Inspection on 12/10/05 for Pilgrims Way Care Home with Nursing

This inspection was carried out on 12th October 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 Way Care Home with... 23/07/08

Pilgrims Way Care Home with... 20/08/07

Pilgrims Way Care Home with... 25/09/06

Pilgrims Way Care Home with... 03/08/05

Pilgrims Way Care Home with... 17/11/04

Pilgrims Way Care Home with... 04/08/04

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St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pilgrims Way Care Home with Nursing 10 Bower Mount Road Maidstone Kent ME16 8AU Lead Inspector Debbie Sullivan Unannounced Inspection 12th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pilgrims Way Care Home with Nursing DS0000026195.V258580.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 Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pilgrims Way Care Home with Nursing Address 10 Bower Mount Road Maidstone Kent ME16 8AU 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) 01622 681300 01622 678181 pilgrims-way@fshdial.co.uk Mr D L Yadave Mrs J P Yadave Mrs Annette Ashley Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76) of places Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old age not falling into any other category 76, with the condition that there are 52 nursing care and 24 older persons not falling within any other category 3rd August 2005 Date of last inspection Brief Description of the Service: Pilgrims Way Care Home with nursing and The Coach House are adjacent to each other on the same site in a quiet residential area near to the main road into Maidstone. The main building provides accommodation on two floors; access to the upper level is gained via a shaft lift. The majority of the residents require nursing care, there are eight residential care beds. The Coach House also provides accommodation on two levels and is a purely residential service. The grounds shared by both units are well kept and attractive. The centre of Maidstone is approximately half a mile away and there is a good bus route from the main road into the town. Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three and a half hours. Information was gained from the homes’ manager, from speaking with residents and staff, direct observation and reading of some documentation such as care plans. A partial tour of the property took place and lunchtime was observed. There were a number of vacancies for residents at the time of the inspection; some rooms were empty in the main building due to redecoration taking place. Action needed as a result of a number of requirements and recommendations from the last inspection held on 3rd August 2005 had been progressed. What the service does well: What has improved since the last inspection? Update medication training has been provided for nursing staff and medication recording is improved on MAR sheets. An index sheet has been devised to improve the accessibility of information in care plans. The complaints book is now in hardback form. Improvements to the cleanliness and furniture in the dining room have been made and new cleaning schedule introduced which includes deep cleaning. A programme of redecoration has commenced in the older part of the building. Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 6 The hairdressing room has been made more homely by putting pictures and photographs on the walls. The CRB monitoring system has been amended to show up correct information regarding the date disclosures are returned. 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 Way Care Home with Nursing DS0000026195.V258580.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 Way Care Home with Nursing DS0000026195.V258580.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): 1,3,4 and 5. Prospective residents and their relatives have access to written information about the home and can view the service so that they can make a fully informed choice. The needs are thoroughly assessed prior to admission. EVIDENCE: The home has a service users’ guide and statement of purpose, the service users’ guide is displayed in the reception area. A thorough assessment procedure prior to admission is in place, the manager assesses potential residents and a comprehensive form is completed which is then placed on the care plan. Potential residents and their families are able to visit the home to view the service. One resident said that a relative had chosen Pilgrims Way having visited several homes for comparison and that a change of room had been possible as the first room they moved into did not allow for the resident to have their bed in their favourite position, they were very pleased at having been able to change rooms. If possible new residents are offered choice of accommodation and a place in a shared room only provided if this is acceptable. If the level of dependency of a resident in the Coach House Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 9 increases so that nursing care is required they are offered a place in the main building so that needs can be fully met. The home does not offer intermediate care. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): 7,8,9,10 and 11 The needs of residents are well documented and reviewed, the confidentiality of personal information needs to be improved. Residents are treated with respect. EVIDENCE: Some care plans at the Coach House were read, the information in them included the pre admission assessment form,information on daily care needs, medical information, a manual handling assessment and recording of the monthly review of needs. A member of the nursing staff at the Coach House tracks the monthly reviews to make sure none have been missed. An index sheet will be placed at the front of care plans so that information can more easily be located. Care plans in the main building are kept in a lockable cabinet in the nurses’ station, although on the first floor this was found to be unlocked and open with no staff in the immediate vicinity. Qualified nursing staff in both buildings administer medication. In the main unit one member of nursing staff on each floor is responsible for medication rounds. Some MAR sheets were inspected and those seen had been correctly filled in, the MAR sheet folder was left open with information clearly visible when the nurse was away from the trolley administering medication. Since the last inspection some nursing staff have received update medication training Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 11 from a pharmaceutical company and whilst procedures have been refined, the confidentiality of information needs to be improved. Residents spoken with were complimentary about care and nursing staff and staff observed were attending to residents promptly and discreetly. The home provides information and training for staff on death and bereavement so that those residents near the end of their lives and their relatives can be supported as well as possible. A local funeral director very recently provided training that will be repeated, and the personal and religious preferences of residents are respected. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): 12,13,14 and 15. Residents are supported in maintaining contact with friends and relatives. Provision of activities in the home needs to be reviewed. Meals are of good quality and there is plenty of choice. Improvements have been made to the dining room to hygiene and comfort. EVIDENCE: Residents spoken with confirmed that they have regular visitors and that they are able to choose to spend time in their rooms or to socialise in communal areas. Information regarding forthcoming social events and a regular activities programme was evident on notice boards in both buildings, such as a Halloween party and musical sessions. Residents spoken with felt that activities were currently lacking and there was little opportunity to socialise outside of the home, although one mentioned a trip out in the summer and there were photographs on the wall of a summer garden fair. The manager is aware that work needs to be done to improve the activities available and is addressing this. Residents are able to make choices regarding their daily lives such as choice of meal, area to access within the home and in which to eat meals and the degree to which individual rooms are personalised. Residents spoken with were aware of the options available that day and one said they “thoroughly enjoyed the meals.” There had been improvements to the cleanliness of the furnishings Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 13 in the dining room since the last inspection and a programme of deep cleaning now regularly takes place. Some damaged or very worn items of furniture had been replaced, the carpet cleaned and round tables been made available for wheelchair users. This has enhanced the hygiene and comfort in the room for residents, although the ventilation could be improved and the dining room would benefit from redecoration, as it is rather dark and generally worn looking. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): EVIDENCE: These standards 16 and 18 were fully inspected at the announced inspection on 3rd August 2005. Standard 18 was fully met. In relation to standard 16 it was recommended that the homes’ complaints book be in hardback form and this has been actioned. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): 19,20,21,22,23,24,25 and 26. Individual accommodation is of a good standard and some areas in the home are being redecorated. Further environmental improvements in both buildings would benefit residents. EVIDENCE: Both the buildings were cleaned to a good standard and improvements to the environment in the main building are being made with the programme of redecoration in the older part. Odours were noticed in three of the bedrooms in the main building, the manager explained that in two cases this was due to the medical needs of the occupants and difficulty in thoroughly cleaning the room of someone who is very unwell. Bedrooms seen were all well furnished and decorated and in some cases very personalised, in shared rooms curtains allow for privacy. Residents spoken with were happy with their rooms one resident upstairs in the main building commented that they got a lot of pleasure from looking at the view from their window. The garden is attractive and well maintained and a patio area off the dining room is accessible via a ramp or from the side of the main building, the ramp Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 16 can be difficult to negotiate although the home has so far been unable to find one that is better for the location. Improvements to the dining room have been made and it is strongly recommended that in addition a ventilation system be fitted. The room can be stuffy and windows not always offer adequate air to circulate or residents may not wish them to be open in cold weather. Redecoration is also recommended. Throughout the home there was evidence of equipment to allow residents to maintain independence both within bedrooms and in communal areas. The maintenance book in the coach house showed that minor repairs are regularly undertaken. The top floor of the Coach House has two quite steep stairways that are guarded by unattractive clinical looking bars with large gaps underneath, these had been agreed by the Health and Safety Department and the manager will consult them again regarding any improved design. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): 27 and 30. Well-trained and supported staff meets the needs of residents and there is an appropriate skill mix. Recruitment procedure recording has been improved. EVIDENCE: These standards were partially inspected; all were met at the last inspection. The Coach House always has two members of care staff on duty the main building is staffed by carers and registered nurses. Plenty of care and nursing staff were in evidence; cleaning, laundry and kitchen staff compliment them. Call bells were attended to promptly and care and nursing staff presented as well organised and confident in their roles. Staff spoken with felt well supported and spoke of training provided, one member of staff said that they had six weekly supervision meetings with the manager that were recorded, the manager supervises all staff and has implemented a system recently whereby nursing staff are given some additional responsibilities which is helping with professional development. Staff are all CRB checked and the list of those checked or awaiting disclosures has been updated as it was out of date at the last inspection. Staff had very recently received medication training and training relating to death and dying. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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): 31,32,33,36,37 and 38. The home is well run and staff are well supported. Improvements need to be made in the security and confidentiality of records. EVIDENCE: The daily routines of both the main unit and the Coach House were seen to run smoothly, policies and procedures are in place that underpin the ruining of the home and although these were not inspected, those seen at the last inspection were thorough and are available to staff in the reception area as well as in the managers’ office so that they can always be accessed. Staff were confident in their roles and were welcoming and friendly, one member of the ancillary staff commented on how much they liked working at the home. Staff receive regular supervision. Measures to protect the health and safety of staff and residents are in place, the home is appropriately insured and maintenance checks are made. Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 19 Improvement is necessary in some areas of confidential record keeping in relation to MAR sheets and care plans to protect the privacy of residents as these were seen left unattended. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 2 3 Pilgrims Way Care Home with Nursing DS0000026195.V258580.R01.S.doc Version 5.0 Page 21 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 31 Regulation 9(1) Timescale for action “ The registered person shall not 01/07/06 manage a care home unless he has the necessary qualifications” Mrs Ashley has now commenced The registered managers’ award. “The registered person shall 31/12/05 ensure that records are kept securely in the care home” In that medication record sheets and related information must not be left unattended during medication rounds” “ The registered person shall 31/12/05 consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation having regard to the needs of service users”. In that the activities programme needs to be reviewed and activities chosen by or provided for residents be provided as scheduled. “The registered person shall 31/12/05 DS0000026195.V258580.R01.S.doc Version 5.0 Page 22 Requirement 2 9 17(1) 3 12 16(m) 4 37 17(1) Pilgrims Way Care Home with Nursing ensure that records are kept securely in the care home”. In that care plans must be kept securely at all times when not in use. 5 38 12 “ The registered person shall ensure that the care home is conducted so as to make proper provision for the health and welfare of service users” In that the use of bars at the top of the Coach House stairs be reviewed with the Health and Safety Department. 31/12/05 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 2 3 Refer to Standard 19 25 38 Good Practice Recommendations It is strongly recommended that the dining room be redecorated to further improve the environment for residents. It is strongly recommended that a ventilation system be fitted in the dining room. It is recommended that the hand washing facilities in the downstairs Coach House toilet be equipped with liquid soap. Pilgrims Way Care Home with Nursing DS0000026195.V258580.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. 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