Inspection on 31/08/05 for Pilgrims Lodge Residential Home For The Elderly

This inspection was carried out on 31st August 2005.

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 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... 15/03/06

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

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St Joseph`s

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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 Christine Lawrence Announced 31/08/05 & 01/09/05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 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 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 None None Mr David Barzotelli Diana Woodridge Care Home 30 Category(ies) of Older People with Dementia (26), Older People registration, with number (4) of places Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 03/02/05 Brief Description of the Service: Pilgrims Lodge is a care home providing personal care and accommodation for 26 people with dementia and 4 older people. It is owned by David Barzotelli, who also owns another home in the area. 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. The home 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 H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out over two days. The inspector spoke with three members of staff and observed interactions between staff and residents, including one mealtime. Eight relatives completed comment cards as part of this inspection and six relatives completed cards on behalf of residents. One resident completed a comment card. The inspector also had some discussions with the manager and viewed various records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents have their needs assessed prior to moving into the home and thus can be assured that the home judges that it can meet those needs. EVIDENCE: Mrs Woodridge or her Deputy undertakes pre admission assessments for all residents. These assessments use a clearly designed format and are used to begin the process of compiling a care plan (see Standard 7). A questionnaire for relatives (or the resident, according to their abilities), called a Memory Album is also used to ascertain personal and background information. Information is also obtained from a placing authority if available and examples of this were noted in individual records. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Residents’ health and social care needs are clearly set out in plans ensuring that these needs will be met. Residents are protected by the home’s policies and procedures regarding medication and they can be confident that their privacy and dignity will be considered important. EVIDENCE: The care plans at Pilgrims Lodge are individual and maintained in ring binders. They are clearly set out and contain the following sections: - Personal Information, Medical Information, Mobility, Personal Skills, Household Skills, Communication and Awareness, Relationships, Continence, Nutrition/Hydration, Activities and Hobbies, Personal Security, Sexual Awareness, Indicators of well being for people with dementia, Night time/sleeping etc. Each section contains specific actions for members of staff and risk assessments. Mrs Woodridge also uses an extra format when an individual’s behaviour gives cause for concern. Four care plans were seen during this inspection. Within the sections there are checklists which are used to record any (or no) changes to care plan objectives/actions and risk assessments. These are reviewed monthly or more often if required. The format for monitoring care on a daily basis is satisfactory but some blanks are Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 9 being left by staff. Mrs Woodridge is aware of this and is endeavouring to ensure that staff are more diligent about this. The individual care plan folders contain information relating to visits from or involvement with health care professionals such as general practitioners, community nurses, community psychiatric nurses, chiropodist etc. Aspects relating to physical care needs such as maintaining skin integrity are included within various parts of the care plan. The Waterlow format is used to monitor skin integrity. Pressure relieving equipment is used within the home. The records indicated that Community Nurses are involved with advice and guidance relating to continence issues. Information regarding diet, appetite, special dietary requirements and the level of support or supervision required for mealtimes with guidelines for members of staff to follow, are also included in the care plan folder. The Medical Information section has sections relating to eyesight, dental care, hearing and foot care. Eight members of staff have undertaken medication training and the medication procedures and policies are in keeping with the Royal Pharmaceutical Society of Great Britain’s guidelines. Medication is appropriately stored. One resident currently self-medicates and there is a risk assessment in place for this. Staff spoken to confirmed an awareness of and a commitment to the need to maintain dignity and privacy in all areas of care for the residents in Pilgrims Lodge. The care plans seen also contained specific information relating to this. The induction training specifically covers dignity and respect. Care plans contained information about how a resident likes/prefers to be addressed. Privacy screens are available in shared rooms. The Inspector observed staff interacting with residents in a respectful manner. Induction records seen indicate that privacy and dignity are covered and Mrs Woodridge said this is also discussed in supervision. Residents are assisted to open their mail by staff or relatives. A telephone is available in the ‘library’ area. Screening is available in shared rooms. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Some aspects of residents needs will not be satisfied because stimulation, activities and entertainments are limited. Residents are enabled to maintain contact with family and friends. A balanced and varied diet is provided. EVIDENCE: Although occasionally staff have the opportunity to provide activities, exercise or stimulation there is nothing planned or individualised. Staffing levels should be reviewed to ensure that in the absence of a designated member of staff to carry out these tasks, sufficient time is available. Examples were noted of staff enabling residents to make choices within the limitations of their dementia. Mrs Woodridge provides information about visiting in the service user guide. Residents can receive their visitors in the communal areas or in their own rooms. There are no restrictions to visiting times. All nine of the relatives who completed comment cards said that they were welcomed in the home at any time. There is a section within the care plan which relates to nutrition and residents’ weight is monitored. An assessment tool (Prideaux) is used to monitor nutritional status. The inspector observed a mealtime and saw staff helping and encouraging residents appropriately. Mrs Woodridge provided a copy of Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 11 the menu which had variety and includes vegetables and fruit. She said that she and the cook plan the menu and they take account of residents’ wishes when these can be ascertained. It is sometimes difficult to inform residents in advance what the meal will be due to their degree of dementia. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints are handled appropriately and residents/their representatives can be confident that any concerns will be listened to, taken seriously and responded to. Staff are aware of adult protection issues and there are systems in place for protecting residents from abuse. EVIDENCE: There is an appropriate Complaints Procedure in use within the home which includes the commitment to respond within a maximum of 28 days. A Complaints Folder is maintained. There is clear information on display on the notice board giving details of how to contact the Commission for Social Care Inspection. The records indicate that Mrs Woodridge takes complaints seriously and is open in her responses. The policies and procedures within the home are clearly written and are available to staff. Policies and procedures are read and signed for within the induction process and this was noted by the Inspector in staff records. Certain policies and procedures (called Special Policies and Procedures, which includes Adult Protection and Whistle Blowing) are given to staff members to keep. There is a policy called ‘Acceptance of Gifts’. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None These standards were not assessed at this inspection. EVIDENCE: Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27and 29 Some needs are not fully met because of staff numbers. Residents are supported and protected by the home’s recruitment procedures. EVIDENCE: Staffing levels for care are adequate. A rota shows which staff are on duty and in what capacity. There are sufficient domestic staff employed. However, as noted in standard 12 there is not always time for staff to engage residents in activities/stimulation. Mrs Woodridge is currently recruiting for new staff. Existing staff cover any shortfall at the moment. Three staff records were viewed and they showed that the home’s recruitment procedures include references, criminal records bureau checks, application forms and interviews. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 38 The manager is competent and experienced. Residents’ financial interests are safeguarded. Residents and staff health and safety are promoted and protected. EVIDENCE: Mrs Woodridge has a Diploma from Bradford University relating to dementia. She has a National Vocational Qualification in care Level 4 and has undertaken a number of short courses. She was a registered nurse. She has a great deal of experience. There are procedures in place to ensure that residents’ finances are appropriately managed and records are kept of any involvement. The manager has involvement with the personal allowances of some people and keeps careful records. Care plans indicate the involvement of relatives or Kent County Council Finance Officers. Relatives are also involved in supporting residents to manage their finances. Where Mrs Woodridge is involved she Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 16 sends relatives/representatives a statement every two months. A spot check on maintenance and service contracts showed that they are appropriate and up to date. Mrs Woodridge endeavours to keep health and safety training as up to date as possible and in keeping with the TOPSS recommendations. Fire safety checks are carried out properly and accidents are properly recorded. Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x x 3 Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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. Refer to Standard 12 27 Good Practice Recommendations Activities should not be dependant on available time. Some activites should be planned and staff made available. Staffing levels should be reviewed to ensure that all identified needs are met Pilgrims Lodge Residential Home for the Elderly H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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 H56-H05 S23990 Pilgrims Lodge RH for the Elderly V237960 310805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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