Inspection on 23/07/08 for Pilgrims Way Care Home with Nursing

This inspection was carried out on 23rd July 2008.

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... 20/08/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pilgrims Way Care Home with Nursing 10 Bower Mount Road Maidstone Kent ME16 8AU Lead Inspector Mrs Susan Hall Unannounced Inspection 08:40 23rd July 2008 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.V367624.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.V367624.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 Enquiries@pilgrimswaycare.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.V367624.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 20th August 2007 Date of last inspection Brief Description of the Service: Pilgrims Way Care Home with Nursing consists of two buildings set in the same grounds. These are the main nursing home, and the “Coach House”. The Coach House has sixteen beds, and is only used for residents needing residential care. The nursing home has some residential beds, but most are for nursing clients. The home is a privately run business, and the providers take an ongoing interest in the day to day running of the home. Other family members are involved in the general management. The home is situated in a quiet residential area in Maidstone, about half a mile away from the town centre. It is set in its own grounds, which are well maintained and attractively presented. There are plenty of car parking spaces. Accommodation in both buildings is provided on two floors, and both buildings have a passenger lift for easy access between floors. The main building also has a stair lift. Some rooms have en-suite toilet/bath facilities. Each of the buildings have their own communal and garden areas, but the residents mix with each other for many activities and events, and are able to make friends across both buildings. Although the Coach House has its own core staff, other staff work between both buildings. This is an advantage for residents who have deteriorating conditions, and move from the Coach House to the main building for nursing care, as they are already familiar with many of the staff. Current fee levels range from £337.02 - £750.00 per week, depending on the assessed needs of each individual, and as to whether they are receiving residential or nursing care. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home is assessed as having a rating of good, 2 stars. This was a key inspection, carried out by one inspector, and included assessing most of the national minimum standards. A key inspection takes into account all information obtained about the home since the previous inspection – in this case, a year ago. Information was obtained from letters and phone calls to CSCI; formal notifications which the home is legally required to make; CSCI survey forms; a completed Annual Quality Assurance Assessment (“AQAA” – a self–assessment completed by the manager); and the visit, which lasted for eight hours. We (i.e. CSCI) received fourteen completed surveys, from residents, staff and health professionals. Some residents had asked their relatives to help to complete these. These were mostly very positive, with comments such as: “I always receive the care and support I need” (from a resident); “all staff here are always kind and considerate” (another resident); and “I think Pilgrim’s Way offers an excellent standard of care” (from a health professional). We met and chatted with sixteen residents from both buildings. Some of these were only brief conversations, but seven were more in depth. We also talked with three visitors and nine staff, as well as the manager, who was present in the home throughout the day. The inspection included a specific hour spent in the main lounge observing the care given to a number of residents, and the staff interaction with them. This is known as a “Short Observational Framework Inspection” (or SOFI). This confirmed that staff generally have a caring and friendly attitude towards residents and visitors, and are aware of their needs and concerns. It also highlighted one issue where there could be some improvement. What the service does well: The reception area contains standard documentation about the home for enquirers, and also includes leaflets from such places as Age Concern, and information about receiving benefits. These leaflets are thoughtfully provided, and are particularly helpful for new residents and relatives. The home has a competent staffing team, who work well together, and provide good standards of care. Many comments were made during the visit about how good the staff are, and their kind and helpful attitudes. No adverse comments were made about the staff. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 6 Residents were unanimous in their praise for the food, with comments such as: “the food is very good –all home cooked”; and “the meals here are very good, and there is a good choice, and plenty of it”; and “ the meals are always a credit to the cook”. The home provides ongoing training for staff, and over 75 of care staff have achieved NVQ levels 2 or 3 in health and social care. What has improved since the last inspection? The home has met requirements given at the last inspection. These include: • • • • Ensuring all radiators have a guaranteed low surface temperature, or are covered. Fitting thermostats to hot water outlets accessible to residents, to decrease the risk of scalding. Improved infection control procedures. Self closures fitted to bedroom doors for fire precautions. Many bedrooms have been redecorated during the past year. The Coach House has had new carpets fitted in communal and corridor areas, and these considerably enhance the building. Care plans have been improved with better documentation for wound care and risk assessments. The home has employed two activities co-ordinators, and the level of activities and events has increased. What they could do better: The service users’ guide does not give any information about the qualifications and experience of the providers, and this should be added in. Care plans could demonstrate more clearly how end of life care is discussed, and how decisions comply with the Mental Capacity Act 2005. The manager is already addressing this, as she has requested some additional advice and training from a specialist nurse who works for the PCT. Medication charts had a number of handwritten entries which had not been signed for by two staff. It was evident that this is the policy of the home - for safety and accountability - and it is important that this is adhered to. A number of medication charts included sticky labels from the pharmacy. This is no longer considered a safe option, as the labels can peel off, and medication be missed. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 7 Further improvements could be made to the environment, such as: • • • • The entrance hall is rather gloomy, and the main building lounges are not as attractive or as homely as the lounge in the Coach House. Carpeting in the ground floor corridor and lounges in the main house is stained, and either needs more frequent cleaning, or replacing. There are some broken floor tiles in the kitchen which should be replaced, so as to promote infection control management. Bathrooms are mostly too small to provide space for two staff, hoisting facilities and a wheelchair; most residents need this support. There is only one showering facility, and this is a cubicle which is not accessible for most residents. These facilities should be reviewed. Breakfast and teatime meals for the Coach House are provided by care staff. Employing a kitchen assistant for this purpose would enable care staff to concentrate on care. Additional cleaning staff would provide domestic cover for annual leave and sickness. The application form for recruitment needs to be altered, so that all applicants are asked to provide a full employment history – i.e. since the time of leaving full time education. 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 be made available in other formats on request. Pilgrims Way Care Home with Nursing DS0000026195.V367624.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.V367624.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): 1-5 (standard 6 does not apply in this home). Quality in this outcome area is good. Residents are provided with sufficient information to be able to make an informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users’ guide have been amalgamated into one document. A copy is available to read in the entrance hall, along with the last inspection report, and a folder with letters showing people’s views of the home. These are copied with their permission. All new residents are given their own copy of the service users’ guide on admission, and this includes the terms and conditions of residency. The service users’ guide does not contain information about the providers’ qualifications and experience, and these details should be added in. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 10 All residents have a pre-admission assessment, and these are carried out by the manager. Four of these were viewed, and contain sufficient information for the manager to assess the suitability of the home for meeting the residents’ needs. The pre-admission assessments are suitably detailed, and include data such as the resident’s personal hygiene needs, medication, nutrition, moving and handling, and social needs. Residents are invited to view the home before admission where possible, although many are too ill to come and view the home, and rely on relatives or advocates to do this for them. Admission is for an initial trial period of four weeks, after which a review is held to ensure that the placement is suitable. Privately funded residents have a signed contract with the home. Residents funded by Local Authorities have a contract with Social Services, and have the home’s terms and conditions set out in the service users’ guide. The terms and conditions show the items which are included in the fees, and those which require additional payments (e.g. chiropody, hairdressing). A monthly itemised invoice is provided for each resident. Residents are advised of the rooms which are vacant, and are able to choose the room they prefer. Pilgrims Way Care Home with Nursing DS0000026195.V367624.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): 7-11 Quality in this outcome area is good. Care plans demonstrate that health needs are being met. Residents are confident that they are well cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are based on the pre-admission and admission assessments, and include all the activities of daily living, such as moving and handling needs; continence needs; pressure ulcer prevention; communication needs; nutritional needs and night care. These are reviewed and updated by named nurses each month. The manager carries out random checks on care plans, and carries out a comprehensive six monthly check for each care plan. Four care plans were viewed in detail, and one other plan was viewed for specific aspects of care i.e. wound care, and risk of falls. Care plans were found to contain comprehensive data to enable staff to carry out health and personal care effectively. For example, moving and handling Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 12 care plans specify details such as which hoist and sling to use, and if one or two carers are needed to assist. Equipment needed for pressure ulcer prevention or treatment is clearly identified with the type of air mattress or pressure relieving cushion to use. Nutritional assessments state if the resident needs assistance with eating and drinking; the type of diet; and any specific cutlery or cups/beakers to be used. Each resident has a general risk assessment for the safety of their room, and if the use of bed rails is indicated. Consent is obtained for these from the resident or their next of kin, and clear details are discussed with them in regards to risks associated with using bed rails, such as entrapment. Wound care is well documented, with a separate care plan for each wound identified; and with a clear description of the wound and the dressing applied at each dressing change. Monthly observations are carried out for blood pressure and weight, and these indicate any rises or falls which are a cause for concern. Residents are able to choose their own GP, and each visit is recorded. Referrals to health professionals such as dietician, optician, community psychiatric nurse, and physiotherapist are made as needed. There have currently been some difficulties with accessing dental care from the NHS. Care plans showed occasions where GPs have been called for residents who are very ill, and record discussions carried out by the GP with the resident and/or relatives in regards to their preferred treatment if they are dying. If a resident knows they are dying, but wishes to be treated in hospital, the wishes of the resident are adhered to. Most residents prefer to stay in their own room, in familiar surroundings, and with staff that they know. Relatives and friends can visit at any time in accordance with the resident’s wishes. Thank you cards from many relatives confirmed that residents are enabled to die with dignity, are kept clean and comfortable, and as pain free as possible. The manager stated that she is accessing further advice from a specialist nurse with West Kent PCT, who will advise on ways to improve end of life care, and document this more clearly. The manager and nursing staff have an awareness of the Mental Capacity Act, and the importance of being able to determine if residents have the mental capacity to continue to make decisions about their care. This could be reflected more clearly in some care plans. A “short observational framework inspection” (known as “SOFI”) was carried out for one hour in the main lounge. During this time several carers were observed speaking in a gentle and caring way to residents and giving them drinks. However, some other staff walked through from one end of the lounge to the other on several occasions, without paying any attention to residents sitting in the first part of the lounge, and this could have felt quite frustrating for them. The teatime “supper” meal was observed being given out to residents who required assistance with eating at 4.30pm. This was given to five residents in the area where the inspector was sitting, and the meal Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 13 (scrambled egg) was given to them each in a bowl with a spoon. These residents were not served with the dignity of a proper tea tray, tray mat, serviette, bread and butter, drink etc., and this way of serving a meal did not promote their dignity. This was discussed with the manager at the end of the inspection visit, and she stated that this practice would be reviewed and addressed. However, conversations with sixteen residents provided only positive comments about the standards of care. Residents said things such as “we are very well looked after”; and “the staff are lovely and always there for me”. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 14 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): 12-15 Quality in this outcome area is good. The home provides a range of activities. There are flexible routines for people to get up and go to bed as they wish. Food is well cooked, and is suitably nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, the home has employed two activities organisers, who complement each other with differing skills and abilities. There is a display of activities in the entrance area, showing crafts, drawings etc. One of the activities organisers works five days per week, and carries out more one to one input, with music therapy and hand massage etc. She was working with a resident to make lavender bags during the morning, with fresh picked lavender from the gardens. Two residents said that there are things to do every day for people who want to join in. The other activities organiser tends to arrange more of the group activities such as singing, reminiscing and bingo etc. A list of activities is provided on the entrance hall notice board, and is included in a monthly newsletter. Friends Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 15 and relatives are invited to join in with what is going on. Some visit every day. The home held a BBQ during the previous week and many said that they had enjoyed this. Special events are organised such as a recent “National Falls Awareness” coffee afternoon; and residents were invited to a Tea Party with the care home next door. Two CSCI survey forms included comments that the residents/relatives who completed them thought that there could still be more activities, particularly for residents who have lost some of their cognitive awareness. Residents from the Coach House who have sufficient mobility said that they can “come and go as they please”; and some enjoy being taken out in wheelchairs. Favourite local venues include going down to the river, or to the local pub. Residents are assisted to carry out religious observance. A church service is held in the home on a regular basis, and visits from the Church of England, the Roman Catholic Church and the local Baptist Church representatives are carried out weekly or monthly. The main lounge has doors (and a ramp) leading out on to a sheltered patio, and this is popular with residents in good weather. One said she had enjoyed having her tea outside one day. The home also has nicely kept gardens – with different areas for seating. Some survey forms from residents and relatives have suggested additional outside seating could be purchased, and have also entered this on customer satisfaction surveys for the home. This would provide a greater choice of outdoor sitting areas. Visitors are welcomed at any time, are often offered hot drinks, and can stay for meals. Residents are able to bring in their own personal possessions and rooms were seen to be personalised. Residents in the main building said that the quality of the food is very good, there is plenty of it, and plenty of choice. One said “ The food is always very good, and very well presented”. Another said “the food here is lovely – all home-cooked food”. They can have a cooked breakfast if they want, and snacks at any time. There is a choice of two main meals, and choice of desserts and tea items. Hot and cold drinks are served throughout the day. Residents in the Coach House also said the food is good. Breakfast and tea are made in their own kitchen; and are prepared by care staff who have completed basic food hygiene training. It is recommended that a Kitchen Assistant is employed for this purpose, so that care staff can concentrate on caring (see section on Staffing). Main meals are cooked in the main kitchen and taken over to the Coach House. The home employs three cooks, and they have completed NVQ training in food and hygiene. A different cook takes over responsibility at 2 pm each day. There is also a kitchen assistant on duty. Menus are discussed between the Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 16 cooks and the manager. Seasonal changes are made, and changes as requested by residents. A record is retained of the food eaten by residents. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. Complaints are taken seriously and are investigated appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is on display on the notice board in the front entrance hall, and is included in the Service Users’ guide, which is also on display. Each resident is given a copy of this. The complaints procedure gives a clear pathway to follow, encouraging people to speak with the nurse in charge in the first instance, and then to speak with the manager if they wish to. A response will be made within twenty-eight days. CSCI details are included. It was suggested that the home could also include local Social Services details in the complaints procedure, as a reminder to people that this is another avenue for people to take. Everyday concerns are logged in a hardback notebook, with a separate page for each concern. The person taking the concern/complaint enters the details, and these are then followed up by the manager. The complaints log shows that complaints are taken seriously and are addressed appropriately. Written complaints are kept as separate documentation, and the manager will reply in writing to these, as well as meeting with the complainant where possible. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 18 Staff are trained in the prevention of adult abuse, and the staff training matrix confirmed that all staff receive this training and have yearly updates. Training is commenced during the induction period. Staff are also made aware of policies and procedures for whistle blowing, and sign to state they have read these. The manager and nurses are aware of the protocols for referring any suspicion of abuse to the Kent Social Services Safeguarding Adults team for their investigation. There was one referral made during the past year, and the home has co-operated with the team in responding to their investigations. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 19 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): 19-22, & 24-26. Quality in this outcome area is adequate. The home provides a safe and comfortable environment. Improvements have been made during the past year, and there is an ongoing plan for further improvements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home consists of two purpose built areas – the main building for up to fifty-six residents, and the Coach House for up to sixteen residents. The entrance to the main building is light and airy, and leads into a reception area. Beyond this, there is a lobby area, which includes a large dispensing cold drinks machine, and leads to other parts of the home. The carpet in the lobby, in the small lounge, and in the ground floor corridors is rather stained and would benefit from more frequent cleaning or replacing. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 20 There have been many improvements made over the past year, so it is a disappointment that first impressions are not particularly good. Many bedrooms have been redecorated, and look fresh and clean. The carpeting in the main house on the first floor looks better than that of the ground floor, where there is more traffic. The main house has a large communal lounge, with a dining room leading through from this. The dining room has doors leading out to a patio area. There is a second, smaller lounge, and a quiet room to use for relatives’ meetings, reviews etc. These lounges could be improved with a change of décor and more pictures etc. The main kitchen was viewed during the afternoon, and is generally in good order. The floor has some cracked tiles which need replacing. The Coach House has sixteen bedrooms, but one of these is too small and is now used as a storage room. The Coach House has had new carpeting in communal areas and bedrooms, and this has enhanced its appearance generally. It has a nicely decorated and homely lounge, with comfortable chairs, and a separate dining room. The tables were attractively laid for lunch. The home has sufficient toilets for use in both buildings. Some of these are in blocks of three in the main building, and are only used one at a time so as to be sensitive to individual residents. So some of these areas are wasted space. There are a sufficient number of bathrooms, but most are too small to admit hoisting facilities and wheelchairs. Some baths have in-built hoisting facilities, and these are the ones in use. However, these are too small to easily cope with two carers, a hoist and a wheelchair. There is one shower unit, but the design of this does not enable care staff to assist residents properly, so it has very limited use. A “wet” room would be more useable, and provide choice for more residents. There is a requirement to review the bathroom and toilet facilities in the main building, so as to provide a suitable number of bathroom/shower facilities with sufficient access for care staff and the necessary equipment. Some of the bedrooms have en-suite toilet/bath facilities, but unfortunately most of these are too small to admit wheelchairs easily, and cannot be used by residents who have reduced or no mobility. The en-suite baths are not safe to use, as they cannot be satisfactorily accessed by staff or cope with the necessary equipment. Most residents use a commode in their own room at night. Disabled toilet areas include an over toilet chair, which is preferable to a commode in the daytime. Most bedrooms are satisfactorily decorated, and furniture, although old, is acceptable. The home would benefit from some upgrading of furniture before long. The maintenance manager explained that there is an ongoing programme of improvements for the home, and the proposed changes are discussed between the providers and the manager. Co-ordinated soft furnishings would make the rooms look much better. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 21 Requirements given at the last inspection in respect of radiator covers, fire closures for bedroom doors, and thermostats for hot water outlets, have all been met. Some residents and relatives would welcome more seats outside, so as to enjoy sitting in different areas of the gardens. The gardens are well maintained, with lawns and patio areas. A small vegetable plot has been commenced, and there are intentions to start a herb garden, at the suggestion of a resident. The Coach House has its own outdoor areas, but residents can access most outside areas from both buildings. Each of the buildings has a laundry, and the main house has designated laundry staff on duty each day. The main laundry has two commercial washing machines and one dryer. It has sufficient space, and has a tiled floor suitable for easy cleaning. The home was generally clean throughout, which was a credit to the cleaner, as there was only one on duty while another was on holiday. There is a recommendation to ensure there are sufficient numbers of cleaning staff to cover for annual leave and sickness. More cleaning staff would enable more frequent carpet cleaning. There was only one area where there was a slightly unpleasant odour, and this was being dealt with. Customer satisfaction surveys had mixed views about the cleanliness and environment of the home. Some said it was very good, and others had comments about items such as communal areas being left “messy” after meals. Staffing records show that there has been increased training in infection control. All nurses and care staff have carried out a twenty week course in infection control via Bexley College. There is antibacterial soap at all handwashing points. Care staff wear clean aprons and gloves for each bedroom they enter when giving personal care, and discard these within the room before moving on to the next person. This prevents the spread of any infection. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 22 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): 27-30 Quality in this outcome area is good. The home has sufficient numbers of competent nursing and care staff. Some increase in the numbers of ancillary staff would benefit the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels in the main building are managed with two nurses on duty throughout the day. They each take responsibility for one floor, but do not cover the same floor each day, so that they get to know all of the residents. They are assisted by eight carers in the daytime – four on each floor. The Coach House has one nurse and one carer. Night shifts are covered with one nurse for the whole home, three carers in the main building and two carers in the Coach House. There are usually two cleaners for the main house, and one for the Coach House. The day staff in the Coach house have to manage meals/food as well as care responsibilities, and it is recommended that this work is carried out by kitchen assistants, so as to enable care staff to concentrate on caring. The home has two maintenance men, and a maintenance manager who is a part of the family team; and an accounts manager/administrator, who is also a family member. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 23 The home promotes staff training for care staff to NVQ levels 2 and 3. There are currently over 75 care staff who have completed this training, and others who are starting training. This is an excellent percentage. Staff recruitment checks were inspected by viewing three staff files for new staff. Basic recruitment procedures are sound. The application form includes a health declaration and criminal declaration. Two written references are taken, and proof of ID, Criminal Record Bureau (CRB) checks, and records of training. The application form does not specify that applicants must be requested to provide a full employment history (since leaving full time education); and with any gaps explored. There is a requirement to amend this. The staff induction training lasts over two full days, and then staff have another two days shadowing experienced staff. This is followed by comprehensive foundation training, which includes mandatory training. The staff training matrix shows good evidence for training in subjects such as moving and handling, customer care, safeguarding vulnerable adults, nutrition, infection control, COSHH, first aid, health and safety, and basic food hygiene. Nurses and care staff carry out medication training. Senior carers can administer medication to residential clients in the Coach House. Lloyds’ pharmacy are providing an additional training programme to the medication “ASET” course, which many have completed. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 24 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 & 35-38 Quality in this outcome area is good. The manager is suitably trained and is competent to run the home. She leads and supports the staff team, and provides effective management. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for several years, is a trained nurse, and is familiar with the illnesses associated with older people. She has completed the RMA/NVQ 4 award, and keeps up to date with new training. She has a visible presence on the floor, and comments were received from residents, relatives and staff stating that she is easily accessible and is approachable. Staff work well together, and can attend regular staff meetings. There is a formal supervision programme in place, and this enables staff to have Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 25 individual one to one supervision approximately every three months. They also have a yearly appraisal carried out by the manager. Residents and relatives’ views are obtained via daily feedback, and via customer satisfaction surveys. The results of these are analysed, and made available at residents and relatives meetings. A number of improvements have been made in the last year as a result of listening to residents’ views. No personal monies for residents are managed in the home. If residents are unable to manage their finances any longer, they are requested to appoint someone to act on their behalf. The manager will help to identify advocacy where needed. Residents who are funded by Local Authority may have the Social Services Client Financial Officer acting as their appointee. Records and documents are stored so as to retain confidentiality, and are well maintained and up to date. The home acts responsibly in meeting health and safety requirements. There are detailed building risk assessments in place. The maintenance manager said they were reviewing their risk assessments regarding window restrictors for first floor windows. Fire training is kept up to date. A number of servicing and maintenance records were viewed and were up to date. The manager also confirmed this data in the Annual Quality Assurance Assessment (AQAA) for CSCI. Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 26 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 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 3 2 2 2 3 X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP10 Regulation 12 (4) (a) Requirement To ensure that the dignity of all residents is maintained when food is served at meal times. This refers particularly to the presentation of food for residents who need assistance with eating. To replace the cracked tiles on the floor in the main kitchen. To review the bathroom and showering facilities in the main building, and assess the alterations needed to provide a suitable number of bathing facilities, which have sufficient space for the use of residents, staff, and equipment. To provide CSCI with an action plan by the given date. 4 OP29 19 and Schedule 2 To ensure that the application form is amended, so that all applicants are asked to provide a full employment history i.e. from the time of leaving full time education; and with any gaps explored. DS0000026195.V367624.R01.S.doc Timescale for action 31/08/08 2 3 OP19 OP21 23 (2) (b) 23 (2) (a,j) 30/09/08 31/10/08 31/08/08 Pilgrims Way Care Home with Nursing Version 5.2 Page 28 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 OP1 Good Practice Recommendations To include more detailed information about the qualifications and experience of the registered providers in the statement of purpose and service users’ guide. To ensure that handwritten entries on Medication Administration Records (MAR charts) are signed by two appropriate staff; And to ensure that sticky labels from the Pharmacy are no longer used on MAR charts. To review the standard of the carpeting in the main building lounges and corridors, and provide a better system for cleaning this, or replace it. To employ more cleaning staff so that holiday leave and staff sickness can be covered more efficiently; To employ kitchen staff to carry out meal preparation for breakfasts and tea in the Coach House. 2 OP9 3 OP19 4 OP27 Pilgrims Way Care Home with Nursing DS0000026195.V367624.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone 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.V367624.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. 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