Inspection on 18/08/06 for Pilgrim Homes

This inspection was carried out on 18th August 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

Pilgrim Homes 03/08/07

Pilgrim Homes 28/11/05

Pilgrim Homes 20/06/05

Pilgrim Homes 22/09/04

Pilgrim Homes 16/06/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pilgrim Homes 35/36 Egremont Place Brighton East Sussex BN2 0GB Lead Inspector Jennie Williams Key Unannounced Inspection 18th August 2006 10:30 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 DS0000014263.V298497.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 DS0000014263.V298497.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilgrim Homes Address 35/36 Egremont Place Brighton East Sussex BN2 0GB 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) 01273 606940 01273 692640 brighton@pilgrimhomes.org.uk www.pilgrimhomes.org.uk Pilgrim Homes Anne Gower Care Home 21 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (21) of places Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-one (21). Service users will be aged sixty-five (65) years or over on admission. Only seven (7) service users with a dementia type illness are to be accommodated. 28th November 2005 Date of last inspection Brief Description of the Service: Pilgrim Homes is registered as a care home providing services for up to twentyone (21) older people, of which seven residents may be admitted with a dementia type illness. There is no nursing care provided at the home. District nurses will visit those residents requiring nursing input. Pilgrim Homes is located on the border of Brighton and Kemptown and is within walking distance to local amenities. This home is run by a charity and is part of a national organisation. Accommodation and care are provided to older people who follow the Protestant Christian religion. Pilgrim Homes provides accommodation for 21 residents who require care and has accommodation for 17 tenants that reside in the sheltered housing part of the home. The tenants within the sheltered housing area are independent and staff employed at the home do not assist with any of their care needs. Residents of the care home and tenants of the sheltered housing mix well together and help each other and creates a ‘family’ ethos within the home. There is no dedicated accommodation for residents with a dementia type illness, however additional safety measures are in place for these residents. The manager is responsible for the entire complex. The care home is located over three floors, with two floors being used for residents’ accommodation. The home has one undesignated room that is used for emergencies. The rest of the accommodation consists of 16 single rooms, of which two have en suite facilities and two double rooms that do not have en suite facilities. There are two assisted bathing facilities, one assisted shower room and nine communal toilets located throughout the home. Grab rails are located throughout the home. There is a good-sized dining area and a good-sized lounge room. There is a smaller lounge room used as a library and can be used by residents when they Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 5 have visitors/parties. The home has been tastefully colour co-ordinated to assist people in orientating themselves to the different areas within the home. A room within the home has also been decorated and furnished as a hair salon for the residents. There is a passenger shaft lift to assist residents to access all areas of the home. There is a large garden area at the rear of the home and residents have use of a small greenhouse if they wish. There is level access provided for wheelchair users. The home has car-parking facilities for up to eight to nine cars, otherwise there is restricted paid parking in adjacent areas. Weekly fees range from £450 to £545 depending on the assessed needs of an individual. Additional costs are; Hairdressing (£4 - £17), chiropody (£9), name tapes for clothing (£3.60), toiletries, outings and newspapers are variable in costs dependent on the individual’s wishes. There may be additional costs for opticians and dentists etc. depending on an individual’s health care arrangements. This information was provided to the CSCI on the 16 June 2006. Copies of previous CSCI inspection reports are available upon request at the home and there is a notice board where a copy of the most recent report is kept for anyone to read. Prospective residents and their relatives find out about the service through the homes’ web site, information from churches, Christian magazines, from living in the area and by word of mouth. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Pilgrim Homes will be referred to as ‘residents’. This unannounced inspection took place over seven and three quarters hours on the 18 August 2006. Thirteen residents, of both genders and over the age of 65 years, were spoken with during the inspection. Some tenants from the sheltered housing were also spoken with throughout the process. Ten resident surveys were sent to the home prior to inspection, of which none were returned. Two care plans were looked at in detail. Specific areas of care needs were looked at in three other care plans. The Registered Manager and three staff were spoken with. Ten staff surveys were sent prior to the inspection of which four were returned. Five staff files were inspected. Out of five GP comment cards sent out prior to inspection, two were returned. No contact was made with visiting relatives/visitors. A pre inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Activity records, fire records, accident records and medication procedures were inspected. The quality assurance system was checked and complaint records were viewed. Previous requirements at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the pre inspection questionnaire. There were 18 residents residing at the home on the day of the inspection. The Registered Manager facilitated this inspection. What the service does well: The home has a homely and inclusive atmosphere and tenants from the sheltered housing and residential care home interact well with each other. A comment made by numerous people was ‘it’s like we’re an extended family’. The home meets the religious needs of the residents. The home has a good admissions procedure that ensures only residents whose needs can be met will be admitted into the home. Staff were observed to have a good professional rapport with residents. The home provides a good standard of care and the documentation in the care plans provides guidance for staff and are regularly reviewed. The home has a good rapport with Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 7 visiting health professionals, ensuring that residents’ health needs are being met. Visitors are welcomed at the home. Residents’ privacy and dignity are respected. Residents were complimentary about the food and are provided with a variety and choice of meals. Residents live in a safe and comfortable environment and are able to personalise their individual rooms. Residents feel comfortable to and know how to make a complaint and feel that they will be listened to. Residents spoken to were complimentary about the staff working at the home. Staff receive regular training and supervision to ensure they are skilled and competent to meet the needs of the residents. There are suitably qualified staff on duty at all times. The home is well managed and staff spoken with were complimentary about the Registered Manager at the home. There is a structured quality assurance and quality monitoring system in place to actively obtain feedback from all people involved with the home, to ensure the home is run in the best interest of residents. There are suitable procedures in place for the safe handling of residents monies. All relevant health and safety checks are regularly undertaken. What has improved since the last inspection? What they could do better: Care notes provide limited information on the health status of an individual and do not refer to the mental health needs to assist staff in monitoring the well being of residents. Notes needs to be expanded and a requirement has been made in respect of this. Clearer information provided to staff on the procedure to take in the event of an allegation of abuse being made will prevent any confusion. The information in the Protection of Vulnerable Adult and Elder Abuse policy and procedures provide conflicting information in the action to take. A requirement has been made in respect of this. It is recommended that staff administering medication should receive training prior to administering medication from an external company that is competence based and ongoing. Any handwritten prescriptions on MAR charts should be checked and double signed by two staff who have undertaken Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 8 medication training and any hand written amendments on MAR charts are to be signed. The recording of activities could be improved to ensure that all residents are provided with opportunities to participate in activities that are within their interests and abilities. It is recommended that individual rooms are locked if the service user is in hospital, to ensure their belongings are safeguarded. The home needs to continue to work towards that ratio of 50 of care staff obtaining National Vocation Qualifications (NVQ) level 2 or equivalent qualifications. 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 DS0000014263.V298497.R01.S.doc Version 5.2 Page 9 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 DS0000014263.V298497.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home and the pre-admission assessments undertaken ensure that only residents whose needs can be met are admitted. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide prospective residents/representatives with information on the facilities and services provided at the home. A copy of these documents was sent to the Inspector prior to the inspection. It was discussed with the Registered Manager that the information provided on the number of NVQ qualified staff be updated to reflect current numbers. The Registered Manager undertakes a pre admission assessment on all prospective residents. Some of the residents have previously lived in the sheltered housing section of the establishment and have moved into the care Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 11 home section when their independence decreased. These residents are already familiar with the home and know other residents and the staff. Prospective residents that come from outside the establishment’s environment are encouraged to visit the home prior to moving in. They are able to stay for a meal if they choose. Some residents that were spoken with confirmed that they or a relative had come to visit the home prior to moving in. The Registered Manager confirmed that it is stated in the contract that the first four weeks are considered as a trial period to ensure the resident is happy at the home and that all needs can be met. The trial period can be extended if necessary. Copies of social services care plans are taken wherever possible. The Registered Manager confirmed that there was no one residing at the home that was from any minority ethnic communities, social or cultural groups with any specific needs or preferences. All residents residing at the home are of Protestant Christian belief and the Registered Manager, Administrator and Care Team Leader are also of the same faith. On speaking with residents, all confirmed that the home does well to meet their religious needs. The home does not have dedicated accommodation to provide intermediate care. Respite care is available if there is a vacancy. The home has a waiting list for prospective residents. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are generally being met with the information provided in the care plans on the assessed needs of residents. Residents’ privacy and dignity are respected. EVIDENCE: Care plans generally provide staff with clear guidelines on the assessed needs of individuals. There was evidence that these were being reviewed on a monthly basis. Daily notes read on one resident referred to a dressing being required, there was nothing in the care plan to reflect this need. Care notes written on individuals do not provide sufficient information to monitor their health. It is important that the mental health status of residents, particularly those with a dementia type illness, is recorded and provides a clear picture of the status of an individual in order to assist staff in the early detection of behavioural changes and any deterioration in health. Writing ‘all well’ or ‘much better’ does not provide suitable information. Staff must also be reminded that if an error is made, it is lined through and signed and not scribbled out. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 13 There is a key worker system in place and care plans are reviewed on a monthly basis. It was confirmed that annual reviews are done with the involvement of residents/representatives. There was evidence that the resident signs the annual reviews. It was confirmed that the senior staff with the involvement of the resident completes monthly reviews. Care plans are sent to the resident’s representative who will sign and return the care plan to the home. Representatives are notified of any changes in the needs of their relative/friend. The Registered Manager confirmed that social services will also visit the home to undertake annual reviews of the residents they are purchasing care for. Residents are weighed three monthly and nutritional records are kept for individuals where staff may have concerns. Residents’ health needs are being met at the home and specialist advice is sought when the needs arise. Some residents observed to be wearing glasses confirmed that they receive regular eye checks. One resident has hearing difficulties and the home has purchased a communicator to assist people to communicate with this individual effectively. Both GP comment cards received demonstrated that they are able to visit their patients in private and are satisfied with the overall care provided to residents within the home. One stated that any specialist advice given is incorporated into the residents care plan. One staff survey received demonstrated that individuals are aware of the needs of residents living in a care home environment. A written comment about what the care home does really well was; ‘We support and encourage them to be as independent as possible and we support them physically, mentally and spiritually.’ The home admits residents with low needs, if they are assessed as having a dementia type illness. To ensure these residents are also able to move freely around the home some wear sensor bracelets that will set off sensors if they wander out of specific areas within the home. These are non-obtrusive bracelets and have been put in place with agreement from the residents/representatives. It was confirmed that there are policies and procedures in place for all aspects of dealing with medications, the content of these were not read. There were no controlled drugs being used at the home on the day of the inspection. There are records kept of all incoming and outgoing medications. On inspection of MAR charts, it was noted that some medication had been signed for but not given. Apart from the few incidents noted, there were clear records being kept of medication being administered. The Registered Manager will know who was administering medication on the day of the errors and will address this with the individual involved. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 14 Some prescriptions on MAR charts had hand written amendments on them, that had not been signed to show who had made the changes. Any handwritten prescriptions on MAR charts should be checked and double signed by two staff who have undertaken medication training, to ensure staff and residents are safeguarded from errors being made. Sample signatures are kept of all staff administering medication. Residents are provided with an opportunity to self medicate, based on a thorough risk assessment being undertaken. Risk assessments for residents self-medicating were unable to be located on the day of the inspection. A copy of these documents was forwarded to the Inspector after the inspection. The pharmacist provides medication training on an annual basis. Staff receive training on in-house procedures by the Care Team Leader who used to be a registered nurse. Staff administering medication should receive training from an external company that is competence based and ongoing prior to administering medication. The staff were signing ‘O’ on MAR charts that relates to ‘other’, there was no specification as to what this abbreviation means. Both GP comment cards stated that residents medication is appropriately managed in the home. Of the residents that were asked, all confirmed that they felt their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term of address. Staff were seen to knock on individual room doors prior to entering. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: There is no activities person employed at the home. Staff have allocated time every afternoon to provide activities for residents, except Sundays when there is a church service. There is no activities schedule and residents decide on the day what they wish to participate in. Residents spoken to were overall satisfied with the activities provided at the home. Some of the activities recorded were; videos, pampering sessions, talk box (cards drawn from a box with discussion topics), reading, soft ball throwing and music. The recording of activities could be improved as records inspected demonstrated that there were no activities provided between the 03/08/06 and 10/08/06. It was confirmed that this was not the case. The Registered Manager confirmed that activities are documented in the residents care plan and daily care report. The home does well to meet the religious needs of the residents. Residents spoken to confirmed that the home meets their religious needs. There is a Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 16 church adjacent to the rear garden at the home, that has level access, and residents are able to use the adjoining entrance to access the church. A resident said grace before residents ate lunch. It was also observed on the day of the inspection that all rooms have a speaker box present and residents are able to listen to a service in their own rooms if they are unable to or choose not to go in person. As one of the activities, residents make cards that are on display in the home and available for sale. The home also has a little shop on site that sells sweets, stationary and toiletries for those residents who are unable to make it to the local amenities. Of all the residents asked, all felt that their lifestyle within the home were their own choice. Individuals choose when they go to bed and get up etc. Residents were observed to move freely around the home. Visitors are welcomed at the home and there is a visitors book that all must sign upon entering and leaving the home. Residents are able to receive their visitors in private if they wish. The home is currently in the process of renovating a guest room that will be available for use to visitors that may require staying overnight. Residents were complimentary about the food provided at the home and confirmed that they have a choice. The menu rota provided to the Inspector demonstrated that there is a variety of nutritional meals available. Days where there is no choice of meals is when a roast dinner is provided. The Registered Manager confirmed that all residents enjoy their roast dinners and an alternative is not required. The Inspector ate fish and chips with the residents and lunch time was observed to be a social time for residents and for the tenants that may have meals provided by the main kitchen. Staff were observed to be available to offer discreet assistance when needed. Residents were observed to be enjoying their fish and chips. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 “Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Clearer written policies and procedures for the Protection of Vulnerable Adults (POVA) will better safeguard staff and residents. EVIDENCE: There is a suitable complaints procedure in place. There have been no complaints made directly to the CSCI and none made to the home within the last 12 months. A copy of the complaints procedure is on the notice board for all residents/visitors to access. Of the residents that were asked, all confirmed that they know who to speak to if they had to make a complaint. There has been one Protection of Vulnerable Adults (POVA) investigation since the last inspection. This was in the form of a complaint made to social services regarding manual handling technique used for a resident. This was found to be unsubstantiated and no further intervention was necessary by Social Services. The home has an Elder Abuse procedure and an updated copy of the POVA procedure has been forwarded to the Inspector. These documents do not compliment each other regarding the advice on the action to take in relation to an allegation of abuse being made. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 18 The updated POVA procedure from the home, dated 01/07/06, instructs management to undertake internal investigations prior to notifying social services and the CSCI. This is contrary to the local multi-agency policy and such action could jeopardise external investigations. Advice should be sought form the local authority to ensure internal guidelines and procedures are compliant. No investigation should be undertaken by the home without guidance from social services, who are the lead authority. The Registered Manager confirmed that she attended the local Brighton and Hove City Council POVA training course designed for managers last year. All staff undertake in house POVA training once a year, unless it is identified as being required earlier. Staff spoken with confirmed that they have received training in POVA and are familiar with the procedures to take in the event of an allegation being made. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Residents spoken with are happy with the environment and with their individual rooms. Rooms were seen to be personalised to reflect the individuals’ character and personality. The home has been decorated to a good standard and is colour co-ordinated throughout to assist all people involved with the home with easier orientation. The home employs a full time maintenance person. Where a resident was in hospital their room was not kept locked. This should be addressed. The Inspector was informed that it was left open for airing. However, when residents are in hospital, steps need to be taken to ensure their belongings are safeguarded. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 20 There is a post box at the home for all residents to post their letters in and this is emptied on a daily basis by the home. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Radiators are guarded or have guaranteed low surface temperature. Hot water taps are regulated and dispense water around the recommended 43°C. The pre-inspection questionnaire demonstrates that the hot water temperatures are tested on a weekly basis. Hot water outlets tested were dispensing water at 42°C. There were some windows that were noted to be unrestricted. The Registered Manager spoke with the Inspector the following day and confirmed that the stops for the window had been pushed in. The Registered Manager confirmed that all windows are now restricted. No requirement has been made in respect of this. The home was clean and free from offensive odours on the day of the inspection. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for communicable diseases and infection control. The content of these policies were not read. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the robust recruitment procedures in place. EVIDENCE: Residents spoken to were very complimentary about the staff working at the home. Staff and residents spoken with on the day of the inspection confirmed that they felt there were sufficient numbers of staff on duty at all times. Both GP comment cards confirmed that staff demonstrate a clear understanding of the care needs of the residents. One comment from a GP was ‘everyone I come into contact with is extremely helpful and caring’. The home employs 24 care staff in total. There are five care staff with NVQ level 2 and a further two with NVQ level 3 qualifications. An additional two staff are currently undertaking NVQ level 2 studies and two will be commencing this course in October 2006. The current ratio of staff with NVQ qualification does not meet the recommended 50 . Staff files viewed demonstrated that there is a robust recruitment process in place. Suitable references, Criminal Record Bureau (CRB) checks and POVA checks are undertaken. The home currently has two staff vacancies and have been using some agency staff recently. The home ensures that the agency provides the same carer wherever possible to ensure continuity is maintained for the residents. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 22 All staff spoken to on the day of the inspection confirmed that they are provided with sufficient training relevant to their roles. There are records kept of the training provided to staff. All new staff must complete an induction booklet that has been designed by Pilgrim Homes. The Registered Manager confirmed that this complies with the Skills for Care specifications. New staff shadow regular staff for five shifts on initial commencement of employment. There is a staff training room at the home and Pilgrim Homes has an in house trainer that provides staff with annual update of all mandatory training such as; manual handling, health and safety and fire training. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 “Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Staff and residents benefit from a well run home. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The Registered Manager is registered with CSCI and has been working at Pilgrim Homes since March 2003. Prior to this position she was a care home manager for eight years. She is an Enrolled Nurse and a Registered Nurse Mental Health and completed the Registered Manager Award in November 2005. Staff spoken with were complimentary about the Registered Manager and Care Team Leader at the home, confirming that they are both supportive and approachable. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 24 Comments written on two of the staff surveys demonstrated that the individuals enjoyed working at the home. Some of the comments were ‘there is a big sense of community within the home. Everyone feels as if they are part of one large family group’, ‘Our care home provides a lovely atmosphere for our residents to live in’, ‘The home is always clean and welcoming’. Staff receive regular supervision and undertake an annual appraisal. All four staff surveys received confirmed that they receive formal one-to-one supervision. The home has a quality assurance and quality monitoring system in place. Views are sought from residents/relatives, staff, GP’s and district nurses. Questionnaires are given to 10 of the residents every month. Relatives are encouraged to complete surveys when they visit. Results of the quality assurance surveys are analysed twice a year, displayed in a bar graph format. These results are displayed on the notice board within the home and shared with the residents at their meetings. Resident and staff meetings are held every three months. There is a monthly newsletter sent to all Pilgrim Homes from the head office providing a variety of information. A magazine is also sent to all the homes every quarter. Anyone involved in any of the homes may contribute to this publication. Personal allowances checked evidenced that there are suitable procedures in place for dealing with residents’ personal allowances. The home does not act as an appointee for any resident. Receipts are kept of any financial transactions. Personal allowances for the residents are kept securely within the premise. There are suitable records kept of any accidents/incidents within the home and the CSCI is notified of all relevant incidents. The home checks the fire alarms on a weekly basis and staff undertake fire training once a year and regular fire drills are undertaken. Other health and safety records were not inspected as this information was provided in the preinspection questionnaire. The Registered Manager confirmed that the homes fire risk assessment is due to be updated soon. The fire door to the laundry and kitchen were not closing effectively on the day of the inspection. The laundry door was getting caught on the flooring and the kitchen door was being wedged open. The Registered Manager has confirmed in writing to the Inspector following the inspection that new fire doors have been ordered. This is not reflected as a requirement as the home is taking action to address this issue. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 25 The Registered Manager confirmed that Environmental Health inspected the kitchen the week before the CSCI inspection. It was confirmed that there were no shortfalls highlighted. The kitchen is due for a refit in November 2007. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 26 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 4 3 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 2 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 X 3 Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 27 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. 1. 2. Standard OP7 OP18 Regulation Schedule 3 (k) 13(6) Requirement That daily records about service users are expanded. That the organisation seeks guidance from the local authority regarding action to take in the event of an allegation of abuse being made. Timescale for action 30/09/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP9 Good Practice Recommendations That handwritten prescriptions on MAR charts be checked and double signed by two staff who have undertaken medication training. That any hand written amendments on MAR charts are signed. That staff administering medication should receive training prior to administering medication from an external company that is competence based and ongoing. That individual rooms are locked if the service user is in hospital. That the home continues to work towards the 50 ratio of DS0000014263.V298497.R01.S.doc Version 5.2 Page 28 OP9 OP9 OP23 OP28 Pilgrim Homes care staff with NVQ level 2 qualifications. Pilgrim Homes DS0000014263.V298497.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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