Inspection on 25/09/06 for Pilgrims Way Care Home with Nursing

This inspection was carried out on 25th September 2006.

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... 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 Unannounced Inspection 09:30 25 September 2006 th 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.V312545.R04.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.V312545.R04.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 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.V312545.R04.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 12th October 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 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. There is bus route from the main road into the town centre. Current fees range from £320 to £760 per week. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.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 9.30 a.m. until 4.30 pm. During that time the Inspector spoke with some residents, visitors and some staff. Parts of the Home and some records were inspected and care practices observed. Some comment cards were received prior to the inspection. Responses received from residents’ and relatives prior to the inspection, varied in regard to satisfaction with the Home: • “I am very please with the care my mum is getting.” • “Overall care is not always very good.” Many comments were made about inadequate staffing levels. Individual statements are quoted throughout the report. The three responses received from health professionals indicated satisfaction with the standards of care. The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 6 The Medication Administration Records and care plans are kept more secure. Service users have been consulted about their preference for activities. The dining room chairs have been recovered. Some areas had been redecorated and large televisions placed in the lounges. The Health and Safety Department has been consulted about the use of safety bars at the top of the stairs in The Coach House. The Environmental Health Officer’s recommendations have been implemented in the kitchen. 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.V312545.R04.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Service users and their relatives/representatives were generally provided with the information they needed about the Home. Pre-admission assessments and the opportunity to visit the Home prior to admission ensured service users were appropriately placed and the Home could meet their needs. EVIDENCE: The Manager said the Statement of Purpose and Service Users Guide were accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Pilgrims Way. She stated a copy of the Service Users Guide was provided for each service user or their representative. These were not inspected on this occasion. A relatives/visitors comment card received prior to the inspection stated: Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 9 • “Not enough information given. Even though my mother has only been in this home a short time, we are not or have not been made aware of how the systems runs”. When informed of this, the Manager undertook to ensure that relevant information was consistently given to service users and their relatives. The Manager and/or a senior staff member visited prospective service users prior to admission to make a decision whether the Home could meet the persons’ needs. Information was obtained from other parties, including relevant health care professionals, to assist in assessments. Service users were able to visit the Home before moving in and a visitor said staff had been very helpful in assisting their relative to settle. Intermediate care was not offered at Pilgrims Way. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service Service users health and welfare would be better promoted by risk assessments being written or reviewed when necessary. Service users health needs would be better protected by improved facilities for the storage of medicines. EVIDENCE: Each service user had a care plan. Four were inspected in detail. Each plan had the component parts listed in the minimum standards and they were regularly reviewed. Staff considered the care plan system easy to use and their understanding of service users’ individual needs was good. Further risk assessments were required to safeguard service users’ safety. This was in instances where service users were wheel-chaired without the footplates being used and where staff did not supervise a service user taking the medication given to them. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 11 The medicines storage room in Pilgrims Way was inspected. Parts of the room and the medicines trolley needed cleaning. Some ceiling tiles needed to be replaced in order to maintain infection control. Although the directions for some medicines stated they should not be stored at more than 25 degrees C., the records showed the room was often 27 degrees C. Records were available to indicate that all staff administering medications had been trained and signed off as being competent to do so. The Medication Record Administration Record (MAR) sheets inspected had been completed appropriately. The administration of medicines was not observed on this occasion. Records inspected and comment cards received indicated the Home had a good working relationship with the specialist and local health care professionals, supporting service users in their health care needs. Service users comment cards received prior to the inspection included the statements: • “Had to complain a few times about the care, regarding toileting, not enough.” • “The carers don’t seem to know who’s job it is to shave me, night or day staff.” This compromising of service users’ dignity might be attributed to the low staff numbers referred to later in this report. It would be difficult to attribute such a reason for service users being left with food on their clothing after meals, as was observed. When there was staff in the vicinity, they did not attempt to promote the service users’ dignity by offering to clean or change their clothes. Staff were seen to speak with service users in a polite and friendly manner.. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service Service users could enjoy a fulfilling lifestyle with good outside links maintained and as much choice and control over all aspects of their lives as their individual abilities allowed. Dietary needs of service users were well catered for with a balanced and varied selection of food that met their tastes and choices. EVIDENCE: Service users comment cards received prior to the inspection stated: • “There are activities but I prefer to knit or read.” • “Not enough activities for people who are chair bound and suffering with dementia.” • The food here is very good. We get a choice of two meals a day and there are two experienced cooks.” Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 13 Service users and visitors spoken with were happy with the flexibility the Home offered in regard to meeting personal preferences where practicable, for example what time they got up, went to bed etc. The Manager stated service users were supported to manage their own affairs for as long as they wished and were able. Family and friends felt welcome and knew they could visit the Home at any reasonable time. The design of the Home provided seating areas within the communal areas of the home where service users could entertain their visitors, in addition to the privacy of their own room. 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 service users could receive their visitors in private should they choose not to use their bedrooms The Manager stated they had consulted service users about the activities they would like and, as a result, was arranging for more entertainers to visit the Home. It was evident that, although a part-time activities co-ordinator was employed, the time available for staff to interact with residents on a one to one basis was limited by their workload. Service users spoke favourably of the meals, said they had plenty to eat and enjoyed the choices available to them. The meals were well presented and looked appealing. A large number of service users required assistance with eating so the mealtime arrangements were set accordingly. All meals were cooked in the kitchen in Pilgrims View. As the slope to The Coach House was too steep to use the hot trolley, meals were carried over and then microwaved. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives had access to a sound complaints procedure. There were systems to ensure service users were protected from abuse. EVIDENCE: The complaints procedure was available to service users and their relatives and visitors. Records of complaints were kept and these included details of investigation and action taken. The Manager stated that even minor complaints were recorded and used to improve practice where required. There were procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager stated that any allegation of abuse would be referred to the appropriate agencies without delay. There have been two adult protection alerts since the last inspection. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 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, 23, 25 and 26 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. The quality of life and safety of service users was adversely affected by the poor state of cleanliness and the required improvements to the environment that had been notified in previous reports. Poor infection control placed service users at potential risk. EVIDENCE: The gardens continued to be well maintained and a pleasant area for service users to use in clement weather. Although some areas had been redecorated and large televisions placed in the lounges, since the last inspection there was still a need for some parts of the Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 16 Home to be repaired or upgraded. This had a consequent adverse effect on service users’ quality of life, compromising their comfort and in some instances, placing them at potential risk. The sluice on the ground floor in Pilgrims Way was dilapidated and did not provide an environment in which staff were able to maintain infection control. For the same reason parts of the nearby toilet floor needed repair and a cracked toilet bowel replaced. The floor at the entrances to the sluice room, laundry and toilets was also damaged. Waste bins in high risk areas were not foot-pedal operated and the one that was, was seen to be continually left open. Also left wide open were the sluice doors. Not only was this unhygienic, but immediately opposite the lounge and dining area. Equipment such as wheelchairs, hoists and tables were unclean. The washing machines also needed cleaning, with large deposits of washing powder having coagulated on exterior parts. Despite some staff having recently attended infection control courses, this was not reflected in the way that cleaning equipment such as mops were stored. A bed had been made with linen that was clearly contaminated. Some smaller items of equipment such as laundry baskets, bins, toilet roll holders etc were broken and in need of replacement. The Manager said there was a system for staff to report these things. The odour in several parts of the building was unpleasant and indicative of the continence management needs of some service users. The Manager said that one of the two cleaners normally on duty was on leave. Staff clearing food from the floors after mealtimes would have aided the cleaner’s efforts. This being a common situation was evidenced by a service users comment card received prior to the inspection, which stated: • “The main lounge is often unclean after meals, i.e. food litters the floor and personal tables often sticky with food and drink. Usually it is the visitors who clean them.” Relatives/visitors comment cards stated: • “His room does smell of urine. This should not happen…” • “Cleanliness could be improved.” Staff said they considered the bathing and toilet facilities were adequate. Some radiators were still without guards or individual thermostatic control valves to guarantee low temperature surfaces to protect service users from the risk of burning. The temperature of the hot water was hand tested at several outlets and found to be at a safe temperature. Emergency lighting was provided throughout the Home. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 17 The Manager stated they had liaised with the Health and Safety Officer about the use of the safety bars at the top of the stairs in The Coach House and their use had been approved. 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 recognised this and, commendably, used some of these rooms for single occupancy. Unfortunately, the second set of furniture, (bed, wardrobe etc), was still in situ. Were this removed the occupant’s comfort would be greatly enhanced. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Recruitment processes were robust and offered protection to people living at the Home. It was not evident the Home’s staffing levels were always of sufficient numbers to meet the needs of service users. EVIDENCE: Service users and relatives/visitors comment card received prior to the inspection stated: • “Not enough staff, especially in the mornings.” • “I do think this home is run with the very minimum of staff. Visitors have to go and find them when we need the toilet. Concerns about lack of staff do fall on deaf ears.” • “Very often had to go and find staff who seem to disappear at a certain time in the afternoon.” • “Understaffed.” • Not enough staff especially at weekends.” • At times not enough staff for the number of clients although that is not always the management’s fault.” • “There are never sufficient staff on duty.” Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 19 • • “Staffing is inadequate for the amount of patients who are incapable of doing anything for themselves. Staff do their best but never enough to cover so many patients.” “The staff are very kind and helpful.” Visitors spoke of the staff, saying they were friendly and helpful, despite being very busy. Staff were seen to be generally sympathetic and supporting of service users. It was not evident that staffing levels were adequate at all times of the day. There were protracted periods of time throughout the day when service users were not supervised. Service users were often requesting assistance when staff were not present. Records and observation indicated a high proportion of service users required assistance with mobility and personal care The staff rosters inspected did not indicate that staff did not work long consecutive shift patterns that might compromise their competency through fatigue. Although the tendency was for staff to work long days, there were sufficient days off between. Records seen indicated that robust recruitment procedures were used and ensured the Home directly employed only staff that had been properly vetted. There was some use of agency staff to maintain staffing levels. The Home’s staff were required to undertake an induction programme. The Manager said they were aware of the new induction requirements highlighted on the Skills for Care website and these would be implemented. There was ongoing training for staff, which had included specialist areas such as dementia and a training matrix was used to monitor individual staff training needs. Data provided by the Manager showed that 68 of staff were trained in NVQ. Some staff spoke of the support and assistance they were given in this. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents’ financial interests were protected. Residents’ welfare was promoted through regular environmental and equipment safety checks. EVIDENCE: Throughout the inspection, the Manager demonstrated an openness. She was currently undertaking the Registered Managers Award. Staff and residents said they considered the Manager to be approachable. It was observed that throughout the inspection the Manager had to deal with telephone enquiries and callers to the Home as there was not reception/administrative support available. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 21 An Accountant and an Assistant were employed to manage invoicing, payroll and associated budgetary work. The Home encouraged service users to manage their own financial affairs or to have assistance from their families / representatives and did not hold any cash on behalf of residents. Staff records seen complied with the Regulations. The Manager stated there was regular formal staff supervision. The Manager described how service users were regularly asked for their views about the service via feedback questionnaires. Particular emphasis was placed on involving them in planning activities. The Manager said relatives meetings were no longer held, as these had not always been constructive and positive. The Manager gave assurance that the Home regularly reviewed all its policies and procedures to ensure they complied with current legislation and good practice guidelines. Most records were seen to be kept in a manner that preserved confidentiality, except for the RGN communication book that contained service users’ personal information collectively. Records seen did not give a ready indicator as to whether all staff had fire training or participated in fire drills at the required frequency. There was some discussion about improving these and of the need to be familiar with forthcoming fire safety legislation and guidance. Fire exits were kept clear of obstruction. The Manager stated there was a staff member trained in first aid on every shift. The standard of cleanliness in the kitchen and surrounding area was good and foods were seen to be stored in accordance with guidelines. Refrigerator and freezer temperatures were being monitored and records of food kept. The Manager stated an Environmental Health Officer had conducted inspections of the kitchen in June and July 2006 and their recommendations had been completed. The Manager said all necessary staff had undertaken food hygiene training or updates within the required timescales. Staff were seen to be diligent in ensuring COSHH requirements were adhered to and those spoken with had a sound understanding of emergency procedures. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 22 The Manager stated that records of maintenance and safety checks were in order. These were not inspected on this occasion nor were the Home’s policies, procedures or environmental risk assessments. Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 23 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 3 8 3 9 2 10 2 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 3 2 3 2 X 2 X 2 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4) Requirement Timescale for action 27/10/06 2. OP9 12(1)(a), 13, The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must recorded to safeguard residents welfare. This particularly refers to: 1. Medication being left with residents. 2. Residents being wheelchaired without footplates being used. An improvement plan must be received by CSCI by the given timescale. “The registered person shall 27/10/06 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that: 1. Medicines must be stored at appropriate temperatures. 2. The medicines room and associated equipment must be kept clean and hygienic. 3. Damaged ceiling tiles in the medicines room must be replaced. DS0000026195.V312545.R04.S.doc Version 5.2 Pilgrims Way Care Home with Nursing Page 25 3. OP10 12(4)(a) 4. OP26 13(3) 5. OP26 16(2)(k) An improvement plan must be received by CSCI by the given timescale. “The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users” in that service users must be able to wear clean clothes at all times An improvement plan must be received by CSCI by the given timescale. “The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home”, in that: 1. The environment of all high infection risk areas must be made good where required. 2. Damaged toilets must be replaced 3. All equipment, for example wheelchairs, lifting hoists, tables, must be kept clean. 4. Cleaning equipment such as mops must be stored in a manner that promotes infection control. 5. Foot operated waste bins must be provided in high risk areas. 6. The sluice room doors must be kept closed. 7. Beds must be made with clean bed linen. An improvement plan must be received by CSCI by the given timescale. “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 DS0000026195.V312545.R04.S.doc 27/10/06 27/10/06 27/10/06 Pilgrims Way Care Home with Nursing Version 5.2 Page 26 5. OP25 13(4)(a) 6. OP27 18 7. OP37 12(4)(a) odours” An improvement plan must be received by CSCI by the given timescale. “The registered person shall 10/11/06 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 radiators must be covered or have a guaranteed low surface temperature. This requirement remains outstanding from the previous inspection. To be completed by the given date if not sooner. Failure to comply may result in enforcement action. 10/11/06 “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate to the health and welfare of service users” in that a review of staff levels must be undertaken to ensure they are appropriate to the needs of the service users at the home. The result of this review and its methodology must be received by CSCI by the given timescale. “The registered person shall 10/11/06 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that personal information must be kept confidential. An improvement plan must be DS0000026195.V312545.R04.S.doc Version 5.2 Page 27 Pilgrims Way Care Home with Nursing received by CSCI by the given timescale. 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 OP13 Good Practice Recommendations 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 It is strongly recommended the redecoration of the Home is continued to include those parts still looking worn. 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. It is strongly recommended a system is implemented to give a ready indicator as to whether all staff had fire training or participated in fire drills at the required frequency. OP19 OP23 4. OP38 Pilgrims Way Care Home with Nursing DS0000026195.V312545.R04.S.doc Version 5.2 Page 28 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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