Inspection on 28/11/05 for Pilgrim Homes

This inspection was carried out on 28th November 2005.

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 18/08/06

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 Glynis McLeod Unannounced Inspection 28th November 2005 13.30p 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.V249654.R01.S.doc Version 5.0 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.V249654.R01.S.doc Version 5.0 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 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.V249654.R01.S.doc Version 5.0 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. 20th June 2005 Date of last inspection 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 DS0000014263.V249654.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was unannounced, took place over three hours and was one of two inspections required over the year. A tour of the premises took place and records relating to care, staffing, management and maintenance were inspected. The inspector spoke to residents, staff members and the manager. Residents expressed their satisfaction with the service, and a new staff member said that the home was run in a very professional way. 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? The home has completed the work of fitting self-closing mechanisms to all the fire doors in the building to ensure that residents and staff are fully protected in the event of a fire. All updated information in residents’ files is now signed and dated so that staff are clear about the latest care instructions. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 6 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. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 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 DS0000014263.V249654.R01.S.doc Version 5.0 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 the following standard(s): The key standards were inspected at the previous inspection. No other standards were inspected at this inspection. EVIDENCE: Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 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 the following standard(s): 7 The homes’ policies, procedures and practices ensure that residents’ health, personal and social care needs are clearly identified and met. EVIDENCE: Following a recommendation at the previous inspection, care plans are now signed and dated when any changes are made so that staff are clear about the latest care guidelines. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 10 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): 14 Residents are encouraged to be independent and to make choices about their lives. EVIDENCE: Residents are able to bring their personal belongings into the home with the agreement of the manager. They are also encouraged to read and sign their care plans so that they are aware of and agree with the information the home holds on them. Residents spoken to were aware of their care plans and said they appreciated being asked to contribute to them. Enduring Power of Attorney forms are signed by each resident on admission and activated if the resident can no longer manage their own affairs. Family members or church friends are able to act as advocates if needed, or the home can access advocacy services from other agencies if required. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 11 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 and 18 Policies and procedures ensure that residents are protected from abuse and that complaints are properly listened to and investigated. EVIDENCE: The home has a clear complaints policy that contains all the information required in the standard and regulations and gives staff clear guidelines on how to respond to and record complaints. The manager stated that she tries to deal with concerns at an early stage before they become complaints and residents confirmed that that was the case. There were no complaints recorded in the home and none had been made to the Commission. Adult protection procedures and policies, including the whistleblowing policy, were also clear and advised staff on their responsibilities to report abuse. The manager was fully aware of local multi-agency guidelines and new adult protection legislation. A recommendation was made that the home should remove the word ‘investigation’ from its adult protection alert forms since it gives confusing messages to staff who might be under the impression that they should investigate allegations of abuse themselves, rather than referring them immediately to the local social services adult protection team. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 12 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): 21 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: The home’s maintenance man has recently built a specialised vanity unit into one of the bedrooms enabling a wheelchair user to be more independent. The wheelchair can be pushed up close to the sink so that the resident is able to wash herself without assistance thus promoting her dignity and privacy. There are plans to build more of these special units to help other residents. The home is to be commended on the action they have taken to help residents maintain their independence. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 13 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 and 30 The home employs sufficient numbers of trained and experienced staff to ensure that residents’ needs are properly met. In order to protect residents, the home carries out the necessary checks on staff before they begin working at the home. EVIDENCE: The home has recently had to use more agency staff than usual due to sickness and staff leaving. They have now recruited more permanent staff and are up to strength again. 50 of staff are NVQ 2 trained, with another three staff members waiting to start their course. Two of the senior staff are NVQ 3 trained. Recruitment procedures are thorough and files contained all the required information. All the necessary police and adult protection checks had been carried out ensuring that only suitable staff are employed at the home. New staff undergo a structured induction programme and have fortnightly meetings with the manager over the first six weeks to monitor how they are settling into the job. On the day of the inspection, a new member of staff was on duty and was shadowing a more experienced worker. She confirmed that she had gone through a proper recruitment process and that she had been given a health and safety induction. Staff are responsible for their own training and development folders with the manager making periodic checks to ensure they are up-to-date. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 14 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, 33, 35 and 38 The manager is experienced and capable, and runs the home efficiently and effectively. The home ensures that residents, their families and other professionals are invited to comment on how the home is run. The management team also regularly monitors and reviews the service it is providing to ensure that it is run in the best interests of the residents. The home ensures that residents’ finances are properly safeguarded by its policies and procedures. The health and safety of residents, staff and visitors is also protected. EVIDENCE: The manager is a trained nurse and has recently achieved her NVQ4 in management. She has 11 years managerial experience and is committed to keeping herself updated with current practice and new legislation. Her senior Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 15 care team is experienced and well-qualified and the home is supported by senior managers who visit on a regular basis. There is an effective quality assurance and monitoring system in place with a rolling programme of questionnaires for both residents and staff. The manager has produced a comprehensive strategy for the home for the coming year, which looks at the premises, staff and training, finance and residents’ quality of life. Policies and procedures are updated annually by the organization’s head office and monthly and annual audits take place. Financial procedures and records in the home were inspected and found to be accurate and up-to-date. Following a requirement at the previous inspection for self-closers to be fitted to doors to provide extra safety in the event of a fire, this work has now been completed. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 16 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x 4 x x x x x 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 DS0000014263.V249654.R01.S.doc Version 5.0 Page 17 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 Refer to Standard OP18 Good Practice Recommendations The home should remove the word ‘investigation’ on its adult alert forms to avoid giving confusing messages to staff. Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 18 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. Extracts may not be used or reproduced without the express permission of CSCI Pilgrim Homes DS0000014263.V249654.R01.S.doc Version 5.0 Page 19 - 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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