Inspection on 15/03/06 for Pilgrims Lodge Residential Home For The Elderly

This inspection was carried out on 15th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

Pilgrims Lodge Residential Home... 10/08/06

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 Wendy Jones Unannounced Inspection 15 March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 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.V283474.R01.S.doc Version 5.1 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 Diana Penelope Woodridge Care Home 30 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (4) of places Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/08/05 – 01/09/05 Brief Description of the Service: Pilgrims Lodge is a care home providing personal care and accommodation for 26 older people with dementia and 4 older people. David Barzotelli, who also owns another home in the area, owns the home. The registered manager is Diane Woodridge. The home is located in a residential part of Canterbury, not far from the city centre with all of its amenities. It was opened in 1992 and consists of two houses joined together to form one building. Some off road parking is available. There are 22 single rooms, none of which have en suite toilet facilities and 4 shared rooms, one of which has en suite toilet facilities. There are gardens to the rear of the building. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by Alison Spreadbridge and Wendy Jones, Regulatory Inspectors between 10:00am and 12:30pm. Judgements are based on conversations with the manager and some staff and residents, reading of records, observation and a tour of the home. What the service does well: What has improved since the last inspection? What they could do better: To avoid the possibility of errors when administering medication Royal Pharmaceutical Guidelines must be followed and medication must be recorded when it is administered. There are currently not enough trained and competent care staff on duty. Staff do not have time to spend with residents and provide them with opportunities for stimulation through leisure and recreational activities that suit their needs, preferences and capacities. Staffing levels must be reviewed so that enough staff are on duty to cover these needs. Particular consideration must be given to residents with dementia. When the staff who are still undertaking NVQ level 2 in Care have completed this course 49 per cent will be trained to this level. The manager should arrange for one or two more staff to undertake this qualification so that 50 per cent of care staff are trained. The plan to provide all staff with training in Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 6 dementia should be implemented as soon as possible so that all staff have the skills and knowledge they need to care for the residents. The second reference on file for one member of staff was addressed “to whom it may concern”. This reference had been brought to interview by the applicant and had not been requested directly by the home. All references should be requested by the home and thoroughly checked. Records of induction training should be signed and dated to show when this has taken place. Residents’ care plans are currently kept in the staff room, which is not kept locked. These records must be kept secure and confidential. Some toilet doors did not have signs. These must be fitted so that residents know they are toilets. A pot of Sudocream and talcum powder were found in a shared room that did not belong to the residents of that room. To maintain residents’ health and safety and to control the spread of infection rooms must only contain the toiletries that belong to the resident(s) who live in them. The boiler cupboard in a ground floor bedroom was not locked and could be accessed by the resident who lived in this room. This poses a safety risk for them and a lock must fitted to this cupboard so that it can be kept locked at all times. The patio area at the rear of the home is very uneven and presents a risk of falling and is difficult for residents in wheelchairs to use. This area must be made safe for residents to use. 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.V283474.R01.S.doc Version 5.1 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.V283474.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Key standard 3 in this section was met when assessed at the previous unannounced inspection on 31 August 2005. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents are not protected by the home’s procedure for administering medication. EVIDENCE: Currently the home is using the Nomad system for medication. Medication is stored in a very small cupboard that has been fitted with shelving to hold the medication and Nomad cassettes. The manager explained that this system is being changed to Boots in the next week. The manager explained that medication is put into a plastic box with a jug of water and taken to the residents. A medication trolley cannot be used due to the number of stairs in the home. When asked if the medication administration records are taken also and medication recorded at the time it is taken, she advised that there is not enough space and medication is recorded afterwards. This could lead to errors and is contrary to the guidelines from the Royal Pharmaceutical Society. Medication must be recorded when it is administered. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 10 The manager advised that medication training is provided by West Kent College and confirmed that only staff who have undertaken this training administer medication. Similarly, she confirmed that only staff who have undergone appropriate training and checks by the District Nurse administer insulin. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Residents have an extremely limited range of activities available to them. Residents have varied and balanced meals. EVIDENCE: Residents were sitting in lounges or in their rooms. One lounge had a television whose picture was very bad. The manager advised that a new television was being purchased. Some residents were sitting in front of this television and others were sitting in the lower half of the lounge. No activities were taking place. The manager advised that staff occasionally have the opportunity to provide activities, exercise or stimulation for residents. However, there are no planned activities and at this time staff were busy and did not have time to spend with residents. The manager has developed a plan of activities and the “props” are available in the home. However, she has not been able to implement her plan, as she does not have the staff to resource it. The manager advised that an outside entertainer visits the home, but only 3 or 4 times a year. Residents must be given opportunities for stimulation through leisure and recreational activities that suit their needs, preferences and capacities. Particular consideration must be given to residents with dementia. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 12 Only one resident handles their own finances. Residents can bring personal possessions with them into the home. Residents rooms seen contained their personal effects. Some residents had small, mobile tables in front of their chairs with a knife and fork on. Residents spoken with said that they were waiting for their lunch. They said that they enjoyed the food. The cook was very knowledgeable about residents’ preferences and special diets. There is a two-week rotating menu. The cook advised that this is based on what the residents’ prefer and can eat, but she will provide alternatives if asked. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Standards 16 and 18 in this section were met when assessed at the previous unannounced inspection on 31 August 2005. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 14 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, 20, 21, 23, 24, 25 and 26 Residents live in a clean home and have rooms that suit their needs. They have access to indoor and outdoor communal facilities. However, the patio area at the back of the house is very uneven and presents a risk of residents falling. EVIDENCE: Pilgrims Lodge is made up of two houses that are joined together to make one. There are a number of small corridors and narrow staircases around the home. There is no lift. The manager advised that only residents who are mobile are given rooms on the first floor of the home and should their mobility deteriorate they are moved to a ground floor room as soon as possible. Bedrooms contained basic furnishings and residents’ personal items including photos, pictures and ornaments. There are 22 single rooms and 4 shared rooms. The manager advised that some shared rooms are being used as singles at present. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 15 There are a number of communal toilets situated around the home. One had no lock and some had no sign to let residents know they are toilets. Signs must be fitted to these doors so that residents know they are toilets. There are also a number of bath/shower rooms around the home fitted with mobile hoists. One large bathroom on the first floor had recently been redecorated. Unfortunately, as this had been fitted with a normal bath and did not contain a bath hoist it was not being used very much. There is a lounge/dining area on each side of the home. Both are on splitlevels with a handrail in the centre of the step(s) to each level. Both have a dining table and chairs for resident who eat their meals at the table. The garden area at the rear of the home has a patio and grassed area in the centre. The patio area is made of paving slabs. It is very uneven and presents a risk of falling and is difficult for residents in wheelchairs to use. This area must be made safe for residents to use. The laundry is a small narrow room with one small sink, one washing machine and two dryers. There are separate boxes for each resident’s clean laundry. Procedures are in place for controlling the spread of infection and keeping clean and dirty laundry separate. Due to its size the laundry is not ideal for the number of residents in the home. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 16 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 The numbers of staff do not meet all residents’ needs and residents would benefit by at least 50 per cent of the staff being trained to NVQ level 2 in care or equivalent. Residents would be further protected by a more robust recruitment procedure and confirmation that new staff have completed induction training. EVIDENCE: There were 23 residents living in the home at this time. The deputy manager, 3 care staff, a cook, and domestic staff were on duty. In addition the manager and a maintenance person were in attendance. Duty rosters seen showed that there were not enough trained and competent care staff on duty to ensure that all residents needs are met. Although staff had time to carry out their care duties they did not have time to spend with residents and provide them with opportunities for stimulation through activities. Currently 17 care staff are working at the home. Five of these have NVQ 2 in care or above and a further three are currently doing the course. When they have completed, 49 per cent of care staff will be trained to NVQ level 2 or equivalent. The manager should arrange for one or two more staff to undertake this qualification to ensure that 50 per cent of care staff are trained to this level. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 17 Staff files and recruitment records seen contained all relevant information, documentation and checks needed to ensure that residents are protected. It was noted however, that the second reference for one member of staff was addressed “to whom it may concern”. The manager confirmed that this reference had been brought to interview by the applicant and had not been requested directly by the home. All references should be requested by the home and be thoroughly checked. The manager confirmed that new staff have completed induction training. However, staff files sampled did not contain completed records evidencing when this had taken place. Records of training staff have received were seen. The manager advised that training courses are organised and provided by the sister home owned by Mr. Barzotelli. The 2006 training plan has been received and the manager advised that training in health and safety, first aid, food hygiene and fire safety are planned. The manager confirmed that she is planning to provide all staff with training in dementia. The first session is planned for 23 March 2006. She advised that she expects to only be able to train 2 to 3 members of staff at a time and that the training will be provided on site. All staff should receive this training as soon as possible so that they have the skills and knowledge to meet the needs of the residents. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 18 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, 32, 35, 36, 37 and 38 Residents benefit from living in a home managed by a person of good character and who is fit to be in charge. Residents’ financial interests are safeguarded. However, keeping their care plans more securely would further safeguard their rights and best interests. EVIDENCE: The registered manager has a Diploma from Bradford University relating to dementia, NVQ 4 in Care, has undertaken a number of short courses, was a registered nurse and has a number of years’ experience of managing a care home. The registered manager advised that she is due to retire in May 2006 when a new manager will be appointed. Small amounts of cash are kept securely for some residents in the home. Individual records are kept and those sampled tallied with receipts. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 19 Records of supervision that had been carried out were seen. However, the manager explained that these had slipped slightly recently but are usually carried out every 6 to 8 weeks. Staff and residents’ files are kept securely in the manager’s office. This room is kept locked when not in use. However, residents’ care plans are kept in the staff room. This room is not kept locked. These records must be kept secure and discussion took place around how this could be achieved. The manager felt that a keypad system would be the answer. Some of the toiletries in one shared room had been labelled to ensure that residents used their own. However, a pot of Sudocream and talcum powder belonging to other residents were also in this room. The manager removed these and gave them to the Deputy Manager. To maintain residents’ health and safety and to control the spread of infection rooms must only contain the toiletries that belong to the resident(s) who live in them. It was noted that the boiler was housed in a cupboard in a ground floor bedroom. Although the door of the cupboard had a bolt on it the manager advised that this door was not kept bolted and could be accessed by the resident who lived in this room. This posed a safety risk for them and a lock must be fitted to this cupboard and it must be kept locked at all times. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 2 3 2 X 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 2 2 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16(2)(n) Requirement Timescale for action 30/06/06 2 OP9.4 13(2) 3 OP19.3 23(2)(o) A programme of activities must be provided that gives residents opportunities for stimulation through leisure and recreational activities in and outside the home and which suit their needs, preferences and capacities. Particular consideration must be given to residents with dementia. Procedures must be in place that 16/03/06 ensure the safe administration of medicines and follow the guidelines of the Royal Pharmaceutical Society. The patio area at the rear of the 30/04/06 house must be made safe for use by residents and appropriately maintained. Action plan to be provided to the Commission by: All toilets and bathrooms must be clearly marked. Action plan to be provided to the Commission by: Appropriate numbers of suitably qualified, competent and DS0000023990.V283474.R01.S.doc 4 OP21.2 23(2)(n) 30/04/06 5 OP27 18(1)(a) 30/06/06 Pilgrims Lodge Residential Home For The Elderly Version 5.1 Page 22 6 OP37.3 17(1)(b) experienced persons must be available to ensure that the needs of residents, including opportunities for stimulation through activities, are met. Residents’ individual care plans must be kept securely and confidentially. Action plan to be provided to the Commission by: Suitable arrangements to prevent infection and the spread of infection must be made so that residents only have access to their own toiletries, particularly when they share a room with another resident. Unnecessary risks to the health and safety of residents must be so far as possible eliminated. A lock must be fitted to the boiler cupboard and it must be kept locked and not accessible to the resident whose room it is in. Action plan to be provided to the Commission by: 30/04/06 7 OP38.2 13(3) 16/03/06 8 OP38 13(4)(c) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3. Refer to Standard OP28 OP29.2 OP30 Good Practice Recommendations Further staff should undertake NVQ2 in care or equivalent so that a minimum of 50 per cent of care staff are trained to this level. All references should be requested by the home and thoroughly checked. Induction records should be signed and dated to show that induction has been received within 6 weeks of appointment. DS0000023990.V283474.R01.S.doc Version 5.1 Page 23 Pilgrims Lodge Residential Home For The Elderly 4. OP30 Dementia training should be provided for all staff as planned. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Pilgrims Lodge Residential Home For The Elderly DS0000023990.V283474.R01.S.doc Version 5.1 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!