Inspection on 10/08/06 for Pilgrims Lodge Residential Home For The Elderly

This inspection was carried out on 10th August 2006.

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

Pilgrims Lodge Residential Home... 14/05/07

Pilgrims Lodge Residential Home... 15/03/06

Pilgrims Lodge Residential Home... 31/08/05

Pilgrims Lodge Residential Home... 06/07/04

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 Pilgrims Lodge Residential Home For The Elderly 10-12 Pilgrims Way Canterbury Kent CT1 1XT Lead Inspector Mark Hemmings Unannounced Inspection 09:30 12 September 2006 th 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 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.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. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilgrims Lodge Residential Home For The Elderly Address 10-12 Pilgrims Way Canterbury Kent CT1 1XT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of acting manager (if applicable) Type of registration No. of places registered (if applicable) 01227 760199 01227 760199 Mr David Barzotelli Mrs Margery Martin Care Home 30 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (4) of places Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Pilgrims Lodge (the Home) is registered to provide accommodation and personal care for 26 older people who experience a reduction in aspects of their comprehension (service users). Also, it can accommodate four older people who do not have these special needs. The Home is located in a residential part of Canterbury which is not far from the city centre. The premises comprise two houses which have been joined together to form one building. The accommodation for the service users is provided on both the ground floor and the first floor. The property does not have a passenger lift or a stair lift. This means that service users accommodated on the first floor, need to be able to use the stairs. There is provision for 22 of the service users to have their own bedroom. There are four shared occupancy bedrooms. Each of the bedrooms has a private wash hand basin. None of the bedrooms have their own toilet or bath. There are gardens to the rear of the building. There is a small amount of off-road parking. The Registered Provider supplies information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure which outlines the principal features of the facilities and services available in the Home. Also, the Registered Provider ensures that a copy of the most recent Inspection Report from the Commission, is available for reference in the Home if requested. The Registered Provider has informed the Commission that the range of fees he charges currently for each of the service users’ residence in Pilgrims Lodge, runs from £367.82 to 425.00 per week. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Report has been based upon a number of sources of evidence. These included a review of the correspondence in relation to the Home received by the Commission since the last inspection. Another source of evidence involved any written information received from service users and from their relatives. Also, the Inspector completed an unannounced site visit to the Home. This took about seven hours to complete. During this time, the Inspector spoke in some detail and/or spent time with eight of the service users. Some of these discussions/periods of time were in private. The Inspector also joined a number of the service users for lunch. The Inspector consulted with both the Acting Manager and with the Deputy Manager. Also, he spoke with one of the senior care workers, with two of the care workers and with the cook. The Inspector examined various parts of the accommodation and he reviewed a selection of the key records and documents. The Inspector concludes that generally the Registered Provider operates the Home in a suitable manner to enable the service users in residence to receive the support and assistance they need. There are eight Required Developments at the end of this Report. With respect to these, the Registered Provider should submit to the Commission a written Action Plan. This should state what has been done and what will be done to ensure that the Registered Provider complies fully with the Required Developments specified in this Report. The Commission should receive this Action Plan by 1 November 2006. What the service does well: Service users said or indicated by their manner, that the Home provides them with a relaxed and generally comfortable setting within which to make their home. They observed or indicated, that they receive all the assistance they need. Also, that the care workers are attentive and kind in their manner. The Inspector considers that the provision of personal care services takes place within a prudent assessment of potential risks to health and safety. The Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 6 Home’s catering service provides the service users with meals which they consider to be enjoyable and sufficient. What has improved since the last inspection? What they could do better: The Registered Provider should correct specific omissions in the planning and delivery of personal care for three of the service users. This is important because it will better enable the care workers to respond to these individuals’ needs for support. The Registered Provider should develop further the calendar of social activities held in the Home. This is important because involvement of this nature can assist people who experience a reduction in aspects of their comprehension skills, to maintain their independence. To achieve this, the Registered Provider needs to give careful consideration to identifying the activities which are likely to best engage the interests of the service users in residence. Then he needs to record in an organised manner who has attended what events so that the success of each can be evaluated. The Registered Provider needs to address a very significant odour management problem in a particular area of the accommodation. The provision of a normally Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 7 fragranced environment is a starting point for service users being able to experience a normal domestic setting. The Registered Provider really should have addressed this problem long before it came to the attention of the Inspector. It must now be resolved. The Registered Provider does not yet have in place a suitable system designed to ensure that all members of staff know how to operate reliably the Home’s fire safety regime. This is important because the actions taken by staff determine largely the level of protection enjoyed by everyone in the Home. 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. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 8 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 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 9 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): 3, 4 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Prospective service users and their representatives should have most of the information they need to choose a home which will meet their needs. They have their needs assessed. EVIDENCE: The Acting Manager said that she completes an assessment of each prospective service user’s needs for assistance, before a decision is made about whether or not the Home is a suitable place for the person’s residence. She said that she is aware of the need to ensure that information is collected about someone’s established lifestyle and preferences. This is very important because it enables care workers to promote the continuation of the person’s chosen way of living, if this is their preference. The Inspector spoke with several of the service users about their experience of having moved into the Home. Those who commented on the matter, indicated that their needs for assistance had been determined before they moved into the Home in the Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 10 manner described. Also, they indicated that the care workers had been prepared in advance to respond to their requirements at the point of their admission. Care workers told the Inspector that they are briefed fully about the needs of new service users. Also, that this constitutes a useful introduction upon which they can build as they get to know someone better with time. The Acting Manager said that she is aware of the range of specialist resources which is available in the community and which can be accessed should a service user need additional help. The Inspector reviewed evidence which showed that some of these resources had been used in a timely manner since the completion of the last inspection visit. For example, use had been made of the local consultant for older people who have special comprehension needs. The Acting Manager said that most service users are admitted to the Home for longer periods of residence. In some residential care homes, service users are admitted for shorter periods of time. This might be done in order to allow some free time for relatives who provide care at home for the person. Or, it might be to enable someone to leave hospital before they are quite ready to return to their own home. The Inspector did not examine this matter further, other than to note that the Acting Manager is aware of the need to promote a service user’s return home if this has been the purpose of the admission. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. The health and personal care which service users receive, is based upon their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service users said or indicated, that the care workers offer them all the assistance they need and that this is provided in a reliable and consistent manner. The Acting Manager said that there is a plan of care for each of the service users. These are important documents because they form one of the means by which each service user can be informed about and agree to the assistance they will receive. Also, the plans constitute a source of reference information for care workers which then helps them consistently to deliver appropriate personal care. The Inspector examined a selection of these documents. Most of the items he sample checked, were found to be present in adequate detail. This assessment was based partly upon the Inspector’s understanding of the related systems in use, which inform care worker’s orally about the provision to be delivered. In so doing, the Inspector recognises that Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 12 not everything needs to be written down when providing effective residential care services. However, there was an omission in relation to Service User A. This involved there not being a suitable strategy in place to enable care workers to respond to the person’s frequent periods of distress. This then related to some uncertainty among the care workers. Having implemented the strategy and seen that it did not work, it was understandable that they seemed not to be sure about what to do next. Strategies are useful only when they work and so plainly this plan now needs to be reviewed and revised. The Registered Provider should address this matter within the timescale established in the relevant Required Development listed at the end of this Report. The Inspector also noted there to be omissions in relation to aspects of the provision to be in place in relation to Service User B and Service User C. The Acting Manager said that these matters would be addressed promptly. The Inspector observed care workers when providing elements of assistance to some of the service users. He noted this provision to be appropriate and to be consistent broadly with that described in the respective plans of care. The Acting Manager was noted to be aware of the need to ensure that service users are assisted to maintain their health. She said that care workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. Care workers confirmed this account. Service users did not comment about this matter. However, the Inspector reviewed evidence which showed that since the last inspection visit, the Acting Manager had indeed requested assistance from a range of medical personnel as and when the need had arisen. The Commission has not received any expressions of concern from local health care providers about any aspect of their working relationships with the Home. The Acting Manager said that all of the service users currently in residence, need assistance to manage their medication. The Inspector considers this to be a reasonable conclusion. None of the service users with whom he spoke, questioned the arrangement. The Inspector examined a selection of the administrative arrangements used by the Registered Provider to organise the completion of this task. He noted that the systems in use were organised well. This means that they should function to ensure that each service user receives medication in the manner intended by their family practitioner. Service users said or indicated, that care workers are cordial in their manner towards them, while at the same time being respectful of their individual preferences. The Inspector saw plenty of examples of this with care workers being observed to be kind in their manner and attentive in their approach. Also noted, was the way in which care workers varied their response depending upon the known preferences of the people concerned. For example, some Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 13 people wanted to spend quiet time in their bedrooms, while others wanted to be in the company of others in the lounges. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 14 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, 14 and 15. Quality in this outcome area is adequate. This judgement is made using available evidence including a visit to this Service. Service users are able to choose their life style and to keep in touch with family and friends. There are some social activities taking place. Service users receive a healthy and varied diet according to their requirements and choice EVIDENCE: Service users said or indicated, that they consider themselves to be occupied suitably. The Inspector noted that the Acting Manager has developed a calendar of social activities. However, he was not confident that all of the events described actually take place. The reason for this seemed to be due to a combination of factors. These included a shortage of time on the part of care workers and the fact that no one had been asked to coordinate this aspect of the Home’s provision. This is not a satisfactory situation because the opportunity to engage in regular activities can be both useful and enjoyable for the service users. The Inspector thinks that the Registered Provider should now revisit both the content of the calendar and its actual implementation. This should be done within the timescale established in the relevant Required Development listed at the end of this Report. When undertaking this exercise, Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 15 it is important that the service users be consulted fully. This is so that their particular needs and preferences can be taken into account. Service users said or indicated, that the pace of daily life in the Home is relaxed and unhurried. They used various examples such as the fact that they can retire to their bedrooms whenever they wish. Also, they observed or indicated, that it is up to them to decide when to get up, when to go to bed and how to spend their day. The service users who commented about this matter, said that the care workers assist them to keep in touch with members of their families. The Acting Manager said that family members are welcome to call to the Home at any reasonable time. Also, that they are free to spend time in private with the service user if this is their choice. The relatives who contacted the Inspector with views about the Home and who commented about this matter, confirmed this account. Service users said or indicated, that they receive good quality meals and they always have enough to eat. The Inspector joined service users for a meal. He noted the food to be adequate in quantity and to have been prepared well. The meal time was a relaxed experience, with people dining at their own speed without any sense of being rushed along. The Inspector examined the record of food served in the Home. He concluded that it indicated that the service users are offered the opportunity to have a normally varied diet. The cook said that there are sufficient provisions in the Home to enable all the meals listed on the planned menu to be prepared. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 16 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users have an effective complaints procedure and they are protected from abuse. EVIDENCE: There is a complaints procedure which explains how service users and other stakeholders can make a complaint about any aspect of the facilities and services provided in the Home. The service users who commented about this matter, indicated that they are confident that any matter they raise will receive serious attention and if possible will be addressed. The Inspector noted that the Registered Provider had received a complaint since the last inspection visit. He concluded that the Registered Provider had responded to the matter in a timely and effective manner. The care workers were noted to have a sound understanding of what constitutes good care practice. As part of this, they were aware of the need to be alert to instances which might jeopardise the well-being of a service user. Service users said or indicated, that they feel safe living in Pilgrims Lodge. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 17 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, 22, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users are provided with a generally satisfactory environment. EVIDENCE: Service users said or indicated, that they are comfortable living in Pilgrims Lodge. They consider the accommodation to be homely and welcoming. The Inspector did not identify any significant defects in the general presentation of the accommodation, although some areas seemed to be a little bare. Pictures and ornaments would address readily this problem. The Inspector noted there to be a background odour management problem in the main lounge. The problem became much more pronounced in a length of corridor on the first floor and in one of the bedrooms nearby. The Inspector acknowledges that the Registered Provider has taken steps to address other Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 18 areas where this has been a problem in the past. However, much more now needs to be done and it needs to be done within the timescale established in the relevant Required Development listed at the end of this Report. Service users said or indicated, that they are assisted by care workers to move around the accommodation safely. The Inspector noted that the Registered Provider has supplied a number of necessary aids such as a bath hoist in the ground floor bathroom and banister rails in hallways. The care workers said that they have all the facilities they need in order to undertake effectively this aspect of their work. The Inspector noted that Service User D is accommodated in a bedroom on the first floor, even though she is not able to negotiate the stairs. This is not a satisfactory arrangement, because it means that the person concerned is not able to access the lounges if she wants to do so. The Inspector was pleased to note the Acting Manager’s intention to invite the service user in question to move into a bedroom on the ground floor. No further service users should be accommodated on the first floor unless they are able to use the stairs. The Inspector understands that the local Department of Environmental Health has not recommended any improvements which remain outstanding. The Inspector examined parts of the kitchen. They were noted to be clean and orderly. The cook was noted to be conversant with good food handling practices. The Inspector understands that the Kent Fire and Rescue Service has said that the Home is safeguarded by a suitable range of fire safety equipment. However, the Registered Provider has not prepared a current assessment of the possible risks to fire safety in the Home and he has not developed a management plan to address any identified hazards. This is important because this assessment and plan, should enable the Kent Fire and Rescue Service to update its evaluation of the adequacy of the fire safety regime operated in the Home. The Registered Provider should address this omission within the timescale established in the relevant Required Development listed at the end of this Report. Service users said that their accommodation is kept comfortably warm. The Inspector noted that all of the radiators have been fitted with guards to help reduce the chance that a service user might accidentally burn himself or herself. Service users said or indicated, that there is a reliable supply of hot water in the Home. The care workers confirmed this account. The Inspector noted that all of the hot water taps accessible to the service users, have been fitted with valves. These are designed to limit the temperature of hot water to a level which is not likely to scald someone. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 19 Service users said or indicated, that their clothes are adequately laundered and that they are returned promptly to them in a presentable condition. The Inspector observed that the service users were wearing neat and clean clothes. The care workers said that the laundry is equipped adequately in that they have the facilities they need in order to complete efficiently the laundering of service users’ clothes and other household linen. The Inspector examined the laundry. He noted it to be orderly and clean. New regulations have been introduced which are designed to help prevent used water syphoning back into the main pipe-work, from appliances such as washing machines and dishwashers. The Acting Manager was not sure about whether or not the Registered Provider complies currently with these regulations. She said that she would make the necessary enquiries and that any additional work which might be necessary, will be completed by 1 January 2006. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 20 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, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the Service. Staff in the Home generally are trained, skilled and in suitable numbers to fulfil the aims of the Home and to meet the changing needs of the service users. EVIDENCE: There are four care workers on duty to respond to service users’ needs for assistance from early in the morning until the two waking night care workers come on duty. The care workers are supported in their work by other people who undertake catering and housekeeping tasks. The Inspector considers that in general there are enough staff on duty to enable service users’ routine needs for support to be met in a timely and reliable manner. This conclusion might need to be amended in that more staff hours may be needed in future to resource what will be the extended calendar of social events. Of the 14 care workers employed in the Home, two have acquired a National Vocational Qualification (NVQ) in health and social care. This Award is useful because it provides care workers with a range of opportunities to confirm elements of good care practice and to extend their range of skills. The Inspector understands that the Registered Provider intends to continue to encourage additional care workers to study for the Award. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 21 The Registered Provider completes a number of security-related checks. These are designed to ensure that all members of staff employed in the Home are suitable to be entrusted with access to service users, who may be vulnerable. The Inspector sample checked one set of these records and he found them to indicate that suitable checks had been completed. The Registered Provider is responsible for ensuring that all care workers are confirmed as having the skills they need to enable them to support effectively the service users currently in residence. The Acting Manager said that all new care workers receive introductory training. This is designed to ensure that they have the basic competencies they need in order to be able to work without direct supervision. This is important because the quality of care service users can expect to receive, depends largely upon the knowledge and skills care workers can invest in the completion of their duties. The Inspector was pleased to note that the Registered Provider has adopted a new national model of good practice in relation to the delivery of introductory training. However, he identified that several aspects of its implementation could be strengthened usefully. This will entail refining the range of subjects to be assessed, being more clear about the evidence to be used when completing these evaluations and being more organised in the timescales to be used. The Acting Manager said that this development will be completed by 1 November 2006. In addition to the introductory training, existing care workers undertake a number of training courses. These are designed to enhance their capacity to deliver care. The Acting Manager said that she intends to now complement this arrangement, by reviewing the adequacy of the competencies possessed by all of the existing care workers. The Inspector understands that this development will be completed by 1 May 2007. As noted earlier in this Report, service users consider that care workers are supportive in their manner and that they are able to deliver the assistance they need. The Inspector observed care workers when they were assisting the service users. He noted this help to be delivered in an appropriate manner. During these observed episodes, the care workers demonstrated that they were able to respond effectively and reliably to the individual requirements of the service users in question. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 22 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, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. The management of the Home generally is effective and there is a basic quality assurance system. EVIDENCE: The Registered Provider was noted to have established suitable systems to oversee the running of the Home. He has established a clear line of accountability in relation to the Acting Manager. However, the Registered Provider has not yet proposed the Acting Manager for registration. This means that the Commission has not had the opportunity to review specific aspects of her suitability to act in this position. The Registered Provider should now address this omission within the timescale established in the relevant Required Development listed at the end of this Report. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 23 Service users said or indicated, that the Home is run without there being any intrusive rules or routines. This means that they can continue to experience a normal home life of their choosing. The Registered Provider operates a system by means of which service users are invited to comment about their home. The Inspector has identified several ways in which these arrangements can be strengthened further. One of these will include the preparation of a Quality Report. This document will summarise the responses received from the service users and from their representatives. Also, it will detail what steps the Registered Provider intends to take in order to act upon the suggestions he has received. The Report should form the basis of feedback given to the service users, who have the right to know what is going to be done. The Inspector understands that the first such Report will be prepared and that it will be shared with service users and with their representatives by 1 January 2007. The Registered Provider assists some of the service users to administer aspects of their weekly personal spending allowance. The Inspector examined a selection of the records relating to the various transactions involved and he noted them to be adequate generally. However, there were no records at all in relation to transactions undertaken on behalf of Service User E. The Registered Provider needs to address this omission within the timescale established in the relevant Required Development listed at the end of this Report. The Acting Manager said that all items of equipment in use in the Home remain in good working order and are serviced regularly. The Inspector did not notice anything which led him to question this account. The Inspector noted that the Registered Provider since the last inspection visit, has completed most of the various checks which are designed to ensure that the Home’s fire safety equipment remains in a suitable operational condition. However, the Inspector did identify that what should be the programme of monthly checks of the emergency lights, was considerably overdue. The Registered Provider should address this omission within the timescale established in the relevant Required Development listed at the end of this Report. The Registered Provider operates a system which is designed to confirm regularly that all members of staff know how to operate correctly the Home’s fire safety regime. This is important because the actions taken by members of staff, determine largely the level of fire safety protection provided in the Home. The Inspector identified several aspects of the system in use which should be strengthened further. The Registered Provider should address this matter within the timescale established in the relevant Required Development at the end of this Report. The Acting Manager said that she monitors regularly the premises so that potential hazards to health and safety can be identified and resolved. The Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 24 Inspector examined various parts of the premises. He did not notice any obvious hazards which led him to question further the Acting Manager’s reported assessment. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 25 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X 3 X 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 2 3 3 2 X X 2 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 Requirement The Registered Provider should correct the omission noted in relation to the planning and delivery of an aspect of the personal care for Service User. The Registered Provider should review the adequacy of the calendar of social activities held in the Home. As necessary, the calendar currently in use should be developed further (this matter is outstanding from the last Inspection Report). The Registered Provider should correct the odour management problem in the first floor hallway and in the bedroom identified by the Inspector to the Acting Manager. The Registered Provider should prepare a suitably detailed fire safety risk assessment and should submit the same to the Kent Fire and Rescue Service. The Registered Provider should submit to the Commission an application to register a suitable person as being the manager of DS0000023990.V299947.R02.S.doc Timescale for action 01/11/06 2. OP12 12 01/1106 3. OP19 23 01/11/06 4. OP19 23 01/11/07 5. OP31 8 01/11/06 Pilgrims Lodge Residential Home For The Elderly Version 5.2 Page 27 6. OP35 17 7. OP38 23 8. OP38 23 the Home. The Registered Provider should ensure that all financial transactions undertaken on behalf of Service User E are recorded in appropriate detail. The Registered Provider should ensure that the monthly checks of the operability of the emergency lights are completed and recorded in the correct manner. The Registered Provider should ensure that all members of staff are included within a suitably organised and recorded system which is designed to ensure that they are able to operate reliably the Home’s fire safety regime. 01/10/06 12/09/06 01/11/06 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 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V299947.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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