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Inspection on 04/12/08 for Hornsey Rise Memorial Home

Also see our care home review for Hornsey Rise Memorial Home for more information

This inspection was carried out on 4th December 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Individuals who spoke with the inspectors felt that the registered persons would address any concerns or complaints that they had. People who spoke with the inspector said that they were satisfied by the lifestyle at the home and enjoyed their Christian way of life.

What has improved since the last inspection?

There have been further improvements in and around the premises and they are well kept. People who spoke with the inspector said that they enjoyed going out into the grounds. The recommendations from the last inspection report have been carried out. Handwritten medications sheets have been replaced with typed sheets. However when it is necessary to do hand written entries they are signed by a member of staff receiving the medicine and countersigned by another member of staff who has checked that they are correct. Guidance for staff as to when to administer drugs given as `when required medicines` also known as `PRN medication` has now been written for staff to follow. A copy of the drugs error procedure is displayed in the room where medications are stored for the staff to read.

What the care home could do better:

To ensure that medications are re-ordered in sufficient time to meet the needs of the individuals. To re-check that exit and access doors are safe and comply with fire safety. To ensure that doors can be opened easily in the case of an emergency by anyone who may need to do so. Safety door alarms can be considered on doors where vulnerable adults may be at risk of leaving the building.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hornsey Rise Memorial Home Hornsey Rise Memorial Home Wellsborough Nuneaton Leicestershire CV13 6PA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lesley Allison-White     Date: 0 4 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Hornsey Rise Memorial Home Hornsey Rise Memorial Home Wellsborough Nuneaton Leicestershire CV13 6PA 01455290851 01455292867 wellsborough@pilgrimhomes.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Pilgrim Homes Name of registered manager (if applicable) Mrs Sally Ann Willis Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: No one falling within category DE(E) may be admitted into the home where there are 14 persons of category DE(E) already accommodated No one falling within category MD(E) may be admitted into the home when there are 10 persons of category MD(E) already accommodated The registered person may provide the following category/ies of service only: Care home only - Code PC To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Old age, not falling within any ca Care Homes for Older People Page 4 of 26 care home 38 Over 65 14 10 38 0 0 0 Date of last inspection Brief description of the care home The fees for 2008 are £484.00 to £572.00 The last report is available from the office. Pilgrim Homes (Hornsey Rise Memorial Home) is a care home registered to take thirtyeight 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, seven 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. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This is an overview of what the inspector found during the inspection The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took six hours to complete. On the day of inspection there were 31 people living at the care home. One person was in hospital. Discussions were held with individuals living at the home and with staff. The primary method of inspection used was case tracking. This involved speaking with Care Homes for Older People Page 6 of 26 individuals who use the service provided, looking at two care plans and observing care practices. The Registered Manager and general manager assisted with the inspection. Some requirements were made. A copy of the Statement of Purpose and Service User Guide is available at the entrance hall to the home. This is information about the service provided. Also seen were the certificates issued by the Commission for Social Care Inspection and a current copy of the Employers Liability insurance. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 3 and Standard 6 People who use this service have information about the home in order to make an informed decision about whether the service is right for them. Evidence: Individuals are assessed prior to moving into the care home and have their needs assessed to ensure that their needs can be met. A trial period is offered to any one who requests this and a copy of the Statement of Purpose, Service User Guide and the in- house newsletter is provided for a new prospective resident to read. Information about external agencies is also displayed at the entrance to the home. Standard 6 Intermediate care is not offered at his care home. Care Homes for Older People Page 10 of 26 Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 7, Standard 8, Standard 9 and Standard 10 Individuals health and care needs are met. Evidence: Two people were case tracked and three other people spoke with the inspector also. In the two care notes looked at in detail the care plan had information needed for the care staff to be able to follow and provide care. All the individuals who spoke with the inspector felt that their health needs were fully met. When they were ill the Doctor was called in to see them and their families were kept informed. Other health care professionals also visited on a regular basis such as the Chiropodist the Optician or the District Nurse for dressings. The inspector spoke with one person who self medicated and they said that they were happy to remain independent to do so. They kept their medications safely. One Care Homes for Older People Page 12 of 26 Evidence: persons medication, a gel that had to be applied to the skin, was not in stock. This person explained how important this medication was to them and they were in pain as a result of not having this local application applied to their body. The inspector checked with the staff and it had run out with no more in stock. A requirement will be made to ensure that individual medications do not run out and that the ordering and checking of medications is improved. In this way no individual needs to be in unnecessary discomfort. The as required medication policy known as PRN medication is now in place and gives guidance as to what staff should do. A policy was now in place so that when drug errors occurred the staff would now know what they should do and the correct reporting systems that would also include a Regulation 37 as part of the incident reporting to the Commission of Social Care Inspection. Instructions are now displayed to guide the staff should a drug error occur. It is kept in the room where the medications are stored. A couple spoke with the inspector. They continued to take charge of their own medications and felt that this was good for them to do. In this way they felt that they were treated with respect. Bath or shower days were offered weekly to each individual on specific days. Individuals who spoke with the inspector felt that care at the home was good. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 12, Standard 13, Standard 14 and Standard 15 The people living at this care home find that it meets their expectations in a pleasant and positive way. Evidence: Two people who spoke with the inspector said that they had been to the home before for a week at a time. They had returned for a week of rest, relaxation and prayers. The care was as they liked it and they felt that they were with friends and in a safe environment. Other individuals said that their friends and families visited whenever they wanted to visit and were made to feel welcome by the people who lived at the care home and by the staff. An internal shop was available to individuals living at the home for half a day each week so that they could buy small items for themselves. Activities were available at the home mornings and afternoons or evenings. In the afternoon of the inspection music and movement took place upstairs in a separate room and up to seven people attended. The Minister visited Tuesday and Sundays and the people who spoke with the inspector said that they liked the home for the regular prayer meetings or services. Individuals felt that they had a choice as to bath days. Care Homes for Older People Page 14 of 26 Evidence: A poster for external help from an older persons organization was seen in the hallway although no one was using the service at the time of inspection the inspector was informed. At lunchtime individuals were seen having and enjoying their meals together. The staff ate their meal together afterwards. The atmosphere was pleasant. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 16 and Standard 18 Individuals living at the home felt that their concerns would be listened to and acted on. Evidence: People who spoke with the inspector said that they felt that if they had any concerns they would approach a member of staff or see the managers in charge of the home. They said that they felt that their concerns would be listened to and acted on. A copy of a complaint that the Commission was made aware of was seen. An understanding of the issues were discussed and peoples roles reinforced. Other complaints were seen they included the fitting of new bolts on bedroom doors to increase the privacy of the individuals. Staff who spoke with the inspector had some knowledge of abuse awareness and felt confident that they would report any incident of this type to the person in charge or go to outside agencies if the problem was not dealt with satisfactorily in house. In this way individuals living at the home would be protected. Care Homes for Older People Page 16 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 19 and Standard 26 Individuals living at the home are provided with a safe, hygienic and comfortable environment. However, privacy is not ensured in all communal areas of the home. Evidence: The home is kept clean and the atmosphere is pleasant. Individuals who spoke with the inspector said that they liked living at the care home. Some of the bedroom doors are named but not all. Items classed as dangerous substances if taken by mouth were safely labelled and locked in seperate cupboards provided for this. Improvements within the home included the replacement of old windows with new windows and some of the bed rooms have had ensuite facilities added. (This includes a toilet and face basin). A downstairs bathroom with a shower and toilet in it was seen. It had no door locks on it. The Registered Manager said that people who used this bathroom were mainly people who were escorted by staff. Interruptions can still take place and a lock must Care Homes for Older People Page 17 of 26 Evidence: be provided for this bathroom also should an independent person wish to use the room. In this way privacy will be available to anyone using this public area. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 27, Standard 28, Standard 29 and Standard 30 People living at the home are supported by a good skill mix of staff. Evidence: People who live at the home have their needs met by a good skill mix of staff and over fifty percent of the staff have a National Vocational Qualification in care at level two or above. A person with nurse experience was seen working at the home as a regular member of staff. They worked as a senior carer and was responsible for medications. A maintainence person, domestic staff and kitchen staff are also employed at the home. Records for mandatory training of staff were available at inspection. Staff who spoke with the inspector also confirmed that they had gone through an induction process and that they had regular supervision. There was evidence of good recruitment practices. Staff records inspected were satisifactory and had relevant information in them. In this way the individuals who live at the home are supported and protected by the staff. Care Homes for Older People Page 19 of 26 Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standard 31, Standard 33, Standard 315 and Standard 38 The home is run in the best interests of the individuals who live at the care home. Evidence: This home is managed by a husband and wife team. The home runs as a place with Christian values and the individuals who live there have often made an informed decision to be there. A policy for the quality monitoring of the services provided at the home includes asking the people who live at the home, their relatives and staff members about the homes performance. A copy of the summary of the quality assurance information was seen at inspection. At inspection a doctor visiting the home was seen who said they are very good here and look after the people living here. Care Homes for Older People Page 21 of 26 Evidence: The monies of two individuals was seen and checked with a manager. The amounts were correct and evidence of documentation to verify the amounts were seen. The Registered Manager said that all aspects of Health and Safety within the home are up to date. It was noticed by the inspector that the gate to the entrance of the building key pad did not always work and there was no other means of accessing someone from the care home. There was no call bell or telephone available for a visitor to be able to use. The inspector found that exit from the home by the front door was not easy to operate. This must be reviewed as anyone should be able to open the exit/ access door to the front of the home in an emergency such as fire. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 2) The registered person 04/03/2009 shall make arrangements for the recording, handling, safekeeping safe administration and disposal of medicines received into the care home. The home should not run out of medications as this can cause pain and distress to individuals when they do so. 2 19 12 The registered person shall 04/03/2009 make suitable arrangements to ensure that the care home is conducted a) in a manner which respects the privacy and dignity of service users. All private bedrooms and communal areas of the home must have acceptable locks on them to ensure the privacy needs of the individual. Care Homes for Older People Page 24 of 26 3 38 23 The registered person shall after consultation with the fire authority (a) take adequate precautions against the risk of fire, including the provision of suitable fire equipment; (b) provide adequate means of escape; (c) make adequate arrangements i) ii) iii) iv) v) For the evacuation in the event of fire the front door should be easy to open and not rely on various handle and lock combinations 04/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - 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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