Inspection on 05/12/06 for Hornsey Rise Memorial Home

This inspection was carried out on 5th December 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 01/02/06

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 Susan Lewis Unannounced Inspection 5th December 2006 08:45 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.V322422.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V322422.R01.S.doc Version 5.2 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) www.pilgrimhomes.org.uk 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.V322422.R01.S.doc Version 5.2 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 1st February 2006 Date of last inspection Brief Description of the Service: The fees for 2006/07 are£418 to £525 The last report is available from the office. 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, 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. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records, talking with them where possible, and observing staff that provide their care. The inspection was unannounced and took place over 7 hours one Tuesday in December 2006, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms were inspected. Residents’ and staff records were inspected and visitors, residents and staff on duty were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: The service provides residents with a pleasant clean and homely environment where they can continue to practice their religious beliefs with support from staff and management. The home is set in open countryside with views over Leicestershire and Warwickshire. Residents spoken with appreciated the rural setting. ‘The views over the gardens are lovely’. Residents spoken with liked living in the home despite initial reluctance to move to a home. ‘I didn’t want to come here but now I am here I really like it’. Residents are provided with space to be quiet if they so wish and activities to enable them to remain part of the community. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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.V322422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. Prospective residents receive the information they need to make an informed decision about where they live. Residents are assessed prior to moving to the home and know their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective residents receive and information pack about the home and what services they can expect. It gives information about the staff and management. Residents spoken with said that they had been given an opportunity to look round the home before making a decision to move in. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 9 Three care plans were viewed as part of this inspection and all had assessments on showing that residents’ needs were assessed before moving to the home and that the home could meet those needs. The assessment then informed the care plan ensuring that residents received all the care identified in the assessment. Intermediate care is not provided at this service. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents’ health, social care and personal needs are set out in an individual plan. Residents’ health care needs are fully met. Medication policies and procedures within the home protect residents. Residents feel they are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans showed that risk assessments were carried out to minimise risk to residents, whilst supporting them to remain as independent as possible. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 11 The plan was set out in detail showing what action care staff should provide to ensure residents were supported appropriately. Where possible residents were involved in the review of plans, residents spoken with confirmed that care staff spoke to them about their care plans and that they knew they could see them if they wanted to. Diary notes showed that residents had their health needs met and residents confirmed that they saw a doctor or district nurse when they felt unwell. Residents’ weights and nutrition were monitored to ensure that if sup[ort was needed such as dietician or pressure care then this could be obtained promptly. Medication was stored in appropriately in a locked facility. Procedures were followed when administering medication to residents ensuring that their safety was maintained. However all the medication Administration Sheets were handwritten it is strongly recommended that where this happens that these are signed and countersigned to minimise any risk of error. It was noted that some residents require medication PRN (occasionally/when required). It is recommended that a framework be established to give guidance to staff when this medication is to be given. Although there is a procedure for what to do in the event of drugs administered in error, it was not on display, it is recommended that this is put on display for all staff to know quickly what to do in this event. Residents were all clean and tidy with hair brushed and residents spoken with said that staff helped them get dressed and provided as much help as they needed. Comments received were ‘I have been here a few months and I like it very much, the staff are very kind’. ‘The girls (staff) are very good to me all the staff are very good’. Staff were observed throughout the day with residents and always spoke to them with courtesy and understanding. This shows that staff treat residents with respect and promote their dignity. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents find the lifestyle in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests. Residents are able to maintain contact with family, friends and the local community. Residents are able to exercise choice over their lives. Residents receive appetising and nutritious meals in a pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that they were able to choose when they got up and went to bed. A variety of activities are available to residents including trips to the local towns and Garden Centres. During the course of the inspection staff were seen sitting with residents reading newspapers together Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 13 and other residents were engaged in cleaning tasks such as wiping the table after breakfast. A resident commented ‘ I like doing bits like cleaning and keep myself occupied’. ‘I can’t do some things but I like going to the Art Group’. ‘I didn’t want to come into a home but now I am here I really like it’’ The home offers daily devotions for those who wish to take part as well as links with local churches and those residents who had chosen the home specifically for its Christian ethos said they found this very valuable. ‘I came to this home by choice as I am a Christian’. The home has a quiet area upstairs where a small library is located; books from the local county library supplement this. This is good practice. Each care plan viewed included a life history of the resident, which included likes and dislikes as well as things that are important to the resident. The diary notes show when residents are involved in activities. Residents confirmed that they were able to have visitors when they wanted and diary notes confirmed that even relatives who lived some distance from the home were contacted and kept informed of their loved ones welfare. The midday meal was observed and it appeared nutritious and appetising, residents spoken with said that ‘The food is good and I get plenty’ ‘There is plenty of food and we get a choice’. Staff were observed discreetly assisting residents who needed help with feeding and soft diets were available for those who needed it. This ensures that residents’ nutritional needs are met. The dining room itself is light and airy overlooking the open countryside, providing residents with a pleasant area to eat in. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents feel able to complain and are confident that they will be listened to and their complaint acted upon. Residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no complaints about this service since the last inspection. The home has a suitable complaints procedure that is given to all prospective residents as part of the Service User Guide. Residents spoken with said that they would feel able to either take any concerns to the staff or the manager, and that it would be dealt with. Evidence was seen from records that the home had received three complaints in the last year and all had been dealt with appropriately detailing the issue and action taken. This provides evidence to show that the manager responds promptly and appropriately to any complaint. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 15 Staff spoken were aware of the complaints procedure and the importance of supporting residents who wanted to complain. ‘If I couldn’t deal with it myself I would take it to the manager’. Residents spoken with said that they felt safe in the home and that staff were kind to them. Staff spoken with understood what constituted abuse and knew what to do. From information received prior to the inspection staff have received Abuse Awareness training as well receiving information about No Secrets (Information regarding Whistle blowing should they suspect abuse and management have not dealt with it). This ensures that residents are protected from abuse. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Residents live in a safe well-maintained environment. The home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was seen during the tour of the building and from maintenance records that the home is well maintained throughout. The home is clean and pleasant with beautiful views over the countryside. There are extensive grounds that are accessible to residents. A resident commented that, ‘The views over the garden are lovely, you can see for thirty miles’. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 17 The large laundry facilities are very good and away from residents ensuring that soiled laundry does not need to be carried through where residents are eating or food is prepared, maintaining good infection control. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Residents’ needs are met by the skill mix of the staff. Residents are supported by competent staff. Residents are protected by the home recruitment policy and procedures. Staff are trained and competent to do their job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received prior to the inspection showed how many staff were employed on each shift residents spoken with said that mostly they felt there were enough staff on to help them if they needed support. Staff spoken with said that although they are busy usually there were enough staff on shift and they worked well as team. Cleaning staff and kitchen staff were seen throughout the inspection and were employed in sufficient numbers to meet the needs of residents. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 19 Evidence seen prior to the inspection showed that 65 off staff had NVQ level 2 with a further five candidates currently on the course this ensures that residents are supported by staff competent and to meet their needs. Three staff files were viewed and evidence was seen that recruitment is thorough with Criminal Records Bureau checks and references being taken up before the person started work. Staff also receive copies of the General Social Care Council Code of Conduct. This document advises staff on how they are supposed to behave when working in a social care environment. Training information was kept on staff files showing what training they had undertaken and when. Each file had a list of training attended so far that year and what training needed to be redone. This enabled the manager to highlight training needs during supervision. Staff confirmed that they were supported to do training and were able access a wide variety including specialist training to help them carry out their work more effectively such as Dementia Care Depression and Infection Control. A new induction pack has just been introduced to comply with the new skills for care, this shows that the manager is keeping up to date with changes in practice and training for staff. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. Residents live in a home that is managed by a person who is fit to be in charge. The home is run in the best interests of the residents. Residents’ financial interests are safe guarded. The health, safety and welfare of residents and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 21 The home runs with a clear Christian ethos and residents’ benefit from this. The manager understands her responsibilities as the registered manager and there are clear lines of accountability within the home. There is a good quality monitoring system in place and the results of this a posted throughout the home for residents to look at. Residents spoken with said that they felt involved in the home and that the care they received was of good quality. The manager does not act as appointee for any residents and money kept for residents is stored securely with limited access; records of all transactions are kept. This means residents are protected from financial abuse by good practice within the home. Evidence was seen that staff receive the mandatory training to support their health and safety as well as residents. Records of all maintenance carried out in the building and equipment were available for inspection and showed that the manager maintains the home so it is safe for staff, residents and visitors. Fire drills are carried out regularly the last drill being 4th November 2006. Accidents are recorded correctly and the manager notifies the Commission in the event of any incident that adversely affects the residents. This ensures that the Commission is kept informed of what is happening in the home. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 3 Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP9 Good Practice Recommendations Handwritten Medication Administration sheets should be signed and countersigned. Create guidance for staff when to administer PRN medication Have a copy of the Drugs error procedure displayed for staff. Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pilgrim Homes (Hornsey Rise Memorial Home) DS0000001651.V322422.R01.S.doc Version 5.2 Page 25 - 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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