Inspection on 16/01/06 for Pilgrims View

This inspection was carried out on 16th January 2006.

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 View 12/06/07

Pilgrims View 04/07/06

Pilgrims View 07/07/05

Pilgrims View 04/11/04

Pilgrims View 06/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pilgrims View Roberts Road Snodland Kent ME6 5HL Lead Inspector Ruth Burnham Announced Inspection 16th January 2006 09:30 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 View DS0000024077.V269099.R01.S.doc Version 5.0 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 View DS0000024077.V269099.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pilgrims View Address Roberts Road Snodland Kent ME6 5HL 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) 01634 241906 01634 243661 Kent Community Housing Trust Mrs Eileen Elizabeth Noonan Care Home 43 Category(ies) of Dementia - over 65 years of age (43) registration, with number of places Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Older people with dementia from 55 years of age and over. Date of last inspection 7th July 2005 Brief Description of the Service: Pilgrims View is care home providing personal care and accommodation for 43 older people specialising in the care of older people with a mental infirmity. Kent Community Housing Trust owns Pilgrims View, which is a non-profit making Trust. Pilgrims View is one of 22 residential care homes owned and run by the KCHT in the Kent and London areas. It holds Investors in People Award and has an ISO 9002 Quality Standard Accreditation.The home is located close to the centre of the small town of Snodland, which has a selection of shops, pubs, post office and other amenities. The home was originally built as a local authority home and was taken over by Kent Community Housing Trust in 1992. It is a purpose built, single storey residential home. The home has 35 single and 4 shared bedrooms located on four wings; none of the rooms have an ensuite facility. All the bedrooms are equipped with call alarms and TV aerial points. There are well-developed secure gardens surrounding the building, which are well maintained and easily accessible. There is a stream on one side of the garden. There is car parking at the front of the home with street parking nearby. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, carried out by 1 inspector who was in the home from 09.30 to 14.30 hrs during which time service users and staff were spoken to and observed around the home. The manager, who also assisted with the examination of records, accompanied the inspector on a tour of the home. What the service does well: What has improved since the last inspection? What they could do better: The care plan should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the service user are met in a way which takes account of their individuality and preferences. Risk assessments should be included in the care plan, which cover all aspects of daily living. Only service users who have made a positive choice to share a bedroom should be required to do so. The registered person shall make arrangements for all service users to take part in a programme of activities and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation and fitness. The registered person shall supply to the Commission at it’s request a statement containing a summary of the complaints made during the preceding 12 months and the action that was taken in response. The registered person shall ensure that the layout of the premises meet the needs of service users and provide adequate means of escape that adequate day space should be provided on all units and fire exits should be kept clear at all times. The registered person shall establish and maintain a quality assurance system for the care provided Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 6 at the care home and supply to the Commission a report in respect of any review of quality and make a copy of the report available to service users. The registered person shall keep a duty roster of persons working at the care home and a record of whether the roster was actually worked Staff should have qualifications suitable to the work they perform in that staff who handle food should receive competence based training in basic food hygeine. 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 View DS0000024077.V269099.R01.S.doc Version 5.0 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 View DS0000024077.V269099.R01.S.doc Version 5.0 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): 1-6 People who are thinking about moving to the home and their supporters are provided with sufficient information on which to decide if this is the right home for them in which their needs can be met. EVIDENCE: People who are thinking about moving to the home and their supporters are provided with detailed information about what they can expect through a statement of purpose and a service user guide, a copy of which is provided in each bedroom. People who live in the home can be clear about their rights and responsibilities through contracts which are in place and were available for inspection, those seen had been signed by all parties. People who are admitted to the home can be confident that their needs will be met as a thorough pre-admission assessment of their needs is carried out by the home. There is opportunity for people who live in the home to visit Pilgrims View prior to admission and meet the staff and other residents, they are able to spend time at the home and have a meal if they wish. The initial residency is for a trial period of four weeks after admission to ensure that the home was Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 9 an appropriate place for the service user, this can be extended if felt necessary and unplanned admissions are avoided whenever possible. The home does not provide intermediate care. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 & 11 Service users benefit from support by staff who are well informed about them however individual personal care needs are not always being met, their privacy and dignity is not being upheld and, in some instances, they are at risk of harm. EVIDENCE: Care plans include excellent information about the background and social history of people who live in the home to help staff to communicate with them. Service users could still be at risk of harm in that risk management still does not take account of all aspects of service users lives, for example there are kettles in each of the units which are accessible to residents, whilst there is a general risk assessment in place there are no individual risk assessments which take account of the fact that unattended kettles in units remain hot at times throughout the day and night which could place resident who wander near them at risk of harm. Service users who are disorientated and wander at night are still compromising the dignity and privacy of other service users. Service users’ individual personal needs may not be met as care plans seen are largely set out in a tick box format with small boxes for minimal comment or Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 11 observations, they contain very limited guidance for staff which takes account of the individuality and personal preferences of residents in how their care should be delivered, daily records do not reflect the content of care plans. Given that all service users in this home are suffering from dementia it is clear that those who share bedrooms are not able to make a positive choice to share with full understanding of the implications of this situation for privacy and dignity in that they will be sharing with other service users who are strangers to them. People who live in the home can expect to be able to remain in the home until death so long as the home is able to continue to meet their needs, and they and their relatives benefit from the support of staff who have received training in bereavement and loss. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 People who live in the home benefit from the wholesome food and flexible routines however recreational interests and needs are not always met. EVIDENCE: A number of responses received from the supporters of people who live in the home indicated some dissatisfaction with the lack of stimulation and arrangements for activities. The home employs an activities co-ordinator however there are no individual programmes included in resident’s care plans for staff to follow, outings are limited by the fact that the home does not have it’s own transport and minibuses have to be hired. On the day of the inspection residents were observed watching television and a few were having beauty treatments. People who live in the home are offered choice at meal times in a way that is appropriate for people who have a diagnosis of dementia in some form, picture menus have been introduced. Baskets of snacks with fresh fruit and yoghurt are offered between meals and in the evening and the health of resident is promoted through a commitment to providing healthy foods which take account of individual needs. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 13 People who live in the home benefit from the flexible visiting policy in that friends and relatives are able to visitor at all reasonable times and can stay for a meal if they wish. They also enjoy some involvement with local community groups; service users are invited to the plays and pantomime at the school, which is across the road from the Home and a local minister conducts a religious service monthly for people who wish to take part. None of the service users currently living at the Home are able to manage their own finances, their interests are safeguarded in this area through clear policies and good record keeping. People who move into the home are helped to feel at home by being able to bring personal possessions with them as long as they do not present a hazard , a record is kept by the home, bedrooms are personalised. - Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 People who live in the home are protected from abuse although inadequate record keeping made it impossible to make a judgement that they can be confident that their complaints will be listened to. EVIDENCE: People who live in the home and their supporters are provided with a written complaints procedure and are free to offer comment or complaint however the home does not maintain a summary of complaints as required, complaints are recorded in individual resident’s records, where complaints are addressed to and are dealt with by the head office of the Trust documentation was not available in the home for inspection. Residents are supported through the arrangement of postal votes are arranged for those service users wishing to participate in the election process. People who live in the home are protected from all forms of abuse and there are written policies and procedures including a whistle blowing policy to ensure the safety and protection of service users. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The quality of life for people who live in the home is enhanced by the clean environment and good facilities although some residents are disadvantaged through sharing bedrooms and inadequate day space. EVIDENCE: Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 16 People who live in the home benefit from the ease of access afforded by the single storey premises and the enclosed gardens to the side and rear of the property provide a safe environment for the residents with ample wandering space necessary for people with dementia. Residents are able to enjoy a homely environment through the division of the home into three units two of which accommodate ten service users and one which accommodates thirteen service users, this unit has only 2.8sq.m of day space per service user which is inadequate, allowing insufficient space to accommodate thirteen easy chairs and small tables for the people who live on this unit, there is also a risk when service users are seated at the dining room tables on this unit as there is insufficient space to access the fire exit. It was good to see that plans to extend this area are in place and work is expected to begin on this project this year and the unit was being redecorated at the time of the inspection. People who live in the home benefit from Accessible toilets which are close to lounge and dining areas. Sufficient toilet, washing and bathing facilities are provided to meet the needs of the service users and all bedrooms are provided with a wash hand basin. Risk of infection is minimised by the provision of sluice facilities which are separate from toilet and bathing facilities. There are two single rooms in the Home, which are over 12sq.m, which could be used to accommodate wheelchair users and residents benefit from having bedrooms which are furnished and decorated to a reasonable standard however divans beds without valances spoiled the homely effect in some rooms as did the hard flooring which has also been laid in a small number of bedrooms. There are four shared bedrooms in the home and, given that all service users in this home are suffering from dementia, it is clear that those who share bedrooms are not able to make a positive choice to share with full understanding of the implications of this situation for privacy and dignity in that they will be sharing with other service users who are strangers to them. Residents who are able to use a key benefit from lockable space which is provided in each bedroom. People who live in the home are protected from injury through thermostatic controls which are fitted to the radiators, radiators covers are also fitted, thermostatic valves are fitted to hot water outlets to prevent the risk of scalding and the maintenance person carries out regular checks, which are recorded. There is a sluice facility on each unit and the quality of life for residents is enhanced through the maintenance of a clean environment which is free from offensive odours throughout. Risk of infection is reduced through the provision of adequate laundry facilities which are sited away from food areas and do not intrude on service users living space. The laundry room is equipped with washing machines complying with disinfection standards, tumble driers, rotary iron and sink unit. People who live in the home can be confident that high standards are maintained in the kitchen, which has again merited the local Environmental Health Department’s Clean Food Gold Award to the home for 2005. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 - 30 No judgement has been made about the adequacy of staffing levels as accurate records were not available. People who live in the home benefit from the support of carefully selected staff who understand their condition. EVIDENCE: People who live in the home benefit from the care and support provided by the staff team who have all received specialist training in understanding the specific needs of people who have dementia, it was not possible to make a judgement about the adequacy of staffing levels at this inspection as not all hours worked by staff were being recorded on the staff rota. People who live in the home are protected through sound recruitment and selection procedures which include taking up 2 written references and carrying out checks with the criminal records bureau prior to appointment, work has been done since the last inspection to ensure that staff records are maintained in a way which meets regulatory requirements. Residents also benefit from the opportunities provided to staff to improve their skills through training and access to National Vocational Qualifications. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 - 38 People who live in the home benefit from an experienced management team who have their best interests at heart however, lack of effective quality assurance systems may hinder future improvements and inadequate training and record keeping may place residents at risk of harm. EVIDENCE: People who live in the home benefit from the qualifications and experience of the manager who managed homes since 1998. She has an NVQ Level 4 in Management and has completed an Open University Course in care for the Elderly and an in-service course in Social Care. Residents benefit from a management structure where there are clear lines of accountability within the home and the organisation with audit visits by the Registered Provider taking place every month. Responses from relatives received before the inspection indicated a general satisfaction with the overall management of the home. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 19 The quality of life for people who live in the home and their supporters is monitored through annual quality questionnaires, which are sent to all relatives/representatives of the service users. However the home does not have a continuous self-monitoring system in place, based on a systematic cycle of planning-action-review, which produces a report to the Commission in line with the regulations and accurate records are not being maintained of the number of staff on duty at all times. The safety of people who life in the home is maintained through periodic routine tests and checks of fire precautions, records seen were in good order. There is a fire safety risk assessment in place however this has not yet been approved by the Fire Safety Officer. Safety is further promoted through the regular maintenance of all equipment and installations; safety certificates were seen and were in good order. Safe working practices also protect residents from risk of harm through training staff in fire safety, moving and handling, first aid and health and safety, there was some concern that care staff who handle food have not received competence based training in basic food hygiene and the temperature of fridges on units was not being recorded on a daily basis. Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 2 3 3 2 3 3 3 STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 2 2 Pilgrims View DS0000024077.V269099.R01.S.doc Version 5.0 Page 21 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 OP7OP7 Regulation 15(1) 13(4) 12(2 & 3) Requirement Timescale for action 31/03/06 2 OP10OP10 12(3)&(4) (a) 12(1) & 16(2)(n) 3 OP12OP12 4 OP16OP16 22(8) The care plan should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the service user are met in a way which takes account of their individuality and preferences. Risk assessments should be included in the care plan, which cover all aspects of daily living. Only service users who have 31/03/06 made a positive choice to share a bedroom should be required to do so. The registered person shall make 31/03/06 arrangements for all service users to take part in a programme of activities and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation and fitness. The registered person shall 31/03/06 supply to the Commission at it’s request a statement containing a summary of the complaints made during the preceding 12 DS0000024077.V269099.R01.S.doc Version 5.0 Pilgrims View Page 22 5 OP20OP20 23(2)a&2 3(4)b&13 (4) 6 OP23OP23 12(3)&(4) (a)&23(2) f 24 7 OP33OP33 8 OP37OP37 Schedule 4.7 9 OP38OP38 13(3) & 19(5)(b) months and the action that was taken in response. The registered person shall ensure that the layout of the premises meet the needs of service users and provide adequate means of escape that adequate day space should be provided on all units and fire exits should be kept clear at all times. Shared rooms should only be occupied by service users who have mad a positive shoice to do so The registered person shall establish and maintain a quality assurance system for the care provided at the care home and supply to the Commission a report in respect of any review of quality and make a copy of the report available to service users. The registered person shall keep a duty roster of persons working at the care home and a record of whether the roster was actually worked Staff should have qualifications suitable to the work they perform in that staff who handle food should receive competence based training in basic food hygeine. 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 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 View DS0000024077.V269099.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 View DS0000024077.V269099.R01.S.doc Version 5.0 Page 24 - 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!