Inspection on 20/08/07 for Pilgrims Way Care Home with Nursing

This inspection was carried out on 20th August 2007.

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 Way Care Home with... 23/07/08

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

Pilgrims Way Care Home with... 12/10/05

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

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

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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Gary Bartlett Key Unannounced Inspection 09:15 20th August 2007 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.V345907.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 Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 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 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.V345907.R01.S.doc Version 5.2 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 2nd February 2007 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 route into Maidstone. The nursing home is situated on two floors with bedrooms on both levels, access to the upper level is 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. Current fees range from £328.50 to £675 per week. Pilgrims Way Care Home with Nursing DS0000026195.V345907.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 Way from 9:15 a.m. until 5.00 pm. During that time the Inspector spoke with some residents, 5 visitors, and some staff. Parts of the home and some records were inspected and care practices observed. The Commission received a completed Annual Quality Assurance Assessment prior to the inspection. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Pilgrims Way prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? There has been some increase in the number of staff on duty. The cleanliness of the Home is improved; equipment such as lifting hoists and wheelchairs are cleaner. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 6 A new bed-pan washer has been installed and infection control is being better maintained. Damaged toilets have been replaced/repaired. Locks have been fitted to bathroom and toilet doors in the Coach House. Records are confidential. Medicines are stored at appropriate temperatures. Some radiators have been made safe and the heating and water supply problems largely resolved. A new induction programme is being implemented for care assistants. Staff are being made aware of the Mental Capacity Act. 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. The summary of this inspection report can Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 8 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.V345907.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are appropriately placed due to good preadmission assessments and benefit from being able to visit the home prior to admission. Pilgrims Way does not provide intermediate care. EVIDENCE: The Manager said the Statement of Purpose and Service Users Guide had been updated to be accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Pilgrims Way. Copies of the Service Users Guide are provided for each resident or their Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 10 representative. These were not inspected on this occasion. The Annual Quality Assurance Assessment completed prior to the inspection indicates information can be made available in large print if requested. The Manager described how a pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. Records show that prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. Residents said they or their families had been able to visit Pilgrims Way before moving in. Some relatives who were visiting confirmed this and said staff are very helpful in assisting new residents to settle in. Intermediate care is not offered at Pilgrims Way. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal health needs are assessed and maintained through their individual care plans and with good liaison with relevant health care professionals. Residents are protected by staff adhering to good practice guidelines in the storage and administration of medicines. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Each resident has a care plan and three were inspected in detail. Those seen are up to date and reflective of the resident’s care needs. The standard of Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 12 daily record keeping is generally good but could be more informative to give a holistic overview of residents’ welfare. Staff consider the care plan system easy to use and their understanding of residents’ individual needs is good. The Manager undertook to address an occurrence where a staff member did not adhere to a resident’s care plan in regard to how the resident should be sat when having lunch. This resulted in the lunch tray sliding to the floor with resultant distress for the resident and additional work for a busy staff group. Risk assessments are improved and written/reviewed in response to incidents and accidents. Further risk assessments should be undertaken to safeguard service users’ and staffs’ safety where using lifting hoists in bedrooms necessitates the moving of furniture. Whilst there are not any records of accidents or injuries that can be directly attributed to this practice, the potential for harm is there and should be recognised and minimised accordingly. At a random inspection conducted on 2nd February 2007, it had been noted that some action had been taken to address the requirements made at the last key-inspection. The medical room in the main home has been fitted with an air conditioning unit and records indicate the temperature is now maintained at appropriate levels for the storage of medicines. The medicines room is clean and well maintained. Records show that all staff administering medications have been trained and signed off as being competent to do so. The Medication Record Administration Record (MAR) sheets inspected have been completed appropriately and medicines were seen to be given in accordance with good practice guidelines. The home has a good working relationship with the specialist and local health care professionals. This assists in supporting residents in their health care needs. Residents feel that staff are kind and gentle, this was confirmed by observation and discussion with visitors. Staff are considerate of the age and dignity of residents and treat them with courtesy. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents 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 allow. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets their tastes and choices. EVIDENCE: Residents are happy with the flexibility the Home offers in regard to meeting personal preferences where practicable, for example what time they get up, go to bed etc. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 14 The Manager stated residents are supported in managing their own affairs for as long as they wish and are able. Family and friends feel welcome and know they can visit at any reasonable time. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of the home provides seating areas within the communal areas where residents can entertain their visitors, in addition to the privacy of their own room. As at previous inspections, there was some discussion that an unoccupied bedroom too small for comfortable occupancy in The Coach House could be used as a visitor’s room. This would provide a room in which residents could receive their visitors in private should they choose not to use their bedrooms. The Manager stated they had consulted residents about the activities they would like and, as a result, had arranged for more entertainers to visit the home. Through observation, it is evident that the time available for staff to interact with residents on a one to one basis continues to be limited by their workload. Residents said they enjoy the meals provided, have plenty to eat and like the choices available to them. The meals are well presented and look appealing. A large number of residents require assistance with eating so the mealtime arrangements are set accordingly. Despite this, whereas the first lunches are served at 12.30, some residents do not get their meal until 1.15 pm. Although staff are trying their best, this was seen to cause upset to some waiting residents. In response, the Manger said she is intending to provide additional staff cover from 9.00 a.m. until 3.00 p.m. after the holiday period and when funding will permit. All meals are cooked in the kitchen in Pilgrims Way. As the slope to The Coach House is too steep to use the hot trolley, meals are carried over and then micro-waved. At a random inspection conducted on 2nd February 2007, it had been noted that some residents in the Coach House felt that food quality was poor and queried the need for food to be brought up from the main house as this meant that the temperature couldn’t be controlled. (It is to be commended that one resident thought the food was ‘excellent’). In response to this, the Manager has arranged for the cook to visit the Coach House more regularly to ascertain residents’ views and comments about the meals. The Manager stated that a cook couldn’t be employed to work in the Coach House, as it would be too expensive. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have access to a sound complaints procedure. There are systems in place to protect residents from abuse. EVIDENCE: The complaints procedure is readily available to residents and their relatives. Most people said they feel confident that they would be listened to and any necessary action would be taken. A few feedback they prefer to go to senior staff as they think their “enquiries are viewed as complaints or criticisms”. The Annual Quality Assurance Assessment completed prior to the inspection indicates there have been nine complaints received by the home in the last 12 months. One complaint was upheld and all were dealt with within a good timeframe. The Commission has not received any formal complaints about the home in that time. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager and other staff spoken with have a sound understanding of safeguarding adults Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 16 procedures. There have been three safeguarding adults referrals since the last inspection. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements to the environment and furnishings would enhance residents’ quality of life. EVIDENCE: The home was registered under previous legislation and some of the double bedrooms would not have been registered for shared occupancy under the Care Standards Act 2000. The Manager says this is recognised and some shared rooms are used for single occupancy. These rooms still contain two sets of furniture. Changes in residential and social care mean that people referred to care homes have increased frailties and care needs than previously. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 18 Whilst Pilgrims Way is able to offer a generally “homely” environment, from observation and discussion with staff, residents and visitors, it is difficult for staff to meet all residents’ care needs safely. Visitors and staff described how it was very difficult to use the lifting hoists in some of the bedrooms, with furniture having to be moved around. In one shared bedroom, the beds have to be moved, thereby impinging on the occupants’ freedom of choice as to when to go to bed or get up. Although some areas have been redecorated there is still a need for other parts of the home and fixtures and fittings to be repaired or upgraded. This has a consequent adverse effect on service users’ quality of life, compromising their comfort. One particular aspect evident from observation and discussion with residents and visitors was the malodorous area outside the lounge room of Pilgrims Way. When asked about this, the Manager responded that she supposed more powerful extractor fans could be fitted to the sluice rooms in that area. The odour in several parts of the building is unpleasant and indicative of the need for a thorough cleaning schedule in response to the continence management needs of some residents. The Manager stated toilets and sluices had been improved where necessary but it was observed that waste bins in high risk areas are still not foot-pedal operated. Equipment such as wheelchairs and lifting hoists are cleaner than previously. At a random inspection conducted on 2nd February 2007, it was noted that three doors to toilets and bathrooms in the Coach House were not lockable. In response the home has fitted sliding bolts. One of these slides into the door frame and would be difficult to open in an emergency. Locks specifically designed for bathroom and toilet doors and with vacant/engaged indicators and facility for emergency access would have been preferable. At the top of some stairs, there are bars, set around waist height and which need to be lifted, to restrict access. The Manager said alternatives are being sought. This should be done as soon as possible to enhance residents’ and staffs’ safety. Information provided to the Commission over the last year referred to a problematic supply of heating and hot water in the Coach House. Residents say this has been generally resolved. In the main home, hot water from one outlet is hot enough to be unsafe. Some radiators are still without guards or individual thermostatic control valves to guarantee low temperature surfaces to protect service users from the risk of burning. The provider has undertaken to ensure that all radiators are safe by November 2007. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 19 At previous inspections it had been established that any maintenance requests made over the weekend would not be acted on until Monday as there is no system to contact outside contractors. The Annual Quality Assurance Assessment completed prior to the inspection indicates this is still the case. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment processes are robust and offer protection to people living at the home. Residents’ quality of life would be improved if more staff were available at peak times of activity. EVIDENCE: Residents and visitors speak very highly of the staff working at the home, saying they are very friendly and work hard. This was confirmed by observation, with staff having obvious concern for the residents’ welfare. The Annual Quality Assurance Assessment completed prior to the inspection states that staffing levels have been generally increased and acknowledges it would be better to have more time for interaction between the residents and staff. As reported elsewhere in this report, the Manger said she is intending to provide additional staff cover from 9.00 a.m. until 3.00 p.m. after the holiday period and when funding will permit. In the meantime some residents have to Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 21 wait for over half an hour for their lunch, whilst others around them have theirs. The staff rosters seen show that staff do not work long consecutive shift patterns that might compromise their competency through fatigue. Although the tendency is for staff to work long days, there are sufficient days off between. Records seen indicated that robust recruitment procedures are used and ensure the Home directly employed only staff that have been properly vetted. New staff are required to undertake an induction programme and there is ongoing training for staff, which includes specialist areas such as dementia. The Manager said a training matrix is used to monitor individual staff training needs. A new induction programme is being implemented for care assistants, which, commendably, some long-term staff have volunteered to undertake. The Annual Quality Assurance Assessment completed prior to the inspection indicates that 85 of staff are trained in NVQ. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would better safeguarded by the home adhering to fire-regulations. EVIDENCE: The Manager has been at Pilgrims Way for a number of years. She is a registered nurse and has experience in residential care. The Manager is currently studying for the Registered Manager’s Award. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 23 An Accountant is employed to manage invoicing, payroll and associated budgetary work. Appropriate insurance cover is provided for the home and a current insurance certificate is displayed. The Home encourages residents to manage their own financial affairs or to have assistance from their families / representatives and does not hold any cash on behalf of residents. The Manager described how residents and their representatives or relatives are regularly asked for their views about the service. There are annual questionnaires and residents meetings at which relatives might be present. The Manager said that relatives’ forums are no longer held as they had not been constructively helpful. Staff are diligent in ensuring COSHH requirements are adhered to and those spoken with have a good understanding of emergency procedures. The standard of cleanliness in the kitchen and surrounding area is satisfactory. An Environmental Health Officer inspected the kitchen on 5th June 2007 and there were not any resultant recommendations. During a tour of the Coach House, the Manager removed two catering containers, one of tomato ketchup and the other of salad cream, which were seen to be stored in a cupboard instead of being refrigerated as directed by the instructions. She also said these should have been decanted into smaller containers. There was some discussion about the advantages of using plate covers when transporting meals on trays to maintain food hygiene and to keep the desert hot whilst the resident eats the main meal. The Fire Safety Officer had written a letter dated 21 March 2006 to the Manager. The letter includes “Self-closing fire doors may be held in the open position by automatic release mechanisms which are actuated by the fire warning system. All other means of holding the doors open to be removed:- to a number of bedrooms”. A large number of self-closing bedroom doors are still held open with wooden or rubber wedges. This puts residents at risk. The Manager stated the fire risk assessment had not been forwarded to the Fire Safety Officer. The Manager stated that records of maintenance and safety checks are in order. These were not inspected on this occasion. The Annual Quality Assurance Assessment completed prior to the inspection indicates the provider regularly reviewes policies and procedures to ensure they comply with current legislation and good practice advice. Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 24 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X 2 X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 13(4)(a) Requirement “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in that all locks on bathroom and toilet doors must be of a design that can be opened in an emergency. This must be completed by the given timescale, if not sooner. “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in that the temperature of the hot water at baths must not exceed 43 degrees C. This must be completed by the given timescale, if not sooner, and maintained thereafter. 3. OP25 13(4)(a) The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably DS0000026195.V345907.R01.S.doc Timescale for action 30/09/07 2. OP25 13(4)(a) 30/09/07 30/11/07 Pilgrims Way Care Home with Nursing Version 5.2 Page 26 practicable, free from hazards to their safety in that, all radiators must be covered or have a guaranteed low surface temperature. This remains a requirement from the previous inspections. Continued failure to comply by the given timescale, if not sooner, will result in enforcement action. 4. OP26 13(3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, in that foot operated waste bins must be provided in high risk areas. This remains a requirement from the last inspection. Continued failure to comply by the given timescale, if not sooner, will result in enforcement action. 5. OP26 16(2)(k) “The registered person shall having regard to the size of the care home and number and needs of service users keep the care home free from offensive odours” This remains a requirement from the last inspection. Continued failure to comply by the given timescale, if not sooner, will result in enforcement action. 6. OP38 23(4)(b) Where the Regulatory Reform (Fire Safety) Order 2005 applies to the care home - The registered person must ensure that the requirements of that DS0000026195.V345907.R01.S.doc 30/11/07 30/11/07 20/08/07 Pilgrims Way Care Home with Nursing Version 5.2 Page 27 Order and any regulations made under it, except for article 23 (duties of employees), are complied with in respect of the care home” in that: 1. Self closing doors must not be held in the open position by unapproved means. 2. If you consider there is an alternative to the items put forward by the Fire Authority, you must forward these suggestions along with your risk assessment in writing to the Fire authority for consideration. An immediate requirement notice was issued. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations It is recommended daily care records should be more informative to give a holistic overview of residents welfare. It is strongly recommended that recorded risk assessments are made to safeguard service users’ and staffs’ safety where using lifting hoists in bedrooms necessitates the moving of furniture. It is recommended the unoccupied bedroom (No.5) too small for use in The Coach House be appropriately furnished and used as a visitor’s room This remains a recommendation It is strongly recommended the redecoration of the Home is continued to include those parts still looking worn. DS0000026195.V345907.R01.S.doc Version 5.2 Page 28 3. OP13 4. OP19 Pilgrims Way Care Home with Nursing 5. 6. 7. OP19 OP19 OP20 This remains a recommendation It is strongly recommended a system is implemented whereby broken equipment is attended to at weekends. It is strongly recommended alternatives to the “lifting bars” are used to restrict access at the tops of stairs. It is strongly recommended the intended repair or replacement of worn and damaged furniture is undertaken as soon as possible. It is strongly recommended the shared bedrooms that do not meet current minimum standards are used for single occupancy and the registration of the Home be changed to reflect this. This remains a recommendation It is strongly recommended an additional staff member is employed at peak times of activity. It is recommended plate covers be used when transporting meals on trays to maintain food hygiene and to keep the desert hot whilst the resident eats the main meal. 8. OP23 9. 10. OP27 OP38 Pilgrims Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Way Care Home with Nursing DS0000026195.V345907.R01.S.doc Version 5.2 Page 30 - 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!