes required gentle restraint to avoid injury to staff. This staff member had not received training sufficient to deal with restraint having only “read a booklet on challenging behaviour”. Although the challenging behaviour did have a corresponding care plan, it did not detail exactly the circumstances surrounding this violent behaviour or the nature of restraint, if any, to be used or have a risk assessment.
Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 24, 25 and 26 The communal areas and individual rooms are such that residents have access to a safe and comfortable environment. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 17 EVIDENCE: The home has rooms off long corridors, which have easy access for both mobile residents and wheelchairs. There are large extensive grounds, which the residents enjoy, especially in the summer months and the home has added awnings to the outside seating area to protect residents from the sun. The lounges are arranged to encourage conversation, and residents were noted to be chatting to each other and laughing together. One resident stated that she had asked for her room to be re-decorated and this was done almost immediately. The home administrator stated that there is a programme for renewal of the fabric of the home and they were also waiting costing for a new impermeable floor for the laundry, which was a previous recommendation. CCTV cameras cover the entrance and exit to the home and there are key coded locks to the outside areas thus protecting residents with dementia from harm. The access codes are available for residents to come and go as they please. The routine checks made on the water system recently showed a problem which the home informed the CSCI. This was dealt with appropriately and there is an external company performing regular checks on the water until the home is fitted with new tanks. Valves had been fitted to all but two hot water taps and these two had been dismantled. The pre-inspection questionnaire showed that water temperatures are tested regularly. Radiator covers were evident throughout the areas visited during the inspection and, on a warm summer’s day, the home was well ventilated. The two rooms inspected were comfortable in their design and clean with the residents’ individual items on display. One resident told of how the home has two cleaners who keep the rooms tidy. Two cleaners were observed during the inspection, one upstairs and one down. One resident had a table and chair in the room for her art work. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, and 29 and 30 Overall staffing hours for the week were generally in sufficient numbers at the time of inspection, with indications being that residents’ assessed needs were generally being met. The home’s recruitment procedure was generally sufficient to ensure that residents are not put at risk of harm. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 19 EVIDENCE: During the inspection the indications were that assessed needs were generally being met. The one comment card received from a relative gave a positive response about the home having sufficient staff on duty. However one resident case tracked stated; • “Staffing levels can drop on Sunday and in the summer months.” Examination of two weeks staff rosters at the time of inspection and from the pre-inspection questionnaire indicated that staffing hours for a week met the guidelines set out in the Department of Health’s Residential Forum, however there are indications that there are fewer staff doing longer shifts on Sundays. A member of staff stated that there is adequate staff to assist those residents who require help with meals. Lunchtime was observed as being unhurried with staff having time to assist with feeding sensitively. The manager stated that there are 8 out of 18 members of staff have NVQ qualifications and the pre-inspection questionnaire shows that staff received varied training in all aspects of care with training being provided by both the Registered Manager at this home and staff from the sister home in Leicester. There was induction training programme for new starters, with evidence seen of an evaluation quiz entitled “ Everyone needs to know”. The recruitment records of two members of staff were examined and the indications were that generally the home performs adequate recruitment procedures with Criminal Record Bureau (CRB) checks being evident before the candidates start working at the home. However, one application form showed gaps in employment, which the Registered Manager stated had been discussed during the interview but could provide no documentary evidence of this. Evidence was seen of CRB checks being performed on the volunteers who enter the home to provide activities. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, and 38. Indications are that the home is run in the best interests of the residents but the unclear roles of responsibility is causing confusion over who is running the home. Health and safety promotion is generally good, but some inadequacies have the potential of putting residents at risk of harm. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 21 EVIDENCE: Quality assurance is maintained through regular residents’ meetings whereby residents are encouraged to voice opinions and concerns. Minutes for one meeting showed that over 15 residents attended plus two visitors. Residents spoken to during the inspection were fully aware of the future plans for the home and felt that they were involved. The results from a satisfaction survey were seen pinned up on a notice board upstairs. Residents in sheltered accommodation do not receive personal care from the home, but can access the home for meals and activities. This accommodation is in the main body of the building. On discussion with a person residing in this accommodation, it was apparent that their medication could be accessible to other residents residing in the home as it was kept in an unlocked drawer in an unlocked room. This is unsafe, especially for residents with dementia, and must be addressed. Accident records examined indicated that they had be filled in correctly and upto-date and that action plans were formulated to reduce the risk of reoccurrence. The pre-inspection questionnaire showed that procedures for the safe running of the home are performed regularly. Discussions with residents revealed that there is some confusion over who runs the home. The inspector was introduced to two people on entering the home, as “joint managers”. When asked to clarify, the Registered Manager stated that she was responsible for the care aspect of the home, and the other manager handled office administration and maintenance, like an administrator. When discussing complaints and concerns to residents and a relative it was the administrator’s name that they stated as the person that they would go to first with some residents calling him “the boss” and “the manager”. It was also clear from discussions with the two managers about a recent complaint about a staff member that it was the administrator that was dealing with this and conducting investigations. Clear lines of accountability need to be addressed to avoid confusion and in dealing with regulatory responsibilities. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 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 x
COMPLAINTS AND PROTECTION 3 x x x x 3 3 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 Standard No 16 17 18 Score 3 x 2 2 x 3 x x x x 2 Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 18.5 Regulation 13 (7), (8) Requirement Timescale for action 13/09/05 2. 31.7 9 (1) 3. 38.1 13 (4) (a) (c) The registered person must ensure that any form of physical restraint of a resident is fully risk assessed, and that documentation includes the circumstances and nature of restraint. This must follow the homes policy on restraint. Details of action plan, risk assessments, care plans and restraint policy to be sent to CSCI. As the manager registered with 13/09/05 the CSCI, the Registered Manager must ensure that managers and the administrators roles and responsibilites are clearly defined for residents and visitors, showing clear lines of accountability for the managing and day-to-day running of the home. Action plan and details of the administrators roles and responsibilities to be sent to CSCI The registered person must 13/09/05 ensure that all aspects of the home accessible to residents are, as far as possible, free from hazards. Risk assessments must
Version 1.40 Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Page 24 be performed on the storage of medication for those residing in sheltered accommodation within the home premises. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 7.2 7.6 8.1 9.3 29.2 Good Practice Recommendations It is strongly recommended that full details of challenging behaviour, including triggers, are documented in care plans and risk assessments if appropriate. It is recommended that residents are offered to have a representative present at care reviews. It is recommended that details of why residents have needed as required (PRN) medication is recorded in residents care records along with its effectiveness. It is strongly recommended that, whenever possible, PRN medication has directions, maximum dose and instructions when to administer, documented on the drug chart. It is strongly recommended that the home thoroughly explores any gaps in a candidates employment record during interview and that the interview process is documented. 6. 7. Pilgrim Homes C51 C01 S1651 Pilgrim Homes ( Hornsey Rise Memorial Home) V235657 190705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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