Inspection on 14/05/07 for Pilgrims Lodge Residential Home For The Elderly

This inspection was carried out on 14th May 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 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... 10/08/06

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

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

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

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St Joseph`s

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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 Key Unannounced Inspection 14 May 2007 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.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 registered manager (if applicable) Type of registration No. of places registered (if applicable) 01227 760199 01227 760199 Mr David Barzotelli Mrs Margery Ann Martin Care Home 26 Category(ies) of Dementia - over 65 years of age (22), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (3) Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2006 Brief Description of the Service: Pilgrims Lodge (the Service) is registered to provide accommodation and personal care for 26 older people (service users). Of this number, 22 of the service users may experience a reduction in aspects of their comprehension due to having a dementia-like disorder. The Service can also accommodate three older people who do not have these special needs. A further service user can be accommodated who has a learning disability. The Service 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 gives information about the Service 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 Service. There is also a document called a Statement of Purpose. This gives a more detailed account of the provision in place than does the Guide. The Registered Provider ensures that a copy of the most recent Inspection Report from the Commission, is available for reference in the Service. The range of fees charged currently for each of the service users’ residence in Pilgrims Lodge, runs from £377.38 to 450.00 per week. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.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 Service 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 Service. This took about five hours to complete. During this time, the Inspector spoke with or spent time with eight of the service users. Some of these discussions/periods of time were in private. The Inspector spoke with the Registered Manager and with the Deputy Manager. Also, the Inspector spoke with three of the support 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 Registered Provider operates the Service in a suitable manner to enable the service users in residence to receive the support and assistance they need. There are two Required Developments listed at the end of this Report. What the service does well: What has improved since the last inspection? What they could do better: More could be done to make some of the bathrooms and toilets into welcoming spaces. The quality assurance system needs to involve the service users more directly. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 6 A part of the fire safety system needs to be developed further. 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. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. Prospective service users have their needs assessed before they move in. EVIDENCE: People who are thinking about moving into the Service, can do a number of things to find out what is provided. They can speak with the Registered Manager and with care workers to ask them questions. Also, they can read the Service Users’ Guide and the more detailed Statement of Purpose. The Registered Manager, in consultation with the person concerned, completes an assessment of each prospective service user’s needs for assistance. This is done before a decision is made about whether or not the Service is a suitable place for the person’s residence. Care workers say that the Registered Manager informs them about the needs of new service users, so that their Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 9 needs for assistance can be met from the point of admission. Care workers are aware of the need to welcome new service users, so that their experience of moving in is as positive as is possible. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. 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. Suitable arrangements are in place to retain and dispense medication. The principles of respect, dignity and privacy generally are put into practice. EVIDENCE: Service users say or indicate, that the care workers offer them all the assistance they need and that this is provided in a reliable and consistent manner. There is a written individual plan of care for each of the service users. These are important documents. This is because they form one of the means by which each service user can be informed about and can agree to the assistance he or she will receive. Also, the plans are a source of information for staff. This then helps them to provide support in a consistent manner. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 11 Sensible arrangements are in place to anticipate and manage potential risks to the service users’ personal health and safety. Service users are assisted to maintain their health. 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. Suitable arrangements are in place to enable service users’ medication to be retained and to be dispensed in accordance with the doctors’ instructions. Service users say that the care workers are cordial in their approach. Also, that they are respectful of their individual preferences. Several relatives think that more should be done to ensure that items of clothing do not become lost, or given back to the wrong service user. Plainly, it is essential that all service users only wear their own clothes. Not all of the service users’ clothes are marked with their name. The Registered Manager needs to address this matter. Without this basic information it will be difficult for care workers to sort out this problem. There is a Required Development about this matter listed at the end of this Report. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. There is a variety of social activities taking place. Service users are able to choose their life style and to keep in touch with family and friends. Service users eat well. EVIDENCE: There is a calendar of social events held in the Service. Service users say or indicate that they are suitably occupied. They can join in with activities or not, according to what they want to do. The Registered Manager is aware of the need to keep the calendar under review. This is to ensure that planned events actually do take place and do not get put aside because care workers are too busy with other duties. Service users consider the pace of daily life in the Service to be relaxed and unhurried. They are free to decide what to do each day. As appropriate, they can retire to the privacy of their bedroom. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 13 Service users are assisted to keep in touch with members of their families, if this is necessary and if it is their wish. Family members and friends are welcome to call to the Service at any reasonable time. Service users are free to spend time in private with their relatives and friends, should they choose to do so. Service users say that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant experience. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. There is a sensible system for addressing complaints. Service users’ wellbeing is promoted and they are protected from abuse. EVIDENCE: There is a written complaints procedure. This explains how service users and their representatives can go about raising a concern. Service users say or indicate that they feel themselves free to speak up if there is anything troubling them. Since the last inspection visit, neither the Registered Provider nor the Commission have received any significant complaints about the Service. The care workers have a sound understanding of what is recognised to be good care practice. As part of this, they are aware of the need to be alert to instances in which the well being of a service user might become compromised. Service users say or indicate, that they feel safe living in Pilgrims Lodge. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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): 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 comfortable environment, which promotes their independence. EVIDENCE: Service users say or indicate that they are comfortable living in Pilgrims Lodge. They consider the accommodation to be homely and welcoming. The Registered Manager is aware of the need to carefully monitor the accommodation to ensure that it remains fresh and pleasant. Some parts of the exterior of the property look rather run down. There are areas where paintwork is peeling away or where it has become discoloured with age. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 16 Some of the bathrooms and toilets are rather bare. More needs to be done to make them into welcoming and personal spaces. Part of this exercise will involve fitting light shades to several locations where at present there are just light bulbs showing. There is a Required Development about this matter listed at the end of this Report. The property is fitted with a modern automated fire detection and fire containment system. This is designed to give a high level of protection to service users. The Registered Provider has completed an organised assessment of the adequacy of the fire safety measures in use in the Service. This has been done so that any potential obstacles to the operation of the fire safety system can be identified and managed effectively. The local Department of Environmental Health is understood not to have recommended any improvements in the kitchen, which remain outstanding. The kitchen is well equipped, orderly and clean. The cook has a good understanding of how to maintain suitable levels of food hygiene. Suitable arrangements are in place to assist those service users who have difficulty getting about. There are hoists in the bathrooms. Also, there are mobile hoists. Care workers say that they have all of the equipment they need to enable them to safely assist the service users. Service users say that their bedrooms are arranged according to their choice. Service users say that the accommodation is kept comfortably warm. However, it did not feel that warm when the Inspector was present. The Registered Manager will need to keep this matter under careful review, so that the central heating is adjusted to respond to changes in the weather. The radiators are protected with guards. These are one of the ways often used to reduce the risk that someone might be burnt if they have a fall near to a radiator. Care workers say that there is always an adequate supply of hot water. Hot water taps which are used by the service users, are fitted with special valves. These reduce the temperature of hot water to a level that is not likely to scald someone. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this Service. There are enough care workers on duty. Care workers know what they are doing. EVIDENCE: There are always at least four care workers on duty to meet the service users’ needs for assistance. The care workers are supported in their work by other members of staff, who complete some of the catering tasks or who do most of the main cleaning. The care workers have a detailed knowledge of the needs and preferences of each of the service users. The Service is adequately staffed given the needs for assistance of the service users who are currently in residence. Of the 14 care workers employed in the Service, seven either have acquired a National Vocational Qualification (NVQ) in health and social care, or are in the process of doing so. 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 Registered Manager says 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.V335000.R01.S.doc Version 5.2 Page 18 The Registered Providers complete a number of security-related checks. These are designed to ensure that only trustworthy people have access to service users who may be vulnerable. All new care workers receive introductory training. This is designed to ensure that they have the basic knowledge and skills they need in order to be able to work effectively without direct supervision. After their introduction to the Service, care workers undertake a number of further training courses. These are designed to enhance their capacity to deliver care. The Registered Provider has complemented this provision by completing a specific review of the adequacy of the knowledge and skills possessed by each of the existing care workers. This is a very good idea, because it has double-checked that everyone knows what they should be doing. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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): Standards 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. Suitable arrangements are in place to ensure that the Service operates reliably. There is a basic quality assurance system. Sensible steps have been taken to promote the health and safety of people who live and work in the Service. EVIDENCE: The Registered Manager has a good knowledge of what is going on in the Service and of any issues to be addressed. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 20 Suitable arrangements are in place to enable the care workers to coordinate their activities. This means that there is good team-work in the Service. The Service is run without there being any unnecessary rules or routines. This means that service users can continue to experience a normal home life of their choosing. In addition to everyday informal consultation, the Registered Provider has a more formal system whereby people such as service users’ relatives are invited to comment about the Service. More is now going to be done to involve service users directly in the process. This is in recognition of the fact that it is the service users who are the experts on what it is like to live in Pilgrims Lodge. This development is going to be completed by 1 September 2007. The Registered Provider assists most of the service users to administer aspects of their weekly personal spending allowance. Suitable arrangements are in place to complete this task. The Registered Manager says that all items of equipment in use in the Service remain in good working order. There are various certificates which confirm this account. Regular checks are completed to ensure that the Service’s automated fire detection and alarm system remains in good order. The Registered Provider needs to take additional steps to ensure that all members of staff know how to operate the Service’s fire safety systems. This is important because the actions taken by members of staff, largely determine the level of fire safety protection provided in the Service. There is a Required Development about this matter at the end of this Report. A limited number of accidents has occurred since the last inspection visit. Their nature and frequency does not indicate the need for any special concern. The Registered Manager monitors the premises and the accommodation so that potential hazards to health and safety can be identified and resolved. She says that there are no significant hazards waiting to be addressed. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 X 17 X 18 3 2 X X 3 X X 2 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 3 X 2 X 3 X X 2 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 22 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 OP10 Regulation 12 Requirement The Registered Provider should ensure that suitable arrangements are in place to enable service users clothes to be returned reliably to them once laundered. The Registered Provider should ensure that suitable shades are fitted to all light bulbs located in areas of the accommodation occupied by service users. 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 Service’s fire safety regime (this matter is outstanding from the last Inspection Report. It should have been addressed by 01/11/06). Timescale for action 01/06/07 2. OP19 23 01/06/07 3. OP38 23 01/06/07 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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. Refer to Standard Good Practice Recommendations Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V335000.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!