Inspection on 07/07/05 for Pilgrims View

This inspection was carried out on 7th July 2005.

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 04/07/06

Pilgrims View 16/01/06

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 Unannounced 07 July 2005 09:30 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 View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pilgrims View Address Robert Road Snodland Kent ME6 5HL 01634 241906 01634 243661 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) Kent Community Housing Trust Mrs Eileen Elizabeth Noonan CRH Care Home 43 Category(ies) of Dementia - over 65 (43) registration, with number of places Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Older people with dementia from 55 years of age and over. Date of last inspection 04 November 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 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. Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out by 2 inspectors who were 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 assistant manager, who also assisted with the examination of records, accompanied the inspectors on a tour of the home. The focus of this inspection was to look at the outcome of actions taken to achieve compliance with previous requirements from 2 inspections, which were carried out in 2004. 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 View H56-H06 S24077 Pilgrims View V236668 070705 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 View H56-H06 S24077 Pilgrims View V236668 070705 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) These standards were not examined during this inspection and therefore no judgement has been made. EVIDENCE: Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 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 &10 Service users benefit from support by staff who are well informed about them however healthcare and 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: Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 9 Service users could be at risk of harm in that risk management still does not take account of all aspects of service users lives and, where incidents or accidents have occurred these have not generated any record of additional risk management strategies. Service users who wander at night are compromising the dignity and privacy of other service users however there were still no risk assessments recorded in care plans to provide clear guidance to staff to help them to manage these behaviours and keep all service users safe from harm or intrusion. Service user’s needs may not be met as some care plans seen were not being updated as and when changes take place and in some instances did not include needs which were identified during the inspection. Service users with specific behavioural difficulties were not always being provided with the best care, in that charts which could identify patterns and triggers were not being completed in spite of advice from healthcare professionals, daily records did not reflect care plans. It was not possible to find out from care records seen if service users healthcare needs were being met in that in some instances there were no records of regular opticians checks and poor communications between staff had resulted in a failure to inform a GP of a recent head injury following a fall. Working practices in the home, in that chiropody was taking place in a room with an open door in the presence of other service users was compromising the privacy and dignity of service users. Service users are protected by effective systems for the administration of medication and appropriate training for staff. Where errors have occurred these have been managed to minimise risk to service users. 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. Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 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) These standards were not examined during this inspection and therefore no judgement has been made. EVIDENCE: Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 11 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) These standards were not examined during this inspection and therefore no judgement has been made. EVIDENCE: Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 12 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) These standards were not examined during this inspection and therefore no judgement has been made. EVIDENCE: Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 13 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) 27&29 The quality of life for service users in enhanced by the caring and committed staff team however they could be placed at risk by inadequate recruitment procedures. EVIDENCE: Service users benefit from a caring and supportive staff team who have a good understanding of the condition and behaviours associated with dementia. In addition to care staff a skilled chef, kitchen staff, a handyman, an activities coordinator, cleaning staff and a laundry person, enhance quality of life of service users. However service users could be put at risk by inadequate recruitment processes, staff files seen had insufficient references and one member of care staff was working without a criminal records and Protection of vulnerable adults check also not all staff files contained photographs. Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 14 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) 33&38 Service users continue to be placed at risk by the failure comply with regulations, inadequate quality assurance systems and risk management processes. EVIDENCE: Service user’s quality of life is adversely affected by inadequate quality monitoring within the home, requirements made following previous inspections have not been complied with, communication between staff and management about the needs of service users is inadequate and there is no effective quality assurance system based on action, planning and review to ensure that the home is run in the best interests of service users. Service users as still being placed at risk by poor working practices which have been highlighted in previous reports such as failing to provide tables between chairs where service users can safely place hot drinks. Service users are being placed at risk of infection by unsafe practice in relation to continence management and providing adequate facilities for the safe disposal of pads. Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 15 Inadequate risk management processes are failing to highlight areas of risk and provide appropriate guidance to staff to maintain the safety of service users at all times Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 1 x x x x 2 Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 17 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 7&8 Regulation 15(1) Requirement A plan of care for daily living must be in place for each service user based on the care management assessment and the home’s own needs assessment. 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. Risk assessments should be included in the care plan, which cover all aspects of daily living. The care plan should be reviewed at least once a month and as changes occur. Medical treatments such as chiropody must be carried out in private. Only service users who have made a positive choice to share a bedroom should be required to do so. The registered person shall not employ a person to work at the care home unless he has obtained the information and documents specified in Schedule 2, specifically 2 written references and a CRB/POVA Timescale for action Action plan by 31/08/05 2. 3. 4. 7 7 10 13(4) 15 12(3)&(4) (a) Action plan by 31/08/05 Action plan by 31/08/05 Action plan by 31/08/05 5. 29 19(1) Action plan by 31/08/05 Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 18 check 6. 33 24 The review of quality of care should produce a report to the Commission, any quality assurance system should ensure that action is progressed within agreed timescales to implement requirements identified in CSCI reports The registered person shall make suitable arrangements to prevent infection, specifically safe systems shall be used for handling and disposal of incontinence pads. All parts of the home to which service users have access must be so far as reasonably practicable free from hazards to their safety, specifically tables should be sited adjacent to arm chairs for items such as hot drinks. Action plan by 31/08/05 7. 38 13(3) &(4) Action plan by 31/08/05 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. Refer to Standard Good Practice Recommendations Pilgrims View H56-H06 S24077 Pilgrims View V236668 070705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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. 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