Inspection on 04/07/06 for Pilgrims View

This inspection was carried out on 4th July 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 View 12/06/07

Pilgrims View 16/01/06

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 Gary Bartlett Key Unannounced Inspection 4th July 2006 09:15 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.V299622.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 View DS0000024077.V299622.R01.S.doc Version 5.2 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.V299622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Older people with dementia from 55 years of age and over. Date of last inspection 16th January 2006 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 en-suite 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. Current fees range from £402.64 to £432.13 per week. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Pilgrims View from 9.15 a.m. until 4.45 pm. During that time the Inspector spoke with some residents, visitors and some staff. Parts of the Home and some records were inspected and care practices observed. Due to the nature of the service provided it is difficult to reliably incorporate accurate reflections of residents’ views of the service in the report. Some comment cards were received prior to the inspection. Responses received from residents’ relatives and health professionals indicated they were satisfied with the standards of care. Statements on comment cards included: • “I am extremely satisfied with Pilgrims View.” • “Wish there were more homes like Pilgrims View.” The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 6 Some parts of the Home have been redecorated and there are plans for the improvement of the environment. Staff recruitment has been ongoing to ensure continuity of care. Further progress has been made in staff training. The staff roster is more comprehensive. 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 View DS0000024077.V299622.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 View DS0000024077.V299622.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Residents and their relatives/representatives were provided with the information they needed about the Home. Good pre-admission assessments and the opportunity to visit the Home prior to admission ensured residents were appropriately placed and the Home could meet their needs. EVIDENCE: The Manager said the Statement of Purpose and Service Users Guide were accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Pilgrims View. Copies of the Service Users Guide were seen to be provided for each resident or their representative. These were not inspected on this occasion. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 9 The Manager and/or the Assistant Manager visited prospective residents prior to admission to make a decision whether the Home could meet the persons’ needs. Information was obtained from other parties, including relevant health care professionals, to assist in assessments. Residents were able to visit the Home before moving in and some visitors said staff had been very helpful in assisting their relatives to settle in. Each resident or their representative was provided with a contract between the Home and themselves. The contract clearly stated the responsibilities of the organisation and the rights of the resident. Intermediate care was not offered at Pilgrims View. Pilgrims View DS0000024077.V299622.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Residents’ health and welfare would be better promoted by care plans being more consistently maintained and risk assessments being written or reviewed when necessary and improved facilities for the storage of medicines. EVIDENCE: Each resident had a care plan. Three were inspected in detail. Although it was clear efforts were being made to improve care planning, they were not adequate in regard to the detail and consistency of information in some parts. Appropriate records had not always been made or reviewed as a result of some incidents. The staff’s understanding of residents’ individual needs was, in some instances very good, but variable. There was discussion about how care plans would benefit from including residents’ strengths and abilities in addition to their frailties. Some senior staff demonstrated a sound understanding of residents’ current behaviour patterns by linking them with the their previous experiences. The formal recording of this would give staff possible strategies Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 11 to use with individual residents. It was important for necessary and current information to be recorded and readily available to staff for them to be able to meet residents’ needs, especially as agency staff were used. The medicines storage rooms were found to be very small and, at the time, too hot for the storage of some medicines. A thermometer was present but the temperature of the room was not being monitored. Although, the directions for some medicines stated they should not be stored at more than 25 degrees C., the thermometers in the rooms were registering 31 degrees C. The floor in one of the rooms needed to be repaired in order to maintain infection control. Records were available to indicate that all staff administering medications had been trained and signed off as being competent to do so. The Medication Administration Record (MAR) sheets inspected had been completed appropriately. Medications were seen being administered in compliance with current guidelines. A Team Leader had a sound understanding of good practice and medications and had devised and implemented a very good system for monitoring and controlling the stock of medicines. Records inspected and comment cards received indicated the Home had a good working relationship with the specialist and local health care professionals, supporting residents in their health care needs. From observation and discussion with residents’ relatives it was clear that staff treated residents with respect and promoted their privacy and dignity. Pilgrims View DS0000024077.V299622.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Residents could enjoy a fulfilling lifestyle with good outside links maintained and as much choice and control over all aspects of their lives as their individual abilities allowed. Dietary needs are well catered for. EVIDENCE: Residents and their relatives spoken with were happy with the flexibility the Home offered in regard to meeting personal preferences where practicable, for example what time they got up, went to bed etc. The home operated a key worker system, which enabled closer resident/staff relationships where likes, dislikes and needs were shared. Family and friends felt welcome and knew they could visit the Home at any reasonable time. Staff always made time to talk with visitors and share pertinent information. The design of the Home provided seating areas within the communal areas of the home where residents could entertain their visitors, in addition to the privacy of their own room. The Home encouraged individuals and groups from the community to visit the home. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 13 Some residents mentioned they would like more activities and outings. The Manager explained they were intending to change the current arrangements in order to provide meaningful activities for residents throughout the week. There were not individual programmes included in resident’s care plans for staff to follow. Outings were limited by the fact that the Home did not have it’s own transport and minibuses had to be hired. On the day of the inspection residents were observed watching television and a few were having their hair done by a visiting hairdresser. Food was considered to be highly important and meal times considered a social occasion. The Cook was qualified and experienced in cooking for older people, was an important member of the care team and was well aware of the recorded dietary and cultural needs of each resident. He was committed to involving residents in menu planning and making sure that they were able to enjoy the food they preferred and liked. The menu was varied, balanced and nutritious. It included choices familiar to residents and a variety of dishes that encouraged residents to try new and sometimes unfamiliar food. Food was served to meet the needs of all residents including those who had swallowing or chewing difficulty. Staff gave assistance to those residents who needed help to eat, in a discrete and sensitive manner. Mealtimes were relaxed, staff were patient and helpful, and allowed residents the time they needed to finish their meal comfortably. Pilgrims View DS0000024077.V299622.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Residents and their relatives had access to a sound complaints procedure although the keeping of some records at area office rather than in the Home prevented a reliable assessment as to whether all concerns and complaints would be acted on appropriately. There were systems to ensure residents were protected from abuse that would be enhanced by the recording of authorisation for the use of restraint. EVIDENCE: The service had a complaints procedure that was up to date, clearly written, and easy to understand. The complaints procedure was widely distributed, and had a high profile within the service. Those spoken with had a good understanding of how to make a complaint and they were clear of what could be expected to happen if a complaint was made. Records of complaints were kept and these included details of investigation and action taken. However, the records of complaints addressed to and dealt with by the area office of the Trust was not available in the Home for inspection. There were procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. Staff spoken with had a sound knowledge of adult protection procedures. The Manager stated that Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 15 any allegation of abuse would be referred to the concerned agencies without delay. This was particularly important taking account of the aggression that can be exhibited due to the nature of the residents’ mental frailties. Staff said that bedrails were only used in the event of residents falling from bed and after referrals to health care professionals. Although the use of such equipment was noted on care plans there were not adequate records of the authorisation for the use of such restraints. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area was adequate. The standard of the environment within the Home was generally good providing residents with an attractive and homely place to live. Some staff practice did not promote infection control and ensure the residents’ health and safety. EVIDENCE: Residents benefited from the ease of access afforded by the single storey premises and the enclosed gardens to the side and rear of the property that provided a safe environment for the residents with ample wandering space. They were happy with their bedrooms and found the communal areas comfortable. Building work was due to begin to enlarge one of the lounge/dining areas. There was an ongoing programme of redecoration and refurbishment. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 17 The bedrooms seen had been personalised with the occupants’ personal effects and reflected their individual tastes and interests. Some bedrooms were shared and fitted with privacy screening. Those who shared bedrooms were 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 would be sharing with people who were strangers to them. The Manager described how careful consideration was given to the compatibility of those sharing. The use of shared bedrooms should be reviewed in view of the mental frailty of the residents and the associated behaviours. Staff said that bathing and toilet facilities were adequate. There was some discussion about the high temperature of the hot water at the unit dining areas. Although there were warning signs, not all residents would understand them due to their mental frailty. Staff spoke of how they were especially observant of residents’ safety in this respect, but there were some occasions when these areas were not supervised. The parts of the Home inspected were clean and free from unpleasant odours. There were policies and procedures for infection control, but these were not adhered to by the practice of retuning some emptied commodes to bedrooms unwashed. The Manager undertook to ensure this practice ceased forthwith. High standards were maintained in the kitchen, which had merited the local Environmental Health Department’s Clean Food Gold Award to the home for the second year running. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Recruitment processes needed to be more consistently followed to offer protection to people living at the Home. The Home was addressing the training of its staff so they had the skills to meet the needs of the residents. EVIDENCE: Resident’s and their relatives spoke highly of the staff, saying they were friendly and helpful. Statements on comment cards received prior to the inspection included: • “Staff are willing to share and give feedback.” • The staff and management have always been extremely kind, helpful and sympathetic.” It was not evident that staffing levels were adequate at some times of the day. At lunchtime it was observed that more residents needed assistance with eating than there were staff in the vicinity to help them. This view was echoed in a statement included in a comment card received from a relative/visitor prior to the inspection; “At times I feel there are not enough staff present”. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 19 The Home had been successful in recruiting staff recently and was resultantly less reliant on the use of agency staff to maintain adequate staffing levels. Where possible, the Home used the same agency staff so there was a degree of continuity. The Home had robust recruitment procedures and, in general, these had been adhered to, although one staff file contained information that should have been followed up before the person had been appointed. On being informed of this, the Manager immediately took appropriate action. A C.S.C.I. Provider Relationship Manager conducted a sample audit on Criminal Record Bureau checks for K.C.H.T. staff appointed between January 2006 and June 2006 inclusively. This showed that: • All staff in the sample had a CRB • The Commission was advised that where an applicant had a criminal conviction, this was discussed at the interview and the Manager then made a recommendation to appoint or not. The General Manager made the final decision. There were two General Managers so this provided the opportunity of consistency in these judgements. Staff were required to undertake a comprehensive induction programme. There was also an induction programme for agency staff to complete on their first shift at the Home. This should be expanded to include the administration of medicines. There was ongoing training for staff, which had recently included specialist areas such as dementia. Each staff file included a “staff training analysis sheet” to record training courses they had attended. Unfortunately there was not a training matrix that gave a ready overview of staff training needs. Such a tool was needed to assist with a more robust approach to ensuring staff received the training they needed, rather than making it “available to them”. Data provided by the Manager showed that 92 of staff were trained in NVQ, a commendably high proportion. Some staff spoke of the support and assistance they were given in this. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 20 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, 33, 35, 36 and 38 Quality in this outcome area was good. The residents benefited from a management team that had their best interests at heart. Residents’ financial interests were protected and their welfare was promoted through regular environmental and equipment safety checks. EVIDENCE: Throughout the inspection, the Manager clearly had the residents’ welfare at heart and demonstrated an openness and honesty. Staff and residents and their visitors said they considered the Manager to be very approachable. The Manager had many years experience and had an NVQ Level 4 in Management Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 21 and had completed an Open University Course in care for the Elderly and an inservice course in Social Care. Most residents were unable to manage their own finances and a senior staff member explained that the Home encouraged residents’ families / representatives to give assistance with this. There was a sound system of holding and recording residents’ cash, which facilitated ease of monitoring. Residents’ relatives did not express any concerns about the Home’s management of monies or valuables held on the residents’ behalf. Staff records seen complied with the Regulations. Staff supervision had been implemented but had not been conducted as regularly as required in recent times. The Manager described how residents and their representatives or relatives were regularly asked for their views about the service via quality questionnaires. The Manager was aware of the need to develop a continuous self-monitoring system, based on a systematic cycle of planning, action and review Kent Community Housing Trust had recently reviewed all its policies to ensure they complied with current legislation and good practice guidelines. Records were seen to be kept in a manner that preserved confidentiality. Records seen did not clearly show that all staff had fire training or participated in fire drills at the required frequency. Fire exits were kept clear of obstruction. Staff were seen to be diligent in ensuring COSHH requirements were adhered to and those spoken with had a sound understanding of emergency procedures. The Manager stated that all records of maintenance and safety checks were up to date. These were not inspected on this occasion. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 22 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X 2 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 2 Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement “The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review” in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information. An action plan must be received by CSCI by the given timescale. Timescale for action 03/08/06 2. OP7 13(4) 3. OP9 12(1)(a), 13, The registered person shall 03/08/06 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive and recorded in response to incidents and changes in residents welfare. An action plan must be received by CSCI by the given timescale. “The registered person shall 03/08/06 make arrangements for the recording, handling, safekeeping, safe administration of medicines” An action plan must be received by CSCI by the given timescale. DS0000024077.V299622.R01.S.doc Version 5.2 Page 24 Pilgrims View 4. OP12 12(1) 16(2)(n) 5. OP16 17(2) Schedule 4 “The registered person shall 03/08/06 having regard to the size of the care home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training”. An action plan must be received by CSCI by the given timescale. “The registered person shall 04/08/06 maintain in the care home a record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint”. All such records must be kept in the Home by the given date, if not sooner. “The registered person shall 10/07/06 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home”, in that coomodes must be properly washed after being emptied and before being returned to servoce users’ rooms. This must be done by the given timescale, if not sooner and thereafter maintained. 03/08/06 “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working DS0000024077.V299622.R01.S.doc Version 5.2 Page 25 6. OP26 12(1), 13(3)(4)( c) 16(2)(j) 7. OP27 18 Pilgrims View 8. OP29 19 9. OP38 23(4) at the care home in such numbers as are appropriate to the health and welfare of service users” in that a review of staff levels must be undertaken to ensure they are appropriate to the needs of the service users at the home. The result of this review and its methodology must be received by CSCI by the given timescale. The registered person shall not 03/08/06 employ a person to work at the care home unless(a) the person is fit to work at the care home in that any gaps in employment records must be explored. An action plan must be received by CSCI by the given timescale 01/08/06 The registered person shall ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life in that fire training must be provided at regular intervals. This refers to all staff, including night staff. This must be done by the given timescale, if not sooner and thereafter maintained. 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.V299622.R01.S.doc Version 5.2 Page 26 1. 2. OP18 OP23 3. OP25 4. OP29 5. 6. 7. 8. OP30 OP30 OP33 OP36 It is strongly recommended that records be kept of authorisation for the use of restraint, for example bedrails. The use of shared rooms should be reconsidered with service users offered a single room or sole use of the shared room unless they have made a positive informed choice to share. It is strongly recommended a risk assessment is undertaken in respect of the high temperature of the hot water in the dining areas and any required additional safeguards be implemented. It is recommended that there are guidelines for the General Managers which support the process of ensuring consistent judgement where applicants have a criminal record and or cautions. It is strongly recommended a training matrix is used to readily identify staff training needs It is strongly recommended the induction programme for agency staff is amended to include the administration of medicines. It is strongly recommended effective quality assurance and monitoring systems based on a systematic cycle of planning-action-review are introduced It is recommended care staff receive formal supervision at least 6 times per year. Pilgrims View DS0000024077.V299622.R01.S.doc Version 5.2 Page 27 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.V299622.R01.S.doc Version 5.2 Page 28 - 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. 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