Inspection on 20/06/05 for Pilgrim Homes

This inspection was carried out on 20th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/08/06

Pilgrim Homes 28/11/05

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 Glynis McLeod Unannounced 20 June 2005 09:45 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Pilgrim Homes Address 35/36 Egremont Place Brighton East Sussex BN2 0GB 01273 606940 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pilgrim Homes Anne Gower Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (OP) 21 of places Dementia - over 65 years of age (DE(E)) 7 Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty-one (21). 2. Service users will be aged sixty- five (65) years or over on admission. 3. Only seven (7) service users with a dementia type illness are to be accommodated. Date of last inspection 22 September 2004 Brief Description of the Service: Pilgrim Homes is a charity that operates eight care homes across the country, aiming to provide care to elderly Protestant Christians. The Brighton building dates back to 1879, and the purpose-built care section, which was added in 1974, is registered for 21 older people, including seven places for people with mental impairment: it also includes additional sheltered and very sheltered flatlets. The home does not provide nursing care. The manager is responsible for the entire complex. The home is built on a hill overlooking the sea, and is close to Queen’s Park, and St James’s Street shopping area. There are regular bus services to the centre of Brighton, and all local amenities are within easy reach. Wide corridors and a lift to all floors make the home particularly suitable for wheelchair users. There is a garden and patio area to the rear of the property. The home has a no smoking policy within the building. Pilgrim Homes has achieved Investors in People Award and Clean Food Award. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was unannounced, took place over four hours and was one of two inspections required over the year. A tour of the premises took place and records relating to care, medication and maintenance were inspected. Three of the residents, three staff members, a visitor and the care manager were spoken to. Comments were very positive about the service; the visitor stated that the atmosphere in the home was ‘friendly and peaceful’. The inspector would like to thank the residents and staff for their hospitality and assistance during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home has started to fit self-closing mechanisms to all the fire doors in the building and this work should continue to ensure the full protection of residents and staff in the event of a fire. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 Prospective residents are assessed appropriately before admission to ensure the home can meet their particular care requirements. Prospective residents and their relatives are given clear and comprehensive written information about the home, and have the opportunity to visit and talk with the manager before moving in so that they are clear about the services offered. EVIDENCE: Residents spoken to confirmed they had been visited and assessed by a senior member of staff before being admitted to the home. Records showed that families and other professionals are also involved in the assessment process to ensure that a full picture of the person’s needs is obtained. Residents are invited to visit the home before moving in so that they can see whether they would like to live there and a trial period is offered after moving in. A care plan summary is drawn up on admission and a full care plan is available to staff within a week to advise them of the resident’s particular care needs. The home offers respite care but does not take emergency admissions. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The homes’ policies, procedures and practices ensure that residents’ health, personal and social care needs are clearly identified and met. EVIDENCE: Care plans examined were clear and comprehensive, and showed that reviews took place regularly to ensure that all needs and risks were properly identified and assessed. The home encourages residents and their families to be part of the process. A recommendation was made that all new information added to the care plans should be signed and dated to ensure its accuracy. Records showed that residents with pressure sores were properly referred to the GP and that district nurses visited to treat as necessary. Records of health professionals’ visits were recorded in individual files and showed that residents had access to a wide range of services including chiropody and opticians. Personal and medical care is given in private. Medication policies and procedures were all in place and the home had recently had its quarterly visit from the pharmacist. Records of storage and administration were up-to-date and accurate. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 10 Staff were observed to treat residents in a friendly and polite manner and residents spoken to said staff were ‘lovely’ and ‘excellent’. Staff receive training in their induction how they should behave towards residents, and this is reinforced during supervision and by the example of senior staff. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home provides a flexible service and offers varied activities to interest residents. Visitors are made welcome in the home and are able to see their friend or relative in private. Meals are nutritious, varied and pleasantly presented with options always available. As a Protestant Christian home, there is great emphasis placed on residents’ religious and spiritual life. EVIDENCE: The home arranges daily activities, including outings, video sessions and ‘pampering afternoons’, to ensure that residents have a varied and stimulating environment. An active volunteer group offers a befriending service and helps residents with practical things, such as writing letters. The religious life of the home is very important and, in addition to the services on Sunday and Monday, residents have the opportunity to attend daily devotions and bible study. The home operates a four-week rolling menu and two choices of main meal and dessert are always available. Diabetic diets are also catered for. The food being served on the day of the inspection was well-cooked and presented and residents spoken to said it was ‘very good’. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the above standards were assessed. EVIDENCE: Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home is safe, well-maintained, clean and hygienic. Residents live in comfortable, well-decorated surroundings and have access to all parts of the building and the garden. EVIDENCE: A full-time maintenance man ensures the home is safe, well-maintained and attractively decorated. Checks on water temperatures, emergency lighting and wheelchairs are carried out regularly to ensure the protection of residents. A significant amount of improvement to the property, both internally and externally, has taken place since the last inspection, including a new handrail and path leading to the back door. A main corridor and several bedrooms have also been redecorated. A dedicated domestic team, including a laundry person, ensure the premises are always clean and odour-free throughout. Sluicing and laundry facilities are provided to ensure the control of infection. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the above standards were inspected. EVIDENCE: Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Safety policies and procedures in the home are comprehensive and staff are given clear guidelines on how to protect their own and the home’s residents’ health and safety. The home does have self-closing mechanisms fitted to all the fire doors on the premises, however the residents prefer the doors to be left open. To ensure the safety of residents in the event of a fire the programme of fitting self-closers to all fire doors must continue. EVIDENCE: The manager and maintenance man have joint responsibility for health and safety in the home and conduct regular internal audits to ensure that the premises are safe and secure, and that staff follow safe working practices. A full audit by the organization’s health and safety officer took place recently and the home acted promptly on the minor recommendations made as a result of the visit. On the day of the Commission’s inspection, many resident’s bedroom doors were observed to be wedged open. These are fire doors designed to protect residents in the event of a fire, and must not be wedged ajar. The Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 16 home has started a programme of fitting self-closing mechanisms to all doors in the building (doors to communal areas have already been fitted) and a requirement was made that this must continue. The need for a requirement is reflected in the score for this standard. Records showed that regular servicing of gas, electrical and fire equipment had been carried out, and that fire drills had taken place. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 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 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 2 Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 38 Regulation 23(4)(a) Timescale for action Self-closing mechanisms must be 31.12.05 fitted to all fire doors. Requirement 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. Refer to Standard 7 Good Practice Recommendations All updated information in service user files should be signed and dated. Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Pilgrim Homes H59-H10 S14263 Pilgrim Homes V218898 200605 Stage 4.doc Version 1.20 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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