Inspection on 14/02/06 for Pilgrim Homes Milward House

This inspection was carried out on 14th February 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 Milward House 12/04/07

Pilgrim Homes Milward House 02/11/05

Pilgrim Homes Milward House 16/03/05

Pilgrim Homes Milward House 02/09/04

Pilgrim Homes Milward House 06/10/03

Pilgrim Homes Milward House 22/05/03

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Pilgrim Homes Milward House 6 Madeira Park Tunbridge Wells Kent TN2 5SZ Lead Inspector Gary Bartlett Unannounced Inspection 14th February 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pilgrim Homes Milward House DS0000026193.V278750.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 Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pilgrim Homes Milward House Address 6 Madeira Park Tunbridge Wells Kent TN2 5SZ 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) 01892 528115 01892 518802 milward@pilgrimhomes.org.uk Pilgrim Homes Mrs Ruth Meltz Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate up to, but not exceeding 7 service users with Dementia over the age of 65 - DE(E) Care may be provided for 1 additional person that is resident within the sheltered housing scheme that is part of Milward House. This care may be provided for up to a maximum of 48 hours. It may not be provided for consecutive periods. The provision of this care must be notified to C.S.C.I. Under Regulation 37. 2nd November 2005 Date of last inspection Brief Description of the Service: Milward House is owned and operated by Pilgrim Homes. It provides personal and nursing care and accommodation for older people with Christian beliefs. Consequently, the Home has a strong Christian emphasis and regular prayer meetings and devotional services are a feature of life within the Home. Milward House is located in a residential area of Tunbridge Wells. The usual facilities of a large town are approximately ¾ mile away with the nearest rail and bus services ½ mile away. Accommodation is over three-storeys, with a passenger lift. Milward House has twenty-four single rooms and two shared rooms. The home employs care staff, working a roster, which gives 24-hour cover. The home also employs other staff for maintenance, catering and domestic duties. The home is adjacent to sheltered housing accommodation that is also provided by Pilgrim Homes. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in the Home from 10.30 a.m. until 1.15 pm. During that time some residents and staff were spoken with. Parts of the Home and some records were inspected. The focus of the inspection was to inspect the Standards not assess at the last inspection. Consequently, this report should be read in conjunction with the last inspection report. The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 6 The proposed amendments to the procedures for holding monies on behalf of residents should be implemented to further protect residents’ financial interests. 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 Milward House DS0000026193.V278750.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 Milward House DS0000026193.V278750.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): 2 Each resident had a clear contract of the terms and conditions of their residency. EVIDENCE: To protect their interests, every resident was given a contract of terms and conditions. There were various contracts available to be used according to the funding arrangements for individual residents; for example privately funded or local authority funded residents etc. The contracts clearly stated the roles and responsibilities of interested parties. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 9 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 11 There continued to be good arrangements to ensure residents’ health needs were identified and met. Residents were protected by adherence to good practice guidelines in the storage and administration of medicines. The Home gave good care to residents in their last days and supported every one concerned at time of passing on. EVIDENCE: The Medication Record Administration Record (MAR) sheets that were inspected had been completed appropriately. The Manager explained that all MAR sheets now clearly recorded any changes and authorisation by the residents’ General Practitioners. The Manager said that training in the care of the dying and the management of bereavement was available to staff. The care plan of a recently deceased resident was inspected. The standard of daily records was excellent and clearly showed relevant health care professionals had been involved where Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 10 necessary and the resident’s family had been kept fully informed. The family had been supported in their wish to be with the resident during their final moments. The Manager explained that many funeral services were held at the Home, enabling other residents and staff to participate. If the funeral service was not held at the Home, a thanksgiving service was conducted there instead. The need to support staff at such times was also well recognised Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 11 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): 15 Dietary needs of residents were well catered for with a balanced and varied selection of food. Commendable efforts were made to meet residents’ individual tastes. EVIDENCE: Meal times are set for practical reasons but could be flexible to accommodate activities when necessary. The Cook described how they regularly spoke with residents to have a good knowledge of their individual preferences. Residents were complementary of the food served and said their tastes were met as best possible. The meals seen were generous in portions and looked appetising. Residents said fresh fruit and hot and cold drinks were available through out the day, as well as snacks; “we never want for anything”. The Manager stated that dieticians had examined menus when they had visited the Home. Staff had a good awareness of meeting special dietary needs. The Environmental Health Officer had inspected the kitchen in January 2006 and awarded the Gold Hygiene Award in recognition of the high standards. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 12 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): 17 The Home effectively promoted residents’ legal rights. EVIDENCE: The Manager said that every permanent resident was on the electoral role. Postal votes were usually arranged but residents could be taken to the local polling station if they wished. The Manager gave assurances that residents had access to advocacy services where required, but this was not currently necessary. Most were supported by their families or Social Services. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 13 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): These Standards were not inspected EVIDENCE: Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 14 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 The Home provided appropriate staffing levels to meet residents’ needs. EVIDENCE: Residents spoke very highly of staff. Comment included: • “The staff are always polite and very friendly”…” • “They are helpful and kind.” The Manager described how they considered the allocated staffing hours to be adequate to meet the present needs of the residents. The Home was currently trying to recruit to the vacant posts of Care Team Leader and part time registered nurse. Some agency staff were used but the Manager strived to ensure consistency so all staff were familiar with the residents. The staff rosters inspected took account of peak times of activity and did not show excessive hours or exhausting shift patterns having been worked. Some staff mentioned that if they were concerned about the pressures of work, they were comfortable in talking with the Manager or other senior staff who would be supportive. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 15 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): 35, 37 and 38 The Home protected residents’ financial interests and provided a safe environment for them to live in. EVIDENCE: The Home encouraged residents to manage their own financial affairs or to have assistance from their families / representatives. Where the Home held cash on behalf of residents, there was were some very good systems for recording amounts, which facilitated ease of monitoring. The Manager said Pilgrim Homes audited these annually. A commendable touch was the inclusion of a photograph of the resident on their money wallet. The amounts of monies held on behalf of five residents were inspected. Four of these balanced with the records. The anomaly in the fifth was quickly traced and rectified. The Manager stated procedures would be modified accordingly to avoid this rePilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 16 occurring. Residents’ did not express any concerns about the Home’s management of monies or valuables held on the their behalf. The Manager said that, since the last inspection, the Fire Safety Officer had signed off the fire risk assessment and the system of monitoring accident reports to identify trends and patterns had been further developed. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 17 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X 3 3 Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 18 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. 1 Refer to Standard OP35 Good Practice Recommendations It is recommended the proposed amendments to the procedures for holding monies on behalf of residents are implemented. Pilgrim Homes Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Milward House DS0000026193.V278750.R01.S.doc Version 5.1 Page 20 - 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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