CARE HOMES FOR OLDER PEOPLE
Pilgrim Homes (Grocot Road) Grocot Road Evington Leicester LE5 6AL Lead Inspector
Mrs Janet Browning Unannounced 8 August 2005 11:30 am
th 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 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) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Pilgrim Homes (Grocot Road) Address Grocot Road Evington Leicester LE5 6AL 0116 2738131 0116 2731788 evington@pilgrimhomes.org.uk Pilgrim Homes Telephone number Fax number Email 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 (CRH) 30 Category(ies) of Old age, not falling within any other category registration, with number (OP) 30 both, Physical disability over 65 years of of places age (PD(E)) 30 both, Dementia - over 65 years of age (DE(E)) 10 both, Mental disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 1 both, Sensory impairment over 65 years of age 1 both. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No-one falling within category MD(E) may be admitted into the home where there is 1 person of category MD(E) already accommodated. 2. No-one falling within category DE(E) may be admitted into the home where there is 10 person of category DE(E) already accommodated. 3. No-one falling within category SI(E) may be admitted into the home where there is 1 person of category SI(E) already accommodated. 4. Service User Numbers - MD(E) or DE(E) No-one falling within categories MD(E) or DE(E) may be admitted into the home when 10 persons who fall within these categories/combined categories are already accommodated. Date of last inspection 3rd March 2005 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 200-year-old Christian charity. The society was founded in 1807 as the Aged Pilgrims’ Friend Society with a vision to care for elderly, needy Christians. It is within a ten-minute drive of the City Centre with a large car park at the back of the home, but it is also on a public transport route. It is registered for thirty residents, categories include mental health needs and includes Dementia care, Sensory Impairment and Physical Disability. Accommodation can be found on two floors, which is accessed by a shaft lift. There is a large lounge and dining room on the ground floor and 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 garden area which are well maintained and accessible to residents. This area is bordered by bungalows belonging to Pilgrim Homes organisation. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 8th August 2005. The inspection commenced at 11.30am and finished at 4.00pm. When undertaking inspections, the Commission for Social Care Inspection (CSCI) focuses on the outcomes for clients living in a home. To support this, three residents living at Pilgrim Home were ‘case tracked’. This means that the care records of three clients were checked; the clients themselves were spoken with where possible, as well as two members of staff supporting their care. Opportunity was taken to speak to five other residents in the home and five relatives/visitors visiting the home at the time of the inspection and some of the home’s documentation was also examined. The inspector received eight resident comment cards, five relatives/visitors comment cards, and three comment cards from health/social care professionals who visit the home. The home also completed a pre-inspection questionnaire, which was received prior to the inspection. The recommendations and requirements arising from this inspection are a direct result of case tracking, comment cards and other observations made by the inspector during and after the inspection. What the service does well:
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. Residents’ rooms vary in size, but residents are able to have their own possessions and furniture, which creates a homely atmosphere. The management endeavour to improve care within the home and to provide the right equipment to meet residents’ needs. The management have good professional relationships with health care professionals and liaise with them when further advice is required. Training within the home, especially of the nurses, is good, with the nurses also having some management skills too lead their own small team of carers. Care plans are of a good standard, particularly the evaluations and daily records which show the outcomes of the care provided and details of the residents’ activities each day. Regular staff meetings are held where good practice and standards are shared and promoted. Varied training is provided ensuring a good skill mix, with nurses having specialist knowledge in different aspects of care. Residents and, if appropriate, relatives are involved in their care and are consulted about the running of the home in the form of residents’ meetings and surveys.
Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 6 The home has an effective complaints and accident reporting procedure and demonstrates a good standard of record keeping for residents’ financial transactions. They also perform a robust recruitment process and the indications are that staff are aware of the correct procedures for reporting any suspicions of elder abuse. All of which reduces the risk of harm for residents. What has improved since the last inspection? What they could do better:
Indications are that the introduction of the new medication system may have prevented residents from continuing to control all of the administration of their own medication if they are able. Care plans are a good quality, but some care plans can be confusing when the residents’ needs have changed with the new care being added to the existing care plan and the old care crossed out without dates or signatures. Residents who reside in the downstairs lounge can be left for long periods after meals without means to call for assistance with the indications being that staff may not always be able to meet residents’ needs at this busy period of the day. Two issues that the home must address to maintain resident safety surround medication and infection control; if medication is given at times other than prescribed, the time it has been given is not always documented on the medication chart and, although staff receive updates on infection control, the indications are that not all staff are fully aware of the risk of cross infection if the correct procedure for glove disposal is not followed.
Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 7 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) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 standard(s) 3, 4 and 6 The assessment process and services provided by the home are of a good standard and residents can be confident that their needs can be met. EVIDENCE: The home completes a comprehensive assessment of residents admitted to the home, which is performed by a registered nurse. It includes all aspects of daily living as well as any health needs that the resident may have. A resident admitted to the home recently had some psychological needs, which were addressed in the assessment and care plan. A full risk assessment is performed including nutritional needs and risk of pressure area development and is reviewed regularly or as required. The staff working in the home are very experienced with some of the nurses having specialities in tissue viability, palliative care, infection control and continence. The nurses and staff receive training linked to the needs of the residents and the nursing/care manager is providing training on person centred care for the care of residents with dementia care needs. The home has recently increased its category for residents with dementia to 10. The home does not provide intermediate care.
Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10, 11 and 12. The care provided is sufficient to fully meet residents’ needs but an aspect of the medication procedure can potentially put residents’ safety at risk. The approach of the staff is such that residents are assured that they are treated with dignity and respect. EVIDENCE: The care plans provided by the home give very detailed information of the residents’ needs and the actions required by staff to meet these needs with monthly evaluations and daily records giving a detailed description of the effectiveness of care provided. One resident stated; “Everything I need is done by the staff.” A relative comment received stated; “My husband couldn’t be in better hands.” Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 11 The home has improved the documentation of wound care with an example being a resident who required specialised bandaging for legs. There were detailed care plans and photos indicating exactly how the dressings needed to be performed and the condition of the legs. However, for another resident whose mobility had changed since admission, the original care plan and risk assessment were still in place, but with some aspects of the care crossed out and some extra details squeezed onto the bottom of the page. This made it difficult to know exactly what the resident’s mobility or moving and handling needs were with the resident informing the inspector that a hoist is now required. Observations of and conversations with nurses and carers indicated that they were aware of the resident’s needs. Positive comments were received via the comment cards from health care professionals who visit the home. An example of the home consulting with these professionals to improve care is a resident who had frequent falls. After consulting with hospital consultants, district nurses, GP and the local Primary Care Trust, the home has ensured extra supervision for the resident and thus the falls have decreased. This was observed in the accident book and a relative stated; “Very, very happy with the home. My mum’s falls have reduced. It’s a great privilege that she’s here” Carers were observed treating residents with respect and a resident stated; “They respect your privacy, we have a key to our door and they always knock.” “Staff are kind and friendly. The home has commenced a new medication procedure, now using a blister pack system and the homely remedies list has been reviewed. Two residents whose care plans indicated that they self-medicated stated that this had been stopped since the introduction of the new system and they now only do a limited amount of medication. The nursing/care manager stated that the residents still administered some of their own medicines. Of a resident case tracked, the indications were that medication is administered correctly, but due to feeling unwell first thing in the morning, the morning medication, including analgesia (painkillers), was administered later in the morning. The nurse recognised that the next dose of analgesia also needed to be given later to reduce the risk of overdose, but had not documented the time it was given on the medication chart. This is unsafe practice relying on memory and the same person administering the medication. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 12 The home’s policy on death and dying incorporates the home’s Christian ethos and that any special requests and requirements would be documented in notes. The policy states that the physical, emotional and spiritual needs of the resident and their family and friends are cared for at the time of death and that inclusion in the home’s activities would remain unless the resident is unable. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 standard(s) 12, 13 and 15 The home’s activities programme and community involvement satisfies the residents’ expectations and preferences with meals providing a varied selection of foods to meet residents’ taste and choice. EVIDENCE: Food is served in two sittings in the large dining room, with the first sitting being for residents who require assistance with meals. It was noticed that this sitting was very quiet with not much conversation between staff and residents. Comments received from residents and relatives about the food were positive such as; “The food is always lovely.” “Food’s marvellous.” “We visit daily to help xxxx with her lunch which she always enjoys.” The home liaises with dieticians as necessary and has recently stopped giving a mixture of prunes and bran as treatment for constipation following advice from a dietician. This was a requirement from the last inspection. The home has formed a nutritional group made up of nurses, carers and kitchen staff, which focus on the nutritional needs and special diets of the residents Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 14 The home provides a monthly activity programme, which is pinned up in the residents’ rooms and a larger printed weekly programme is also available. Activities are based on the Christian ethos of the home with bible readings and hymn singing, which are enjoyed and outside activities are organised such as art class and trips out, with a recent trip being a barge trip. There is evidence that one-to-ones occur with residents who are unable to participate with group activities. Relatives stated; “The staff communicate with xxxx, talking about family and looking at photos.” “The Christian aspect of the home comes through everything. They (residents) are all loved with a lovely approach.” Residents can use the well-maintained gardens and relatives were observed taking residents out to sit in the garden. Involvement in the wider community is encouraged with an open day taking place in June with games and bouncy castle. This was well attended and also raised money for the home. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 The home’s complaints procedure and adult protection awareness is sufficient to ensure that any concerns will be listened to and that residents will be protected from risk of harm. EVIDENCE: The home has a robust complaints procedure with detailed descriptions seen of actions taken to resolve any complaints made. The complaints procedure was seen pinned up on residents’ notice board. Relatives and most residents spoken to indicated that they knew whom to complain to if needed. “I would complain at first to the manager and then take it higher if not happy, but I have never had to complain.” “I would complain to xxxx (manager) or xxxx (nursing/care manager).” Two residents were not sure who to speak with one stating; “I have never had to complain anyway.” Residents also use the residents’ meetings to bring up general concerns. Two staff members spoken to indicated that they were aware of the reporting procedures for allegations of adult abuse with one new member of staff, although not having yet received training on adult abuse, giving a good response to a scenario given. Residents spoken to commented on how safe that they feel in the home. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 standard(s) 19, 22, 24, 25 and 26 The communal areas and individual rooms are such that residents have access to a safe, clean and comfortable environment with adequate equipment to meet their needs. EVIDENCE: The premises are well laid out with the pre-inspection questionnaire indicating that there is a routine maintenance programme with the regular inspections from fire and environmental health. The rooms inspected during case tracking were clean and had the residents own possessions evident including furniture such as beds and sideboards. On a warm day the home was well ventilated and a random check of the hot water indicate that it was delivered within a safe temperature. There are two lounges, a smaller lounge upstairs and a larger lounge with a sun lounge attached downstairs. The grounds to the front of the home were well maintained with sun chairs evident and a canopy for shade. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 17 The indications were that there were adequate equipment to meet residents’ needs and there were stored appropriately in a separate storeroom. Staff stated that they were enough equipment such as hoists to meet residents, needs. One resident had her own reclining chair and another resident had a wheelchair for her own needs. Baths were seen equipped with seating to lower and raise residents in and out of the bath. One nurse stated that occupational therapists were used if there was any special equipment required. It was noticed that some residents were unable to call for assistance when in the downstairs lounge. The nursing/care manager stated that some residents did have pendant alarms and that the residents’ abilities to use these would be assessed or measures put in place to provide supervision. The home has the relevant equipment in clinical areas for hygiene and infection control. Hand washing guidance for staff is also evident. Continence pads are stored appropriately and equipment such as gloves, aprons and bags are provided for staff. Sluicing facilities were evident and were seen utilised by staff. The residents’ comments were; “My room is beautifully cleaned every day.” “It always smells nice.” Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 A good staff training programme and recruitment procedure ensures that residents are not put at risk of harm. Indications are that at times of increased activity for staff, not all residents’ needs are fully met. EVIDENCE: Care hours provided by the home for a week just met the guidelines set out in the Department of Health’s Residential Forum, for the level of dependency of the residents. This does not take into account both the nursing needs of residents nor the nursing hours provided by the home. The indications are that care needs are generally being met. One resident stated that; “When I call staff they come quickly, everything is done to time.” However, during the inspection, one resident sitting in the downstairs lounge requested to be taken to the toilet after lunch. A carer was heard to say; “I will get someone, they will be five minutes, they are busy with someone else at the moment.” The resident waited 40 minutes for someone to take her to the toilet, despite shouting out numerous times. Carers were observed extremely busy bringing residents back from the dining room and taking residents to and from the toilet. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 19 The staff and nurses receive regular training with person centred care being a new addition to the training programme. Three nurses have also been on a national course run by Pilgrim Homes on management to progress their professional development with one nurse describing how they have more responsibility within the home and managing their own team of care staff. Two recruitment records were examined, and the indications were that adequate procedures were being followed to ensure the safety of residents. A new starter with the home for four months was still completing the induction programme and had not yet received training on dementia care but was still being supervised by a mentor. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 The home’s quality assurance and financial processes indicate that the home is run in the best interests of the residents, but an aspect of working practice can have the potential of putting residents at risk of harm. EVIDENCE: The views and opinions of residents are sort by a variety of means with residents meetings held every three months and user surveys carried out. The records and notes are audited regularly to ensure that standards are maintained and minutes to staff meetings indicated a commitment to maintaining and raising standards with study days shared with the rest of the staff. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 21 The management is always looking at new ways of developing the care provided by the home in the form of consultation and training. The nurses are given more responsibility to encourage ownership of the care provided and to encourage them to look at the wider picture of care. The management process within the home over sees all of this. The financial transactions for one resident case tracked were examined and were found to be clear and precise, and signed by the resident. The resident also confirmed this working practice. The home keeps small amounts of money in the safe for residents to pay for extra services and gains permission if payments are for over £20. Most working practices observed in the home were adequate. The use of Stand-Aid equipment on two residents was observed and used appropriately and safely. The staff receive regular updating on moving and handling and infection control. A carer was observed wearing the correct clothing and using the correct equipment for the changing of a soiled continence pad. However, the carer then handled a piece of equipment still wearing the dirty gloves before disposing of her gloves and washing her hands. This has the hazard of causing cross-infection. The nursing/care manager stated that she monitors staff in the appropriate wearing of gloves, especially as the home did have an outbreak of a “stomach bug” earlier in then year. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x 3 x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 23 No 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. 1. Standard 9.3; 9.4 Regulation 13 (2) Requirement The home must ensure that all staff administering medication are aware of the correct procedure for documenting medication given at a different time than prescribed. The home must ensure that all staff are aware of the correct procedures for the disposal of soiled gloves and the risks associated with cross infection. Timescale for action 03/10/05 2. 38.2 13 (3) 03/10/05 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. 2. 3. Refer to Standard 7.2 9.2 22.8 Good Practice Recommendations It is recommended that the care plans and risk assessments are updated in line with NMC guidelines for good record keeping. It is recommended that residents who wish to selfmedicate are supported by the homes medication procedure. It is recommended that residents using the communal areas are able to call for assistance as required.
C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 24 Pilgrim Homes (Grocot Road) 4. 27.4 It is recommended that the home ensures that there is adequate staff on duty at peak times during the day e.g. during and after meals. Pilgrim Homes (Grocot Road) C51 C01 S1923 Pilgrim Homes (Grocot Road) V238736 080805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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