Inspection on 02/11/05 for Pilgrim Homes Milward House

This inspection was carried out on 2nd November 2005.

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 14/02/06

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 Announced Inspection 2nd November 2005 09:20 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.V259330.R01.S.doc Version 5.0 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.V259330.R01.S.doc Version 5.0 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.V259330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to, but not exceeding 4 service users with Dementia over the age of 65 - DE(E) 16th March 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 28 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. The Home can also accommodate up to, but not exceeding four service users with Dementia over the age of 65. 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.V259330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Milward House from 9.20 a.m. until 4.20 pm. During that time the Inspector spoke with some residents, a visitor, a volunteer and some staff. Parts of the Home and some records were inspected. A number of comment cards were received prior to the inspection. Residents and their relatives responded that they liked the home and staff. Responses from health professionals also indicated good standards of care. Statements on comment cards included: • “The care is generally excellent and the staff are very dedicated.” • “Excellent care.” • “In a word “excellent”.” • “Milward House is an excellent nursing home where residents are always shown affection, help and respect.” • “The home is excellent and caring in all respects.” • “Milward House gives a very high standard of care to the residents. It is peaceful, very clean...” During the inspection, residents said: • “I am very happy here”. • “I would not want to change anything” The Manager and staff gave their full co-operation throughout the inspection. The Chief Executive of Pilgrim Homes was present during the inspection. What the service does well: Staff operated a good pre-admission assessment process and were helpful in assisting residents to settle in to the Home. Residents’ health care needs were recognised and managed well. The Home provided a comfortable environment and met the residents’ expectations of spiritual and social support. Residents and their visitors liked the staff. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 6 The Manager has a clear vision for the Home and was supported well by the senior staff in providing leadership. 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 Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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.V259330.R01.S.doc Version 5.0 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, 4, 5 and 6 The Home’s Statement of Purpose and Residents Guide provided service users and prospective service users the information they need to make a decision about moving into Milward House. Good pre-admission assessments and the opportunity to visit the Home prior to admission ensured residents were appropriately placed and the Home could meet their needs. The Home did not provide intermediate care. EVIDENCE: The Manager said the Statement of Purpose was accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Milward House and copies of the Service Users Guide were provided for each service users or their representative. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 9 The Manager described how a pre-admission assessment was made of each prospective resident using an aide-memoir which went on to inform the care plan. Records seen indicated prospective residents, their families, advocates, and relevant health care professionals were involved in the assessment process. The Manager said prospective residents or their families were able to visit the Home before moving in. A resident confirmed this and also said staff had been very helpful in assisting them to settle in. Records showed specialist training was provided for staff and specialist health care support was obtained where required to ensure residents’ needs could be met. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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 and 10 There were good arrangements to ensure residents’ health needs were identified and met. Residents’ safety would be better promoted by the Medication Administration Records being completed in such a way as to clearly indicate any changes in residents’ medications and to show these changes had been authorised by the General Practitioner. Residents’ health needs were met with good liaison with relevant health care professionals. Staff treated residents with respect and maintained their privacy and dignity. EVIDENCE: Each resident had a care plan. Three care plans were inspected in detail. They were comprehensive, clearly identified the care needs and how they were to be met and were regularly reviewed. Daily records were informative and of Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 11 a generally high quality. Consequently. staff referring to them would have a good knowledge of how to give residents the care they needed. The Duty Room was inspected and medications were seen to be stored in accordance with their instructions. Records were available to indicate that all staff administering medications had been trained and signed off as being competent to do so. The Medication Record Administration Record (MAR) sheets that were inspected had been mostly completed appropriately and there were systems to monitor this. It was identified that one MAR sheet needed to be updated to clearly indicate a change and to show this change had been authorised by the residents General Practitioner. The administration of medicines was not observed on this occasion. The Home continued to have a good working relationship with the specialist and local health care professionals, supporting residents in their health care needs. From discussion with residents and observation it was clear that staff treated residents with respect and promoted their privacy and dignity. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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 and 14 Residents enjoyed routines of daily living and activities that were flexible and varied to suit their preferences. Where practicable, residents could participate in local community activities and their autonomy and choice was promoted. EVIDENCE: Staff spoken with were aware of the rights of residents to have the opportunity to have choice in daily routines and activities. Residents described how their inks with the local community were maintained according to their wishes and taking account of their needs. Staff indicated that prayer meetings and devotional services were pivotal to the routine of the Home and were provided every day. Many residents were involved with local churches and events. During the inspection a number of visitors were seen in the Home and the visitors book recorded regular visits by families, friends and others. Residents could meet with visitors in a designated room, various communal rooms or in their bedrooms. Residents said they were happy with the Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 13 arrangements. A visitor described how they could visit at any reasonable time and was always made welcome by staff. The Manager stated residents were supported to manage their own affairs for as long as they wished and were able. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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 and 18 Residents and their relatives knew their complaints would be listened to and acted on. There were systems to ensure residents were protected from abuse. EVIDENCE: The complaints procedure was readily available to residents and their relatives and visitors. Residents described how they knew of the complaints procedure but had not had cause to use it; “ if something is not quite right it is always dealt with very quickly and fairly”. Records of complaints were kept and these included details of investigation and action taken. The Manager stated that complaints were used to improve practice where required. There were procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager and other staff spoken with demonstrated a sound understanding of adult protection procedures and stated that any allegation of abuse would be referred to the concerned agencies without delay. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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 The standard of the environment within the Home was good providing residents with an attractive, homely and safe place to live. EVIDENCE: The parts of the Home inspected were clean and free from unpleasant odours. Residents said they had access to all parts of the Home and facilities they needed. They were happy with their bedrooms and found the communal areas comfortable. The bedrooms seen had been personalised with the occupants’ personal effects and reflected their individual tastes and interests. The Home’s cat, “Buster”, clearly found the environment comfortable and the residents warmly welcomed his presence. The recently acquired aquarium also provided a focus of interest, (not just for Buster), and discussion. There was an ongoing programme of redecoration and refurbishment. The Manager described how it was intended to refurbish the kitchenette on the ground floor and undertook to address the high running temperature of the refrigerator in there. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 16 Staff were seen to effectively maintain infection control to promote residents’ health. The hot water was tested at several outlets was at a safe temperature. There were regular tests for Legionella and safety measures were taken as required. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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): 28, 29 and 30 Recruitment processes are robust and offer protection to people living at the Home. The arrangements for staff induction are good with the staff demonstrating a clear understanding of their roles. The Home provided ongoing training for staff so they had the skills to meet the needs of the residents. EVIDENCE: Residents spoke very highly of staff. Comment cards received prior to the inspection included the statements: • “The staff are very kind and patient…” • “Very caring staff.” • “Staff always knowledgeable about patients and helpful and very caring.” • “..the staff are kind, efficient and friendly.” Residents benefited from a relatively low staff turn over. The recruitment processes were sufficiently robust to ensure only properly vetted people were employed at the Home. Commendably, these checks were made in respect of volunteers as well. A volunteer spoken with demonstrated a very good understanding of the parameters within which they were to support residents. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 18 All new staff were required to undertake an induction programme and did not work unsupervised until deemed competent. A comprehensive training programme was available to staff and NVQ training was encouraged. Some staff spoke of the support they had received in this. There was a training matrix for easy monitoring of staff members individual training/update requirements. Staff were seen to be attentive and demonstrated a commitment to meeting residents needs. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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, 33, 36, 37 and 38 The Manager has a clear vision for the Home and was supported well by the senior staff in providing leadership. The Home regularly reviewed aspects of its performance through a programme of self-review and consultations, which included the opinions of residents and relatives. EVIDENCE: The Manager was qualified, competent and experienced to run the Home. She was a registered nurse and had a postgraduate qualification with many years experience in the care of older people in a senior capacity. The Manager had also obtained NVQ level 4 and Registered Manager’s Award qualifications. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 20 Throughout the inspection, the Manager and senior staff demonstrated a commendable honesty and commitment to a high quality service. Staff and residents said they considered the management team to be approachable, understanding and supportive. There was regular supervision for all staff. The Manager placed great importance on having quality assurance systems to gather the views of residents, relatives and other stakeholders to further develop the service as required. Staff were seen to be diligent in minimising risks to residents by carefully placing equipment to avoid obstruction and in ensuring COSHH requirements were adhered to. Records seen indicated that staff had regular fire training and participated in fire drills. Indeed, during the inspection there was an unplanned fire alarm that was responded to efficiently and professionally by all concerned. There was some discussion about the advantages of having the fire risk assessment formally signed off by the Fire Safety Officer and of further developing the system of monitoring accident reports to identify trends and patterns. There records to indicate that regular maintenance checks were made of equipment as required and environmental risk assessments were undertaken to promote residents and staff safety. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 2 3 Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 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. 1 Standard OP9 Regulation 12(1)a,13 17(1)sch3 Requirement “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that M.A.R. sheets must be completed in such a way as to show any changes in residents’ medications and their authorisation by the residents General Practitioner. Timescale for action 30/11/05 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 Refer to Standard OP38 OP38 Good Practice Recommendations It is recommended the Home has the fire risk assessment formally signed off by the Fire Safety Officer. It is recommended the system of monitoring records of accidents for trends and patterns be further developed. Pilgrim Homes Milward House DS0000026193.V259330.R01.S.doc Version 5.0 Page 23 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.V259330.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!