Inspection on 05/12/05 for Pilgrim Wood

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/01/07

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 Marianne Barham Unannounced Inspection 5th December 2005 13:25 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.V261391.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 Wood DS0000013744.V261391.R01.S.doc Version 5.0 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 Mrs Emily Hayward 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.V261391.R01.S.doc Version 5.0 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. 9th August 2005 Date of last inspection Brief Description of the Service: Pilgrim Wood is an elegant 1920s built country house located in an elevated position overlooking the North Downs yet within a few miles of Guildford town centre. The home has been extended and provides accommodation and care for up to 35 older people, 6 of whom 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 stairlift. 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 assisit those with moblity 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. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken at 13.25pm by Marianne Barham, lead inspector for the service. The inspection was carried out over a period of three hours and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mrs Emily Hayward has recently left the service and a new manager Mrs Linda Humphries has been appointed. Mrs Humphries had been in post only three weeks at the time of this inspection and is not yet registered with CSCI. Mrs Humphries was present and a total of twelve service users four visitors one district nurse and five staff members were spoken with during this inspection. Records relating to care of service users and management of the home were also examined as part of this inspection. What the service does well: The décor and furnishings in the home are attractive and comfortable. Service users rooms are of a good size, pleasantly decorated and furnished with their own belongings if they wish. The home has beautifully maintained gardens with walkways that are easily accessible to service users and are used regularly in fine weather. Several service users spoken with reported that their views are listened to they are aware of the complaints procedure and know how to raise issues or concerns they may have. All service users spoken with expressed their happiness with the care and services they receive and their rooms. All were very happy with the quality and variety of the meals served. Visitors spoken with were very happy with the care and facilities in the home and made comments such as I cant think of anything that’s wrong with the home, this is a lovely place, the care staff are wonderful etc. The district nurse said that the home provides a good standard of care and communication between the GP practice and the home is excellent. Members of staff spoken with said they enjoyed working in the home and feel they have enough training and support to carry out their jobs well. Staff members were observed to have a caring but friendly and informal relationship with the service users and were seen to welcome visitors to the home in a positive manner. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pilgrim Wood DS0000013744.V261391.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 Wood DS0000013744.V261391.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): N/A These standards were not assessed at this inspection. Please see report dated 9th August 2005 for detail on these standards. EVIDENCE: Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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): 8 and 10 Service users’ health needs are fully met by the home and they are treated with respect and their right to privacy upheld. EVIDENCE: All service users are registered with a local GP and specialist health professionals and district nurses are accessed through the practice. The GP visits the home routinely once a week and also comes out in between times as necessary. A chiropodist visits the home every six weeks and all service users are registered with an NHS dentist and a local optician. Health needs assessments are carried out by, the district nurse when needed and each service users have an annual health check-up with the GP. A visiting district nurse spoken with during this inspection stated that there is excellent communication between the home and the GP practice and that the care provided to service users is very good. The home has a policy in place for respecting the privacy and dignity of the service users. All members of staff are made aware of the policy at induction and it is reinforced at team meetings. Members of staff were observed to relate to the service users in a respectful and courteous manner during this Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 10 inspection and service users and visitors to the home confirmed that they are treated with respect in the home. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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 Service users are provided with a wholesome, balanced diet that takes account of their needs and preferences and is served in a pleasant environment. EVIDENCE: The home has four weekly menus in place that are put together in consultation with the service users and approved by a dietician. The menu is written in large print daily and placed on the notice board for service users to view. There is always a choice of two main meals and puddings. The home employs two cooks and kitchen assistants. The kitchen has recently been re-fitted to a high standard and was seen to be very clean and all food stock stored appropriately. Records are maintained of the fried, freezer and cooked food temperatures and of foods consumed. Service users spoken with made comments such as the food is lovely, excellent food, I can have what I want, I like the food and I think the meals are very good. All those spoken with expressed satisfaction with the food on offer in the home. The dining room is spacious with several tables all nicely laid, with tablecloths and napkins. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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): 16 Service users, their family and friends can be confident that their views will be listened to and acted upon by the home. EVIDENCE: The home has a complaints procedure in place, a copy of which is given to every service user. Members of staff are made aware of the procedure at induction. A record of complaints is maintained in the home and also a record of compliments. Service user meetings are held every two months and recorded. Several service users spoken with and a visiting relative confirmed that they knew how to make a complaint if they needed to. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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): N/A These standards were not assessed at this inspection. Please see report dated 9th August 2005 for detail on these standards. EVIDENCE: Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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, 29 and 30 Service users are supported by, a trained, competent staff team that is sufficient in numbers and skill mix to meet their needs. The recruitment policy and practices in the home protect the service users. EVIDENCE: The staff team consist of the manager, the deputy, senior carers and carers. Domestic and catering staff are also employed and a full time maintenance worker. There is also an administrator who is employed part time. The duty rotas were examined. These show that there are sufficient numbers of care staff on duty each day to meet the needs of the service users. All service users spoken with were highly complimentary about the care provided by the staff team. Members of staff spoken with said they enjoyed working in the home and received enough training and support to do their jobs well. It was however apparent from discussion with them that they had not been receiving formal supervision. This was discussed with the manager and it was pleasing to see that despite having only commenced her post three weeks previously, the manager had already identified this issue and had carried out and recorded supervision of the majority of the staff team. A requirement was made at the last inspection on 9th August 2005 for references to be obtained and held on file for named members of staff. It was pleasing to see that this had been done. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 15 The home has a programme of planned training in place. All members of staff have an individual record of training kept in the home. Training is provided by an external training provider and also through the Primary Care Team with training given by the district nurse and the continence advisor. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 16 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): 33 The home is run in the best interests of the service users, however the registered provider needs to carry out monthly visits to assess the quality of the service provided. EVIDENCE: The registered provider sends out a survey annually to all service users, their families and other interested parties requesting their views on the service provided. The information received is then collated and the results posted on the notice board for all to read. Service users meetings are held every month and any feedback is recorded along with any actions taken. The registered provider has carried out audit visits to the home, however there has not been an audit since July 2005 and prior to this they were completed every other month instead of monthly. A requirement has been made to address this. Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 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. 1 Standard 33 Regulation 26(1)(3) (4)(a,b,c) Requirement The registered provider must undertake monthly inspection visits of the home in accordance with this regulation and these must be recorded and a copy held in the home. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pilgrim Wood DS0000013744.V261391.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Wood DS0000013744.V261391.R01.S.doc Version 5.0 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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