CARE HOMES FOR OLDER PEOPLE
Pilgrim Homes (Grocot Road) Grocot Road Evington Leicester Leicestershire LE5 6AL Lead Inspector
Mrs Helen Wilson and Lesley Allison-White Unannounced Inspection 4th May 2006 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.V292698.R02.S.doc Version 5.1 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.V292698.R02.S.doc Version 5.1 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 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) Pilgrim Homes 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.V292698.R02.S.doc Version 5.1 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 5th January 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. This garden is bordered by sheltered housing bungalows owned by the Pilgrim Homes organisation. The current range of fees is from £442.00 to £795.00. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 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 is on outcomes for residents and their views of the service provided. Inspection planning took three hours and consisted of a full review of the Inspection record, any previous requirements or recommendations made, the Home’s service history record including notifications of accidents, events and incidents, any previous comments received from residents and relatives and previous correspondence between CSCI and the Home. The information was collated and analysed to form the plan of inspection focusing on the outcomes for Residents. This inspection was carried out unannounced and lasted for some eight hours in total with the Registered Manager and Care Manager present. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, talking with them and/or observations of practices of care staff. The outcomes for residents were, given the various health conditions of residents, mainly judged on observations made at the visit. Six staff and two residents were spoken with to obtain their views. The inspector also had the opportunity to speak to two relatives visiting the home on the day of the inspection. What the service does well:
Pilgrim Homes, Grocot Road, Evington is well managed and records necessary for the health and welfare of the residents are maintained to a high standard. A regular monthly visit is done on behalf of the company to ensure that the home is being operated in a satisfactory manner. The home’s published information for potential residents clearly states the intention that the home promotes a Christian ethos with daily religious services being part of the activities offered to people living at Evington. Residents care plans are thorough in content and give very detailed information of the residents’ needs and the actions required by staff to meet those needs. Care plans for individual residents showed that staff are guided to focus on daily routines and individual activities for people living at the home. New friends and relationships are encouraged. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 6 One resident said that staff were ‘lovely’ and that she was going out for a walk with the staff member. Other residents appeared relaxed, happy and enjoying their lunchtime meal with some people being assisted by staff members. Several visitors were seen at the home and one person commented that she was happy with the care and appearance of her family member when she visited. The personal monies of two residents held by the home for safekeeping were inspected. The monies and receipts tallied, records were accurate and residents’ monies kept safe. Arrangements for managing residents’ medication were appropriate. The Care Manager gives training to all carers, nursing and ancillary staff in Person Centred Care (treating each resident as an individual and a unique person) to ensure consistency across the whole team approach. From observations of care practices it was clear that staff treat residents with respect and sensitively ensure that privacy is given during personal care. Menu plans indicated a range of traditional home cooked meals with occasional Asian meals. Residents were seen eating and enjoying a mid-day meal that was appropriate for portion size and quality. CSCI have not received any recent complaints about the operation of the home. Whilst balancing the clinical needs of nursing residents the home provides a comfortable and homely environment. Bathrooms have a variety of specialised equipment including assisted baths and disabled showers. Thermostatically controlled water valves have been fitted to all wash hand basins to ensure the safety of residents. Staff records for four people demonstrated that there had been full recruitment procedures including Criminal Record Bureau checks, induction and foundation training. Staff said that supervision sessions had commenced. Staff records indicate that 61 of the staff team hold National Vocational Qualification at Levels 2 and above and other relevant nursing qualifications. As a result of this focussed approach to staff development the outcome for residents is that the staff practices and care given are of a very good standard. What has improved since the last inspection?
Electricians and carpet layers were working in the downstairs corridor and downstairs lounge installing flooring, additional lighting, ventilation and alarm
Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 7 systems. When completed this will produce a brighter living environment for residents to match the standard achieved already in the dining room.. 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 (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 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 (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust admission process with clear information available describing the services of the house. Assessment of the individual needs of residents is thorough. EVIDENCE: The home’s published information for potential residents clearly states the intention that the home promotes a Christian ethos with daily religious services being part of the activities offered to people living at Evington. Two case files looked at included an admission assessment of need completed by the care manager prior to the resident’s permanent admission into the home. The needs assessment document is thorough in content and covers all aspects of daily living, risk assessments and how staff are to meet health care needs.
Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 10 Contracts and terms and conditions relating to the individual placements were evidenced in case files. The home does not provide rehabilitation services. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is successful in delivering appropriate care to individual residents. EVIDENCE: Both case files examined showed that there were individual plans of care that were explicit and gave clear instructions to staff about how care needs were to be fulfilled. There were thorough risk assessments carried out and cross referenced in the care plans. In both cases the family members had been involved on behalf of the residents in agreeing their care plans. Health care needs were clearly identified and potential areas of risks such as pressure sores had been identified and successfully monitored and treated. Residents identified as being at risk of falling are routinely monitored by staff. Care plans covering nutrition were in place periodically residents weights are monitored and action taken to oversee dietary intake. The system for administering medication was checked. Discussions were held and a decision was made that when new supplies of syrup medication were
Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 12 opened the container should be signed and dated. A discussion took place about a medication that was not labelled for a specific resident. The home said that they would obtain named labels from the suppliers. Medication stocks were being stored appropriately. From observations of care practices it was clear that staff treat residents with respect and sensitively ensure that privacy is given during personal care. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home succeeds in meeting the identified daily and social needs and the outcome is positive for the residents. EVIDENCE: Care plans for individual residents showed that staff are guided to focus on daily routines and individual activities for people living at the home. New friends and relationships are encouraged. There is also a wide range of spiritual and social activities on offer on a monthly basis. There are also opportunities for specific therapy sessions during each week. It was noted that two residents were taking a walk with staff in the garden enjoying the sunshine. From care plans it was seen that staff give specific support to residents who have specific dementia related conditions to maintain their quality of life and inclusion in social activities. One of the residents care plans showed that she enjoyed having the bible translated into her mother tongue and this had been identified to staff. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 14 Several visitors were seen at the home and one person commented that she was happy with the care and appearance of her family member when she visited. The personal monies of two residents held by the home for safekeeping were inspected. The monies and receipts tallied and records were accurate. Menu plans indicated a range of traditional home cooked meals with occasional Asian meals. In addition one family during visits bring in traditional Indian food for their family member. The kitchen staff are aware of one persons need for a special diet due to diabetes, food is pureed for one other resident and a member of the catering staff prepares Asian meals to ensure that they meet the diet and cultural needs of one resident. Whilst menu plans are documented where alternative foods are provided there is no record held of these meals eaten by residents. It was agreed with the Registered Manager that improvements would be made with recording of alternative meals provided in the kitchen records. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 15 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, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust procedures for dealing with complaints and protection however further training for staff will potentially give protection to residents. EVIDENCE: CSCI have not received any recent complaints about the operation of the home. The Registered Manager said that she has been dealing with an issue concerning poor communication skills of one staff member; inspectors were happy with the manner in which this has been undertaken. One visiting relative confirmed that she felt welcomed by the home and felt that if she was unhappy with the care of her family member that she would know who to contact to make a complaint. Both case files evidenced that legal arrangements had been made regarding the affairs of the individual residents. On talking to four staff, two people were unable to fully demonstrate awareness and understanding of the Protection of Vulnerable Adult issues. Following discussion with the Registered Manager it has been identified that refresher training on POVA awareness will take place. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a safe, hygienic and comfortable environment. EVIDENCE: Whilst balancing the clinical needs of nursing residents, the home provides a comfortable and homely environment. Electricians and carpet layers were working in the downstairs corridor and downstairs lounge installing flooring, additional lighting, ventilation and alarm systems. Although this work has been disruptive to residents, the Registered Manager has assessed the risks thoroughly, moved all mobile residents to the upstairs lounge during the day and maintained staff interaction with nursing residents remaining in their downstairs bedrooms. The work is scheduled to finish within one week. The lounges and other communal areas are well maintained and decorated. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 17 Bathrooms have a variety of specialised equipment including assisted baths and disabled showers. Thermostatically controlled water valves have been fitted to all wash hand basins to ensure the safety of residents. The Registered Manager stated that arrangements are in hand to box in low pipework in the downstairs bathroom for safety of residents. Individual residents have their own walking frames and wheelchairs as necessary. Footplates were noted on all wheelchairs for the safe use of residents. Bedrooms were not seen but inspectors were assured that residents bring in personal items of furniture and photographs. There were no unpleasant smells in the home. All areas were clean and hygienic. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust recruitment procedure. The home succeeds in providing a competent qualified staff team that meets the needs of and protects residents; although staff are supervised, there was no documentation to evidence that supervision sessions had taken place. EVIDENCE: Staff rotas were inspected and reflected good deployment of both nursing and care staff to meet the needs of current residents. Additional staffing for one highly dependent resident has in recent months been agreed with the placing authorities. Staff in interview said that they had been given thorough training including health and safety, moving and handling, fire safety, person centred care, specific dementia training, training in specific nursing interventions. The Care Manager gives training to all carers, nursing and ancillary staff in Person Centred Care (treating each resident as an individual and a unique person) Staff records for four people demonstrated that there had been full recruitment procedures including Criminal Record Bureau checks, induction and foundation training. Staff said that supervision sessions had commenced. The Registered Manager confirmed that supervision sessions had been held on an informal
Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 19 basis but not always formally recorded. She undertook to bring the programme of supervision up to date and structure this into the routines of the home. Staff records indicate that 61 of the staff team hold National Vocational Qualification at Levels 2 and above and other relevant nursing qualifications. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of residents. EVIDENCE: The Registered Manager and the Care Manager have both attained their Registered Manager’s Award. The management style of the home creates an open positive atmosphere. A regular monthly visit is done on behalf of the company to ensure that the home is being operated in a satisfactory manner. From observations of practice it is evident that the organisation creates equal opportunities for staff and residents, the staff group is reflective of differing cultural backgrounds and the resident group are from a variety of backgrounds.
Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 21 The Registered Manager produced a detailed budget plan for the future upgrading of the home that reflected a quality assurance review of the service. The Registered Manager is aware that formal staff supervision is not done regularly. She undertook to bring the programme of supervision up to date and structure this into the routines of the home. Individual case records and the home’s required records were up to date, clear in their content and safely stored. Records concerning the health, safety and welfare of residents and staff were examined and found to be up to date and current. The home evidenced that service contracts and maintenance visits are completed for electrical, fire safety, water safety, specialist equipment, lifts and hoists. The home’s procedures for the management of domestic chemicals and cleaning materials are sound. Regular fire drills are held, emergency lighting checks are done and fire safety equipment serviced. Notifications are made to CSCI of accidents, incidents and events where necessary. Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 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 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Pilgrim Homes (Grocot Road) DS0000001923.V292698.R02.S.doc Version 5.1 Page 23 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.V292698.R02.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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