Inspection on 24/10/07 for Pilgrim Homes (Grocot Road)

This inspection was carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 (Grocot Road) 04/05/06

Pilgrim Homes (Grocot Road) 05/01/06

Pilgrim Homes (Grocot Road) 08/08/05

Pilgrim Homes (Grocot Road) 03/03/05

Pilgrim Homes (Grocot Road) 01/09/04

Pilgrim Homes (Grocot Road) 08/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Pilgrim Homes (Grocot Road) Grocot Road Evington Leicester Leicestershire LE5 6AL Lead Inspector Lesley Allison-White Unannounced Inspection 24th October 2007 10:00 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 (Grocot Road) DS0000001923.V351921.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 (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilgrim Homes (Grocot Road) Address Grocot Road Evington Leicester Leicestershire LE5 6AL 0116 2738131 0116 2731788 evington@pilgrimhomes.org.uk www.pilgrimhomes.org.uk Pilgrim Homes 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) Mrs Jennifer Leach Care Home 30 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (30), Physical disability over 65 years of age (30), Sensory Impairment over 65 years of age (1) Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category MD(E) may be admitted into the home where there is 1 person of category MD(E) already accommodated No one falling within category DE (E) may be admitted into the home where there are 13 persons of category DE (E) already accommodated No one falling within category SI (E) may be admitted into the home where there is 1 person of category SI (E) already accommodated Service User Numbers - MD (E) or DE (E) No one who falls within categories MD (E) or DE (E) may be admitted to the home when 13 persons who fall within these categories/combined categories are already accommodated 4th May 2006 Date of last inspection Brief Description of the Service: Pilgrim Home, Grocot Road, Evington is registered as a care home providing nursing care for thirty persons over the age of sixty-five. The home is situated in the village of Evington three miles from Leicester city centre and is owned by Pilgrim Homes, a Christian charity. It is within a ten-minute drive of the Leicester City Centre with a large car park at the back of the home and is also on a public transport route. Accommodation is on two floors with passenger lift access. There is a large lounge and dining room on the ground floor with a further lounge on the first floor. All the residents rooms are served by the homes call system. At the front of the premises there is a large wellmaintained garden area accessible to residents. Sheltered housing bungalows owned by the Pilgrim Homes organisation border this garden. The current range of fees is from £464.00 to £815.00 per week. There is a £20.00 reduction for shared rooms. The Statement of Purpose and Service User Guide (information about the service provided) is available for each resident or their relatives. A copy of the Commission for Social Care Inspection report is available from the foyer of the home. The current Employers Liability and The Commission for Social Care Inspection (CSCI) registration certificate are also displayed. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. The home provides care for up to thirty residents. On the day of inspection there were twenty- eight residents in the care home. The inspection took over six hours to complete. Preparation included examining inspection records and information obtained from the Annual Quality Assurance Assessment (AQQA) pre-inspection questionnaire sent to the Provider about Pilgrim Homes (Grocot Road). This aided the inspection process by providing background information. Discussion was held with four residents. However, other residents were observed in their daily routine. The two residents were unable to communicate very much with the inspector and residents relatives spoke with the inspector at length. The primary method of inspection used was “case tracking”. This involved speaking with the residents who use the service provided, looking at three residents care plans and making observations. All the required key standards were inspected during this visit. The Deputy Manager facilitated the inspection. What the service does well: What has improved since the last inspection? What they could do better: Some residents have requested to be provided with activities after tea- time. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 6 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 (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment ensures that residents’ diverse needs are identified before they move to the home. EVIDENCE: The pre-assessment forms were completed and a full assessment of need entered into the care plans, as seen by the inspector. (Care plans are care notes giving specific information about the care required for an individual resident). A trial period of four weeks is given to residents to ensure that the needs of the residents can be fully met. The Service User Guide explains that the home is able to care for elderly, needy Christians and that the Christian Society (of Pilgrim Homes) underpins everything they do. Clear information about terms Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 9 and conditions are clearly set out. Time is spent making the admission to the home personal. Standard 6 is not offered at this home. However, this Pilgrim home establishment is able to offer a variety of choices in accommodation depending on individual abilities by providing bungalows within the grounds of main home. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At Pilgrim Home (Grocot Road) staff are successful in delivering appropriate care to individual residents. Residents’ physical, mental and spiritual health care needs are met. EVIDENCE: Three care plans were inspected. Care, social, spiritual and mental needs was identified. Care plans included a record of residents’ interests and during the inspection this was seen. This is recorded in the activities and social care section of this report. Care plans are regularly reviewed and changes to care updated. Feed back and involvement by residents and their families is an ongoing process and forms part of the homes quality assessments. A key worker system is in operation at the home. The key worker ensures that the residents’ stay is made comfortable by befriending the resident, ensuring that the residents’ health and social care needs are fully met. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 11 Medications of the three case tracked residents’ at the home were checked. All were satisfactory. One of the medicines was a controlled drug. (Controlled drugs fall under the Misuse of Drugs Act 1971 which aims at checking the unlawful use of the drugs liable to produce dependence or cause harm if misused). It was checked and fine. Blister packs for dispensing medicines are used at this home. None of the residents that the inspector case tracked were self-medicating residents. (These are residents’ who manage and administer their own medications with minimal involvement by staff). Privacy and dignity is a key part of the delivery of care within the home. Staff was seen moving and handling residents after lunchtime. Once transferred to an armchair staff placed a cushion under the residents’ feet to make it more comfortable when someone was unable to touch the floor. This was seen practiced on more that one occasion and the interaction between residents and staff was good. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities within the home meet the identified daily and social needs of residents. EVIDENCE: Regular religious services are held each week, and regular bible readings are part of the daily events within the home. Those residents who are unable to attend church on Sunday morning with volunteers are able to take Holy Communion with the religious minister who visits the home on a regular basis. Residents who spoke with the inspector and their family members said that they liked the home because of the religious atmosphere of the home. One of the upstairs lounges has a room dedicated to reading. It contains many religious books for residents to use. The upstairs lounge contains a magnifier machine that enlarges written print that is too small for the reader it is available to all residents who use the lounge. A couple of residents mentioned that they would like more actvities after teatime. The deputy manager has been made aware of this suggestion from the residents. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 13 Visitors are made to feel welcome and there is a communication book in the hallway to discretely inform them of any changes in life at the home such as the hospital admissions or the loss of a resident through death. Once a fortnight, a shop “opens” in the home and sells a range of personal items. Residents who spoke with the inspector were able to confirm this. The inspector spoke with the cook. When menus are slightly changed the cook takes a list of names of those residents who had an alternative meal. Food is an important part of the lives of each resident and the meals are served to meet the need of all residents needs including those who have swallowing difficulties. A mealtime were seen and appeared satisfactory. Residents said that they enjoyed the meals. A menu board was clearly written and placed in the dining area to remind residents of the meal choices for each of the meal times. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, their relatives and friends are confident that their complaints will be listened to and acted on. EVIDENCE: The Commission of Social Care Inspection has not received any complaints about Pilgrim Home (Grocot Road) since the last inspection. Residents who spoke with the inspector were able to explain what they would do if they had a problem and relatives who spoke with the inspector were happy to express their concerns or complaints and would expect the Registered Manager to address them. There are policies in place for dealing with complaints and protection and a copy of the policy is available within the entrance hallway. The deputy manager was able to show the inspector the staff training records. Staff receives training on the Protection of Vulnerable Adults (POVA). Staff who spoke with the inspector were able to demonstrate their understanding of the issues involved ensuring that residents are protected in this way. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pilgrim Home (Grocot Road) is kept clean and provides a pleasant environment for the residents who live there. EVIDENCE: Residents who spoke with the inspector said that they liked their rooms and had their own personalised items of furniture in them. In this way residents are encouraged to settle into the home easily. Equipment is available to assist residents and staff in the delivery of personal care. Two communal areas (downstairs female toilets) did not lock this was discussed with the deputy manager and the maintenance person will deal with this issue to ensure that residents have privacy when they use these two areas also. The outdoor area remains attractive and is well maintained. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 16 Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management of this home ensures that training is seen as being very important to the delivery of care within this home. EVIDENCE: All new staff receives training for the skills for care common induction foundation standards. Training is on going as part of their development. Supervisions and annual appraisals take place for all staff. There are regular staff meetings where issues concerning care and life within the home are discussed. (A training diary seen by inspector was very comprehensive. It included fire safety, manual handling, wound care and products, supervisions training, understanding diabetes, person centred care, infection control, abuse awareness and POVA, customer care, understanding dementia, understanding the mental capacity act (senior staff attended this). Staff who spoke with the inspector appeared well informed. Recruitment procedures are well maintained. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 18 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 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a home managed by managers who listen to the residents’ wishes then act on them. EVIDENCE: The mangers of the home are able to demonstrate that they have a good awareness in the care of older people and have ongoing monitoring systems in place to demonstrate their commitment to ensuring quality assurance within the daily practices at the home. Regular meetings are held for residents and their relatives are invited to these meetings also. In this way they are able to share their views and concerns. The inspector saw a sample of the minutes. Relatives who spoke with the inspector were aware of the meetings and attended when they could. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 19 Health and Safety policies and procedures are in place and records of these checks are available at the home. Pilgrim Home (Grocot Road) actively encourages residents who are able to, to manage their money. Families are also encouraged to take over this role. Some residents have small amounts of money held for them by the home; they can have access to it when they need it. This money is well documented and securely kept. One resident’s money was checked it was correct with evidence of good systems in place. There is a strong religious ethos within the home and the views of residents, staff and relatives are listened to and valued by the managers of the home. Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 20 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X X X X 4 Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 21 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. Refer to Standard Good Practice Recommendations Pilgrim Homes (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 (Grocot Road) DS0000001923.V351921.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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