Inspection on 05/01/06 for Pilgrim Homes (Grocot Road)

This inspection was carried out on 5th January 2006.

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 (Grocot Road) 24/10/07

Pilgrim Homes (Grocot Road) 04/05/06

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

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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 Mrs Diane Butler Unannounced Inspection 5th January 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.V275408.R01.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.V275408.R01.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.V275408.R01.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. 8th August 2005 Date of last inspection Brief Description of the Service: Pilgrim Home’s, Grocot Road, Evington is registered as a care home providing nursing care for thirty persons over the age of sixty five. The home, which is situated in the village of Evington, is three miles from Leicester city centre and is owned by Pilgrim Home’s, a 200 year old Christian charity. The society was founded in 1807 as the Aged Pilgrim’s Friend Society with a vision to care for elderly, needy Christians. The accommodation, which can be found on two floors, is accessed by a shaft lift. There is a large lounge and dining room on the ground floor and a further lounge can be found on the first floor of the building. There is a large gardened area to the front of the building which is well maintained and accessible to both residents and visitors and a large care park is available at the rear of the building for visitor parking. Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four and half hours and commenced at 10.00 am on the 5th January 2005. The main method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The inspector also had the opportunity to speak to two relatives visiting the home on the day of the inspection. Twenty six of the Thirty Eight Standards were inspected on this occasion. The registered manager and care manager were most helpful during the inspection process. 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. The home promotes a Christian ethos, which is evident throughout the home with bible readings, hymn singing and services being part of the varied activities programme. The staff are friendly and respectful to both residents and their visitors and a peaceful atmosphere is evident in the home. The registered manager and care manager are both supportive and approachable and families, friends and the local community are strongly encouraged to be involved in the life of the home. 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. A comprehensive induction and training programme is in place and the care manager is committed to training all staff in Person Centred Care (treating each resident as an individual and a unique person). The care manager is extremely knowledgeable in the care needs of the residents currently living in the home. Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 6 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. Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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.V275408.R01.S.doc Version 5.1 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): 1,3,5 The admission process is well managed with all prospective residents having their needs assessed before entering the home. EVIDENCE: • A statement of purpose document is available to all prospective and current residents. This document, which was reviewed last year, includes information about the facilities in the home and the services that can be provided. Three residents files were checked during the inspection. All three files looked at included an assessment of need completed by the care manager prior to the resident’s admission into the home. The needs assessment document is thorough in content and covers all aspects of daily living and health care needs. • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 9 • Residents and relatives spoken with during the inspection explained that they had been given the opportunity to look around the home before moving in. This enabled them to see the facilities that were offered within the home and reassure them that their individual needs could be met. Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents are looked after well in respect of their health and personal care needs and personal support is offered in such a way as to protect the resident’s privacy, dignity and independence. EVIDENCE: • Three care plans were looked at during the inspection. All were found to be thorough in content and all were being reviewed on a monthly basis. The care plans give very detailed information of the residents’ needs and the actions required by staff to meet those needs. At the back of the care plan there is a summary sheet, this allows the reader to see at a glance the care needs that are required. One staff member spoken with explained that a copy of this is kept in the resident’s room, this enables care workers to check that they have completed all the required tasks. • • All three care plans included a risk assessment on daily activities. This included activities such as bathing, using the stairs, using the lift, sleeping DS0000001923.V275408.R01.S.doc Version 5.1 Page 11 Pilgrim Homes (Grocot Road) and transferring from one place to another. All activities are assessed, any risks identified are recorded and actions to be carried out to reduce the risk are implemented. • • Moving and handling risk assessments, nutritional risk assessments and pressure area risk assessments were also in place. Evidence was seen to confirm that residents have full access to health care services. These include local GP’s, community nurses, Occupational Therapists and chiropodists. Discussion with residents and staff and observations during the inspection showed that the staff had a good awareness of how to ensure that a resident’s privacy and dignity are maintained at all times. The procedures for the administration of medication were checked during the inspection. All records checked on this occasion were in order with the exception of three signature omissions. The manager explained that a lot of work has been carried out to improve the homes medication system and regular monitoring of the records now takes place. Controlled medication is appropriately stored and the relevant records are in place. Comments received during the inspection included: “The staff are very good”. “The staff are very kind and always very obliging” “They are excellent, sensitive and patient”. “I’ve only got to ring and they help me into my chair”. • • • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Visiting is encouraged to enable residents to maintain contact with family, friends and the local community. EVIDENCE: • Activities are offered on a regular basis. Each resident is given a copy of the activities programme and a copy is displayed on the homes notice board. Activities include, weekly keep fit sessions, out side speakers and film shows. A film was being shown on the afternoon of the inspection. Pilgrim Home’s Christian ethos provides spiritual support for both the residents and its staff group. Bible groups, daily devotional time, weekly services and monthly communion are offered. Family and friends are encouraged to visit. One relative spoken with stated “They always make us welcome”. A second relative explained, “We are so happy with the place”. All the residents and relatives spoken with shared how satisfied they were with the care and support that is received/offered. DS0000001923.V275408.R01.S.doc Version 5.1 Page 13 • • • Pilgrim Homes (Grocot Road) • Choices are offered on a daily basis. Choices include when to get up or go to bed, what to wear, where to eat meals and whether to join in activities. One resident stated, “There’s no excuse to be bored here!” A second resident stated, “Your not forced to do anything”. All residents spoken with shared how much they enjoyed the food served at the home. Comments included: “The food is very good, varied and fresh” “They give you a choice and you can have as much as you want” “Foods good, we just have to sit and eat it, they do the rest”. • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Suitable arrangements for the receiving and responding to complaints are in place and residents are confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: • A complaints procedure is in place and all residents spoken with were aware of who to go to should they have a concern of any kind. Comments received from residents included, “I would talk to xxxxx [care manager] she will come any time, she’s always got time for you”. “ I would go to Jenny [manager], any issues are dealt with seriously and quickly”. “ I would go to matron, she’s very good” • The registered manager stated that no complaints had been received since the last inspection in August last year. This statement was supported on inspection of the complaints file. All staff spoken with were aware of what to do should they suspect any act of abuse and the registered manager and care manager are aware of the procedure to follow with regard to adult protection. DS0000001923.V275408.R01.S.doc Version 5.1 Page 15 • Pilgrim Homes (Grocot Road) Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.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): 19,23,24,25,26 The standard of the accommodation within this home is good providing residents with a safe, clean and comfortable place to live. EVIDENCE: • • The home is well maintained both internally and externally and the decoration and furnishings are presented in a comfortable and homely way. The rooms belonging to the residents who were case tracked were seen. These were clean, appropriately furnished and included the residents personal belongings. The laundry facilities were seen and were found to be in order. One relative spoken with stated, “Clothes come back clean everyday”. All areas of the home seen on this occasion were clean and fresh. • • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 An appropriate recruitment procedure is in place to ensure that the residents in their care are protected and not put at risk. EVIDENCE: Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 18 • An appropriate recruitment procedure is in place. Application forms are completed, references are collected and the registered manager and care manager carry out a face-to-face interview with all applicants. Two staff files were checked. Both included two references, proof of identity and evidence of a CRB (Criminal Records Bureau) check. There is a comprehensive induction and training programme in place, which all staff work through to ensure they have the appropriate skills and knowledge to care for the residents in the home. Both care workers spoken with confirmed that they had received induction training. All new staff are given copies of the Pilgrim Home’s staff handbook and copies of the policies relevant to their role within the home. On checking the training records it was noted that a number of training courses had already been booked for 2006. These included, First Aid, Health and Safety and Fire Safety, Understanding Challenging Behaviour, Abuse awareness and Infection Control. Training on Person Centred Care (treating each resident as an individual and a unique person) is also to be delivered throughout the year. All the residents and relatives spoken with on the day of the inspection felt that the home was adequately staffed. Two staff members spoken with stated that they felt that there were currently enough staff on duty to enable them to care properly for the residents. • • • • • • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,37,38 The home is managed efficiently and appropriate policies and procedures are in place to ensure the safety of the residents. EVIDENCE: • It was evident during the inspection that the residents benefited from the ethos, leadership and management that the registered manager and care manager provide. One resident stated: “Your never alone, there’s always someone around”. A second resident stated: “I’m sure this is the nicest place”. Positive relationships between staff and residents were evident throughout the inspection. • • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 20 • • All staff and residents spoken with during the inspection stated that both managers were approachable, supportive and always available. Evidence was seen of staff supervision sessions and annual appraisals being carried out and staff spoken with during the inspection explained that a staff meeting was arranged for the following week. The fire risk assessment was seen and service users spoken with confirmed that the fire bells are tested on a regular basis. Fire records were in order with the last fire drill being carried out on 4th November 2005. A comprehensive Health and safety policy is in place and the relevant environmental risk assessments have been completed. All documents looked at on this occasion had been appropriately reviewed. The accident book was seen and was found to correspond with the resident’s daily records. Records seen on this occasion were found to be up to date and accurate. • • • • Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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 3 X 3 X 3 X 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 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 3 Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. x Standard x Regulation x None Requirement Timescale for action 05/01/06 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 OP9 Good Practice Recommendations The Registered Person should look at the current medication monitoring system that is in place so as to eliminate any further signature omissions. Pilgrim Homes (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 (Grocot Road) DS0000001923.V275408.R01.S.doc Version 5.1 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. 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