Inspection on 26/01/07 for Pilgrim Wood

This inspection was carried out on 26th January 2007.

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 Wood 23/01/09

Pilgrim Wood 05/12/05

Pilgrim Wood 09/08/05

Pilgrim Wood 29/12/04

Pilgrim Wood 07/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pilgrim Wood Pilgrim Wood Sandy Lane Guildford Surrey GU3 1HF Lead Inspector Lisa Johnson Unannounced Inspection 26th January 2007 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 Wood DS0000013744.V325442.R01.S.doc Version 5.2 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 Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilgrim Wood Address Pilgrim Wood Sandy Lane Guildford Surrey GU3 1HF 01483 573111 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) Mrs Jean Ann Walker Mr John Albert Flexer To be advised Care Home 35 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (35) of places Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 65 Years and over. Up to 6 (six) of the 35 older people (OP) may be in the category DE (E) elderly people suffering from dementia. 5th December 2005 Date of last inspection Brief Description of the Service: Pilgrim Wood is located in an elevated position overlooking the North Downs within a few miles of Guildford town centre. The home provides accommodation and care for up to 35 older people, 6 of who may also have dementia. The accommodation is arranged over 4 floors, with the first and second floors being reached by stairs or passenger lift, and the basement by stairs or stair lift. Most bedrooms are located on the ground and first floor, with a small number on the second floor and 2 in the basement. All bedrooms have en-suite toilet and hand basin and 5 bedrooms also have a shower fitted. There are ample bathing facilities located on all floors, with most having adapted toilets and baths to assist those with mobility problems. The home has a spacious lounge area that is able to be split into three areas and a large dining room. There are large, well maintained gardens around the home that are fully accessible to the service users, and parking for several cars to the front of the building. The weekly fees range from £495- £675 per week. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over eight hours commencing at ten o’clock and finishing at six thirty pm. The visit was carried out by Mrs. L Johnson Regulation Inspector. Since the previous visit a new manager has been appointed whom the Commission for Social Care Inspection has not yet registered. For purposes of clarity the report will refer to the Manager. The inspector spoke to ten residents to gain their views on the care provided. Twenty resident comment cards and twenty-one relative comment cards were received. These comments are reflected in this report. A full tour of the premises took place. Information was examined which was provided by the manager with the pre- inspection questionnaire. Staff training records, and policies and procedures were sampled. The inspector spoke to four members of staff. The inspector would like to thank the staff and residents for their time, assistance and hospitality during this inspection. What the service does well: The home provides a good standard of accommodation, which is well maintained, comfortable and clean. Comments received from residents and their relatives included, “first class”; “spotless”; “the flowers that are provided in the main room give a homely feel and “I can’t imagine a nicer place”. The home provides a good range of recreational and social activities such as musical evenings, entertainers, talks, flower arranging, shopping trips and visits to place of interest. A number of positive comments were received from residents about this service and comments included, “ I enjoy the entertainments by visiting singers and speakers”; “I enjoy the activities” and “the activities coordinator is extremely good and she always wants us to be happy”. Comment cards received from relatives indicated that they are satisfied with the care provided and comments included “this is an excellent facility”, “the home provides excellent care for my relative at all times”; “ everybody is ready to help and staff act upon any worries” and “excellent in all respects”. The home provides a varied menu and during this visit the lunchtime meal was well presented with a range of choices available. Residents and relative’s comments included, “ we have a brilliant new chef”; “the chef always asks if Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 6 the food is ok”. “The chef is ready to prepare alternative meals and they are beautifully served”. 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. The summary of this inspection report can be made available in other formats on request. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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 Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. The home does not support residents for intermediate care. EVIDENCE: Pre-admission assessments were sampled for four residents. Two individuals have lived in the home for a number of years and these assessments were available. However two assessments had been completed for two other individuals who had moved in the home more recently and these were observed to be detailed and comprehensive. The manager reported that – prospective residents have the opportunity to visit the home prior to admission and that the cultural and diversity needs of residents are considered as part of this assessment such as social and leisure needs. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs are met. Resident’s health care needs are met. Residents are protected by the homes medication policy and procedures and are treated with respect and their right to privacy is respected. EVIDENCE: During this visit four residents care plans were sampled. Care plans were in place based on full needs assessments including health, personal, emotional and social needs. The manager stated that new care plans have recently been introduced and it was required that residents and or their representatives sign these. Individual care needs were identified and recorded but it was recommended that the plans need further detail and expansion as to how these needs will be met. Three residents spoken to were not aware of their care plans. A requirement was made that this matter is completed to ensure that residents and /or their representatives are consulted and agree to their care plan. During this visit the manager and care team demonstrated that they Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 10 wished to continue to make improvements with care plans. The manager has provided confirmation to the inspector that care plans have now been signed by residents and arrangements are in progress in respect of consultation with relatives where this is applicable. Evidence of monthly care plans reviews was recorded in individual’s files. Mobility and falls risk assessments were completed. All residents are registered with a local GP and specialist health care professionals are accessed through the practice including district nurses. One person commented, “ We have an excellent doctor”. Another individual commented, “ I have been happy here and I am well looked after”. Seventeen out of twenty resident comment cards received indicate that residents receive the medical support they require. A comment card received from one health care professional stated that the home works in partnership with them and any specialist advice was incorporated into the care plan. Residents are supported to access services including chiropody; dentist, optician and referrals are made to the dietician when this is required. During this visit staff were observed to be knocking on residents doors before entering and closing doors while carrying out personal care. A number of residents were observed to have telephones in their rooms. Staff and residents were observed to be all on first name terms and residents spoken to stated that this was their preference. Three residents spoken to say that staff always respects their privacy and one individual stated, “Staff always knock on my door”. Twenty relative comment cards received confirmed that they are able to visit their relatives in private and one health specialist also confirmed that she could consult with residents privately. The home has a medication policy in place. Photographs were available with resident’s medication administration records and a list was maintained for all staff that are trained and authorized to administer medication. It was evident that staff had gained permission from residents who have chosen to receive their medication from staff respecting their rights and these documents were observed on individual’s files. Records were maintained for the receipt and disposal of medication. The medication arrangements in place were mainly satisfactory although improvements were required for service users who manage` their own medication such as safe storage and risk assessments and in relation to the recording of some items on medication record sheets. Since this visit the manager has taken prompt action to deal with these matters and has provided written confirmation and evidence to the Commission that these matters have been attended to. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that residents have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Residents are supported to make choices and individual preferences are respected. Residents receive well-presented and balanced meals. EVIDENCE: Residents are supported to access a range of recreational and social activities, which meet their needs and preferences. The social needs, hobbies and interests of individuals are recorded in their care plan. The home employs an activities coordinator and it was clear that a wide range of activities is available. During this visit some residents were participating in flower arranging and a choir attended the home in the evening to provide entertainment. During this visit residents spoke positively about the activities provided. One resident spoken to stated that the activities coordinator was “enthusiastic” A number of comment cards were also received from residents and relatives which indicated satisfaction with this service and comments Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 12 included, “ I enjoy the entertainments by visiting singers and speakers”; “I enjoy the activities” and “the activities coordinator is extremely good and she always wants us to be happy. An activities programme was in place and other activities provided included, movement to music, newspaper discussion, and monthly tea at three social meetings, shopping, and musicals. One individual spoken to chooses not to attend activities but enjoys watching television and reading in his room. Another individual spoken to had a sensory disability and is unable to participate in some of the activities, but stated that she is able to enjoy listening to the singers and speakers. The inspector spoke with the activities coordinator who was able to demonstrate that the needs of some of the residents who have mild dementia are being met. The coordinator keeps accurate records of all the activities that residents attend to ensure that their recreational, social and leisure needs are monitored. During this visit relatives were observed to be visiting the home and all relative comment cards received indicated that they are able to visit at any time and are made to feel welcome. One relative commented, “There is a friendly, warm atmosphere”. A number of residents spoken with have access to a phone in their rooms to maintain links with their family and friends. Residents are provided with the opportunity to bring their furniture and personal items into the home, which was seen, on display. It was clear that residents are supported to attend activities in the community. The home has a vehicle and opportunities are available to go shopping, visit garden centres, theatre and places of interest. Some resident’s access local churches that meet their cultural and religious needs and services are also held in the home. The home provided copies of the menus with the pre- inspection questionnaire. The inspector spoke with the cook who said that she discusses menus and preferences with residents which was confirmed by two residents comments, which stated, “the chef is prepared to provide alternative meals and the chef always asks us if the food is ok”. Choices were recorded on the menu. The chef informed the inspector that she always uses fresh produce and during this visit home made cakes and pastries were available. The inspector observed the lunchtime meal, which was well prepared, well balanced and nutritious. A range of deserts were available to choose from. The inspector spoke to a number of residents to gain their views about the meals and responses included, “very good” and we are always asked what we like”. Some residents told the inspector that, “breakfast is served in their bedrooms and a cooked breakfast is available in the dining room if you wish to have this”. Lunch is served at 12.45 pm and supper is served at six pm and a supper trolley is available in the evening with sandwiches being available. Two residents spoken to state that they felt that mealtimes were too close together and two other individuals said that at times they have to wait half hour before the meal is served and this matter was discussed with the manager. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protects residents from abuse. EVIDENCE: The home provides a complaints procedure, which is available with the service user guide. The manager reported that she has recently reissued the complaints procedure to all residents who have been residing in the home for a long time ensuring that they have the up to date information they require. The complaint records maintained by the home were sampled and it was observed that the home has received twelve complaints since the previous visit, which included issues such as laundry and food. The manager provided evidence that these matters had been appropriately responded to and resolved. Two residents spoken to during this visit confirmed that they were aware of the homes complaint procedure. Eighteen out of twenty comment cards received from residents indicated that they were aware of how to make a complaint and nineteen out of twenty relatives stated that they were also aware of the procedure. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 14 A number of positive comments were received from residents and relatives about the home and the care provided including, “the home provides excellent care for my relative”; “ an excellent friendly facility with caring and friendly staff”, “Staff listen and act upon worries”;” everybody is ready to help in any way”; “Everybody tries to make you happy”; “It’s a marvellous place and I would recommend it”; “staff are very good and I get all the care I need” and “ any problems are sorted to our satisfaction”.“ Safeguarding adult policies and procedures were present in the home and staff training records were sampled which concluded that staff were receiving appropriate training. Staff spoken with during this visit was clear as to their responsibilities if they ever witnessed any abuse taking place. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained, clean, comfortable, homely and safe environment. EVIDENCE: The home is spacious, well maintained and safe. The home is decorated and furnished to a good standard. There are extensive, well maintained grounds for residents to access. All areas in the home are accessible by a lift and a chair lift was observed in operation to the lower ground floor. Call bells are provided. Information was provided to the inspector that subject to planning approval an extension to the home is to take place to enhance the facilities including a new hairdressing salon, laundry room and staff office and a second lift is to be provided. Currently two bedrooms are being knocked into one, three ensuite Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 16 showers have been upgraded and some redecoration has been completed. Three comments had been received by the inspector that the current lift has ceased on some occasions. The manager stated that this has now been repaired and there have been problems for some time. During this visit the lift was observed to be in working order. During this visit the home was cleaned to a good standard and no pervading odours were present. A separate utility is available and the laundry assistant stated that she had received training in infection control. A number of positive comments were received from residents and relatives in respect of the décor and cleanliness of the home and included, “First class”; “spotless” and “the flowers provided in the main room give a homely feel”. Two comments that were received indicated that the communal areas could be too warm especially on days when the weather is mild. On the day of this visit no problems were observed. A recommendation was made that the ventilation of the communal areas should be regularly monitored for the comfort of residents. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of residents. Residents were protected by the homes recruitment policies and procedures and were in the safe hands of the staff who were competent and trained to do their jobs. EVIDENCE: Copies of the staff duty rota were provided with the pre- inspection information supplied to the inspector. During the day there is four carers plus one senior carer and in the evening there are three carers plus one senior carer. The manager stated that that there is also either a manager, deputy or assistant manager. The home is employs cooks, ancillary staff a fulltime maintenance person and an administration member of staff. Fifteen comment cards received indicated that staff are available when they are required. Four comments received stated that there have been some occasions when the home has been short staffed. The manager stated that there have been some staff vacancies and recruitment process is in operation with the use of agency staff having been reduced. Two members of staff spoken to during this visited stated that the present staffing levels are manageable. One resident spoken to stated, “ If I need to call my bell staff always arrive promptly”. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 18 During this visit evidence was gathered to indicate that a number of staff have completing or are completing National Vocational Qualifications. Two staff spoken to felt their training and development needs were supported. Training records sampled concluded that staff receive mandatory training which is updated including infection control, food hygiene, first aid, moving and handling, safeguarding adults, food hygiene, medication and health and safety. Training is also arranged for the management of dementia and continence. New staff receive induction training and the home is in the process of introducing new induction packs based on good practice. Staff recruitment is conducted using an equal opportunities policy and the home has a policy in place for racial harassment. The personal files for four members of staff were examined. All the required information was available including evidence of Pova First and police checks. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home, although one issue was identified for improvement. The home is able to demonstrate that it is run in the best interest of residents and that their financial interests are protected. The health, welfare and safety of residents are mainly protected with one issue identified needing attention. EVIDENCE: The manager came into post in March 2006, holds the Registered Managers Award and has the appropriate skills and experience to manage the home. During the inspection she was seen to be making herself accessible. Two Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 20 residents spoken to during this visit stated, “that the manager is friendly and approachable”. Another comment received stated, “ There is an excellent new manager this year who has a positive approach”. Two members of staff spoken to stated, “Things get done and the manager is approachable and supportive”. An application to register the manager with the Commission for Social Care Inspection has not been completed. Therefore a requirement was made that this matter must be completed to ensure that the home has a registered manager in place. The home conducts quality assurance questionnaires, which have been updated. The manager stated that the outcomes of the surveys are discussed during resident and relative meetings. The responsible individual completes monthly quality visits and these were available for viewing. The home has a range of policies and procedures with evidence that these are reviewed and updated. The home has a policy in place for the protection of resident’s finances. The arrangements for records that are in place were discussed and sampled for four residents. Monies held on behalf of residents were stored securely and all expenditure was recorded and receipts maintained. The manager stated that she makes these records available to relatives where this is applicable. A number of health and safety procedures were in place. Policies and procures have been updated. Substances hazardous to health were stored securely and appropriately. Accident records and records of incidents were maintained. Examination of records and certificates identified systems are in place for routine service and maintenance arrangements for the environment. The manager provided evidence to the inspector, which indicated that regular water temperature monitoring takes place. Appropriate food storage and temperature records were maintained. The manager stated that the home has been visited by health and safety. Fire maintenance records and checks were recorded. It was discussed that a full evacuation in the event of a fire had not been conducted for some time. However the manager provided the inspector with a written report from the health and safety consultant that confirmed that a planned fire evacuation was conducted with staff in December 2006 and a date has been arranged for a full evacuation in the near future. During a tour of the premises it was observed that a two radiators in the sitting room have not been provided with covers. Therefore a requirement was made that a risk assessment must be completed to ensure that the welfare and safety of residents is protected. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 22 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. 1 Standard OP7 Regulation 15(1)(2) (A)(c) Requirement The registered person shall after consultation with the service user or a representative prepare a written plan (“the service users plan”) as to how the service users needs in respect of his health and welfare are to be met. The responsible individual must submit an application to the Commission for Social Care Inspection for registration of the manager. The registered person must complete a risk assessment in respect of radiator covers to ensure that unnecessary risks to the health or safety of residents are identified and as far as possible avoided or minimised. Timescale for action 26/02/07 2 OP31 9(1)(2) 26/02/07 3 OP38 13 (4) (a) (c) 26/02/07 Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 23 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 OP7 OP19 Good Practice Recommendations It is recommended that more detail is included in the care plan to ensure that the identified needs of residents are fully met. The registered person should consider regularly monitoring the temperature of the communal areas. Pilgrim Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wood DS0000013744.V325442.R01.S.doc Version 5.2 Page 25 - 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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