Inspection on 03/08/07 for Pilgrim Homes

This inspection was carried out on 3rd August 2007.

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 18/08/06

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 Gwyneth Bryant Key Unannounced Inspection 3 August 2007 09:30 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.V345533.R02.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.V345533.R02.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 anne.gower@wfcsmail.com 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.V345533.R02.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. 18th August 2006 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.V345533.R02.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. Currently weekly fees range from £490 to £588 depending on the assessed needs of an individual. Additional costs are; Hairdressing, chiropody, 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. . 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.V345533.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over 5.5 hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. There were twenty people in residence on the day of which two were spoken with individually. The Registered Manager, two relatives and carers, as a group, were also spoken with. Following the site visit three relatives were contacted via telephone to seek their views on the service. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Both relatives and people living in the home spoke highly of the care and the dedication of staff and manager. Comments from those spoken with included: ‘couldn’t wish for better care’ ‘we certainly are looked after – no doubt about that’. ‘staff are very good – they really look after mum’ ‘I was very impressed by the way they identified all mums specific needs and how well she is looked after’ ‘Staff very helpful and friendly, shame that they have some agency staff, but I have a good relationship with manager and regular members of staff’. ‘they (staff) always let me know if there is a problem’. What the service does well: The atmosphere of the home is comfortable, homely and relaxed. The home has a core team of staff who have a good understanding of the needs of the people living at the home and they were observed to treat them with care and respect. People living in the home are encouraged to bring their own possessions to the home and many have done so and individuals’ bedrooms are well maintained and the décor of the home is good throughout. Systems for dealing with complaints are satisfactory ensuring that any concerns are listened to and acted upon. Routines are flexible enabling people to maintain control over their daily lives and a daily programme of activities is provided, including daily devotions to ensure religious needs are met. A suitably qualified person has assessed the premises and sufficient equipment is provided to enable people in the home to remain independent. Staff have sufficient training to ensure they have the skills and knowledge to meet the assessed needs of people in the home. Visitors are welcome at all times and during the site visit it was evident that they were comfortable with both staff and manager. Comprehensive safety checks are carried out on all equipment Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 7 on a regular basis to ensure the health and welfare of people in the home is consistently protected and promoted. 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 DS0000014263.V345533.R02.S.doc Version 5.2 Page 8 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.V345533.R02.S.doc Version 5.2 Page 9 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): 3 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to people moving into the home, which ensures that their needs can be met, and they are provided with detailed information on services offered by the home. EVIDENCE: Pre-admission documentation was viewed and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective service users. At the time of admission information is also sought from social and healthcare professionals to ensure all needs are clearly identified and planned for. Relatives spoken with confirmed that they were provided with detailed information prior to admission. Intermediate care is not provided. Pilgrim Homes DS0000014263.V345533.R02.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. All aspects of the health, social and care of those living in the home are met but improvements need to be made to some aspects of the care recording process to enable staff to deliver care in a structured and consistent manner. EVIDENCE: Five care plans were examined and found to contain most of the required information although recording was not always consistent with the information in the daily notes. There is a key worker system in place to ensure those living in the home always have a named person to deliver care. In addition, individuals’ bedrooms contain a written profile of the role of their particular key worker. Some inconsistencies were found in respect of risk assessments. One care plan showed that the individual had an unsteady gait but this was not reflected in the moving and handling risk assessment. A further issue was that while one person was noted to need encouragement to eat, their care plan did not include direction to staff as to how this was to be achieved. While the Registered Manager and staff were knowledgeable about the care needs of individuals, it is important to record all care needs, as currently there is a reliance on good staff communication and good memory. Those spoken with Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 11 said they felt staff looked after them well and staff were seen to treat them with care and respect. Relatives spoken with confirmed that people are well looked after and that care needs are met. In addition relatives said that they were involved in the care planning process and are notified of any changes in needs or issues. There was evidence that people living in the home have access to healthcare professionals including opticians, dentists and chiropodists. Medication records were viewed and systems are satisfactory and medication administration charts were up to date and clear. The Registered Manager confirmed that all staff who administer medication have received up-to-date training on the safe handling of medication. Pilgrim Homes DS0000014263.V345533.R02.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have the opportunity to experience a lifestyle that matches their expectations, choice and preferences in respect of meals and leisure activities. EVIDENCE: The Registered Manager confirmed that a varied programme of activities is provided including doll therapy, visiting dogs and rabbits in addition to visits from local youth groups and schools. In keeping with the ethos of the home devotions are carried out each morning and again after supper, ensuring religious needs are met. The Registered Manager also said she is in the process of obtaining simple musical instruments with a view to providing an opportunity for individuals to play them. The Registered Manager has also arranged exchange visits with another care home in West Sussex in order to widen social contacts for people living in the home. Relatives spoken with all confirmed that they were made welcome by staff and the manager and offered refreshments when they visited. Comments included: ‘the food is fine but I like my sweet and sour instead of fish on Fridays’. ‘we are offered refreshments when we visit’. Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 13 ‘we can use the small lounge for birthday get togethers’. ‘some meals are a little too heavy, especially the sausages which are a little indigestible for older people’. The current weeks menus were viewed and found to be well balanced with a choice at each mealtime. Two relatives spoken with following the site visit said that some meals tend to be heavy for older people and although this had been mentioned to the Registered Manager but no action had been taken. Therefore it would be of benefit to people living in the home if menus were reviewed following consultation with both relatives and individuals living in the home. The lunchtime meal was observed and the food was attractively presented and it was clearly enjoyed by those living in the home. Pilgrim Homes DS0000014263.V345533.R02.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 28 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system with evidence that those living in the home, felt confident their views would be listened to and further protection is provided by robust adult protection procedures. EVIDENCE: The home has detailed policies and procedures on complaints and all complaints are recorded and include actions taken and outcomes. In addition all comments from surveys are collated and action taken to address identified shortfalls. People spoken with confirmed that they knew who to contact if they had a complaint. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. All staff in the home have now been trained in adult protection procedures ensuring that appropriate action will be taken in the event of an allegation. Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. . The standard of decor throughout the premises is good, providing a homely, safe and comfortable for those living in the home. EVIDENCE: A tour of the premises was carried out and all parts of the home are well maintained and attractively decorated. Individuals’ bedrooms were attractively decorated and it was evident that many had taken the opportunity to personalise their rooms with pictures and ornaments. Although the front of the premises opens onto the street there is a large garden to the rear of the property and people living in the home may use the small greenhouse if they wish. Hand and grab rails are fitted as required and communal bathing facilities include assisted baths for the comfort and safety of those whose mobility is impaired. There is a light and airy large lounge and dining area both of which are furnished with good quality furniture and attractively decorated. The small Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 16 lounge is used for visits and includes a telephone to enable calls to be made in private. Systems are in place for the control of infection and all staff have been trained in this area and were observed to be working in ways that minimised the risk of infection, by wearing gloves and aprons when required. Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with the skills and knowledge to provide consistent care to those living in the home and recruitment practices are robust and offer further protection to those living in the home. EVIDENCE: There is three care staff on duty for the morning shift and two for the afternoon and night shifts. The home also employs a gardener, administrative staff, domestics and laundry staff. Currently there a seventeen care staff of which four have National Vocational Qualification in care at level 2, and two have National Vocational Qualification at level 3. In addition four staff have just completed this qualification and are awaiting certification and a further two are in the process of achieving level 2, demonstrating that the service meets the target of 50 of care staff with at least National Vocational Qualification at level 2. Comments from those spoken with included: ‘staff seem incredible’ ‘I’m so grateful for the care given by staff’. ‘staff know what they are doing, a good bunch and they work together – makes a lot of difference to the atmosphere’. ‘the staff are so kind and caring’. ‘staff are always helpful when I visit’. Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 18 One relative said ‘ I have staff found to be very helpful and friendly, its a shame that they have some agency staff, but I have a good relationship with manager and regular members of staff’. The staff handover was observed and it was clear that senior staff and other carers are familiar with the individual care needs of people living in the home and know what action to take to meet those needs. The Registered Manager confirmed that all new staff undergo a 12-week induction period that meets the Skills for Care criteria. Recruitment records for the last three people to be recruited were examined and all had provided proof of identity and two written references in addition to satisfactory Criminal Record Bureau and Protection of Vulnerable Adults First checks. In addition they also provided a full employment history and completed a health declaration. Staff training records showed that there is a comprehensive staff training programme to ensure all staff receive up to date training in moving and handling, Control of Substances Hazardous to Health, Protection of Vulnerable Adults, health and safety and fire safety. 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 Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 19 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. . People living in the home benefit from clear leadership and direction and all aspects of their health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager is suitably experienced and qualified and provides good leadership, in an open and approachable manner. Throughout the site visit it was evident that staff, visitors and people living in the home were happy to approach her with any concerns and those people spoken with confirmed this. The Registered Manager carries out a number of quality assurance procedures including providing surveys for both relatives and those living in the home, staff training, resident and staff meeting and staff supervision. These activities are structured and collated as part of the quality monitoring process to enable Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 20 the Registered Providers to evaluate all aspects of the service and ensure it is run in the best interests of those living in Pilgrim Homes. The home holds some monies on behalf of those living in the home and receipts are provided and all transactions recorded satisfactorily. The Registered Manager confirmed that regular checks are carried out to ensure that equipment, gas and electrical systems and appliances are safe. In addition call bells, fire alarms and water delivery temperatures are checked weekly to ensure that the safety of both staff and those living in the home is maintained. A fire safety risk assessment has been carried out on the premises and an evacuation plan has been devised to ensure compliance with the latest fire safety guidance. Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 21 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 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 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 DS0000014263.V345533.R02.S.doc Version 5.2 Page 22 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. Standard OP7 Regulation 15(1)(2) (b) (c) Requirement That care plans are consistent with the daily notes and the information in risk assessments. Timescale for action 03/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pilgrim Homes DS0000014263.V345533.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000014263.V345533.R02.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!