Inspection on 09/08/05 for Pilgrim Wood

This inspection was carried out on 9th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pilgrim Wood 23/01/09

Pilgrim Wood 26/01/07

Pilgrim Wood 05/12/05

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 Sandy Lane Guildford Surrey GU3 1HF Lead Inspector Miss Marianne Barham Announced Inspection 09 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pilgrim Wood Address Sandy Lane Guildford Surrey GU3 1HF 01483 573111 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jean Ann Walker & Mr John Albert Flexer Mrs Emily Hayward CRH (PC) 35 Category(ies) of Old age, not falling within any other category registration, with number (OP) 35. of places Dementia - over 65 years of age (DE(E)) 6. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 65 years and over. 2. Up to six (6) of the 35 older people (OP) may be in the category DE(E) elderly people suffering from dementia. Date of last inspection 29 December 2004 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 H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken at 11.25am by Marianne Barham, lead inspector for the service. The inspection was carried out over a period of three hours and fifty minutes and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mrs Emily Hayward was on holiday so, the home was represented by the deputy manager Ms Theresa Pitter. A total of eighteen service users and five staff members were spoken with, and records relating to care of service users and management of the home were examined during this inspection. A large number of comment cards were received from service users, their relatives and other involved professionals prior to this inspection, all of which were complimentary about the care and services received at the home. What the service does well: What has improved since the last inspection? The home has introduced a relatives meeting, to which service user’s families are invited to come to the home and meet with the manager in order to gain information or to raise any issues or concerns they may have. The manager is awaiting feedback from the relatives as to how often these meetings will be held. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 6 A large fireguard has been secured in front of the fireplace, increasing safety for service users when the fire is lit. Care plans are now signed by, the service user or a representative, demonstrating that they have been involved and consulted about their care. Homely remedies such as paracetamol and cough mixture are now recorded and authorised by the GP, making sure that staff know what they can give and when. 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 H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 standard(s) 2, 3 and 5 Each service user has a written contract stating the terms and conditions of living at the home. All service users have their needs assessed and are able to visit the home to assess its suitability to them before they move in. EVIDENCE: The home sends out a statement of terms and conditions of residence in the information pack sent to prospective service users prior to admission. The service user or a representative then signs the statement on admission to the home, a copy of which is given to the service user with the original kept by the home. All service users have an assessment carried out before they move into the home. This is carried out by the home manager or the deputy manager and covers all aspects of the persons care needs. The home encourages service users and their families to visit the home prior to moving in, with half-day visits initially leading to longer stays. All new admissions are for a trial period of one month to ensure that the service user is happy and the home can meet their needs. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 9 Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 The service users’ health, personal and social care needs are set out in an individual plan of care and they are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Each service user has an individual care plan that is generated from the initial assessment. The care plans are reviewed monthly and any changes made are recorded. The plans give detailed instructions to care staff on how to meet the person’s needs and all plans are signed by the service user or by a representative. This meets a requirement made at the last inspection on 29th December 2004. The home has policies and procedures in place for the safe storage and handling of medication. Medication is administered by the senior staff in the home, all of who have received training to do so. Medication records were examined and were accurately maintained. The home carries out monthly audits of medication and the supplying pharmacy also audits twice a year. The homely remedies used in the home are now recorded and authorised by the GP, meeting a requirement made at the last inspection. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 standard(s) 12, 13 and 14 Service users are supported to keep in contact with their family and friends and are able to make choices about their everyday lives. The lifestyle they experience in the home reflects their individual preferences and needs. EVIDENCE: The home produces a ‘what’s on’ guide weekly, this details various activities available for the week and this is posted on the notice board. Service users are also asked individually whether they would like to take part in any activities. There is a good range of puzzles, games and books in the lounge area and service users were observed to make use of them during this inspection. The home also arranges for outside entertainers to visit the home regularly and parties are thrown for special occasions such as birthdays. Service users are able to receive visitors at any time and they may stay for meals if they wish. Most service users have a telephone in their rooms and there is a payphone in the main hallway. Two members of the clergy visit each week from local churches and service users are supported to take part in services if they wish. Service users spoken with reported that they enjoyed the activities on offer and were able to make choices about what they did and where they went. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 standard(s) 18 Service users are protected from abuse. EVIDENCE: The Surrey Multi-Agency Procedures on protecting vulnerable adults are available, however the home does not have its own procedures for staff to follow. A recommendation has been made to address this. All staff have received training on adult protection. The home has a whistle blowing policy in place that gives clear guidance to staff on how to raise concerns they may have. Staff members spoken with were aware of the policy and demonstrated a good understanding of adult protection issues and their individual responsibilities. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 standard(s) 19, 24 and 26 Service users live in a clean, pleasant, well-maintained environment, and their rooms are safe, comfortable and have their own belongings around them. EVIDENCE: The home is very clean, well maintained and decorated and furnished to a good standard. There are adapted facilities throughout the home to assist those with mobility problems and there are ramps on all external doors providing access for all service users to the beautiful gardens. Service users bedrooms are pleasantly decorated and comfortably furnished. All have en-suite facilities and are of a good size. All rooms are personalised with service users own belongings and furniture. Service users spoken with expressed their happiness with their rooms and the facilities provided in the home. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Service users are protected by the homes recruitment practices, however all records relating to recruitment must be kept at the home. EVIDENCE: All records relating to the recruitment of staff are held at the home and several of these were examined. All contained the information required by The Care Homes Regulations (as amended) 2001, with the exception of one file that did not contain references. This was disappointing to note as a requirement had been made concerning the absence of references at the last inspection on 29th December 2004. A further requirement has been made to address this. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 The financial interests of the service users are safeguarded by the home and their health, welfare and safety is promoted and protected. EVIDENCE: The home is not involved in service users finances. A small amount of cash is held in the home for personal expenses. This is kept securely and only the manager or the deputy can access it. A record of all transactions is kept and both the manager and the service user sign when transactions occur. The home carries out regular health and safety audits, risk assessments are in place for safe working practices and all staff members receive training in all areas relating to health and safety. The home employs a maintenance worker who tests and maintains the premises, equipment and appliances throughout the home. A large fireguard has been purchased and secured to the fireplace, meeting a requirement made at the last inspection on 29th December 2004. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 4 x x x x 4 x 4 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 x x 3 Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 17 YES 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 29 Regulation 19 (1) (b) Requirement The registered person must ensure that all records as specied in Schedule 2 (1-9) of the Care Homes Regulations (as amended) 2001 are maintained in the home. Timescale for action 09/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 18 Good Practice Recommendations It is strongly recommended as good practice that the home produces, in line with the Surrey Multi-Agency Procedures, its own policy and procedures for staff to follow on the protection of vulnerable adults. Pilgrim Wood H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 18 Commission for Social Care Inspection 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 H58 H09 s13744 Pilgrim Wood v238923 090805 Stage 2 ann.doc Version 1.40 Page 19 - 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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