Inspection on 03/08/05 for Pilgrims Way Care Home with Nursing

This inspection was carried out on 3rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

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

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

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

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 Debbie Sullivan Announced 03 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pilgrims Way Care Home with Nursing Address 10 Bower Mount Road Maidstone Kent ME16 8AU 01622 681300 01622 678181 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr D L Yadave Mrs Annette Ashley CRH Care Home 76 Category(ies) of OP Old Age (76) registration, with number of places Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 17 November 2004 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 accomodation 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 good bus route from the main road into the town centre. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7.45 hours. Information was gained during the inspection from discussion with the manager, care, nursing and other staff, from speaking with residents and relatives and from documentation and direct observation. A full tour of the accommodation at both Pilgrims Way Nursing Home and The Coach House took place. The pre inspection questionnaire was completed by the home and a number of comment cards were received. Some of the views from residents, relatives and health and other professionals on the comment cards are incorporated into the report. At the time of the inspection there were a number of vacancies for residents in the service and the post of deputy manager had very recently become vacant. What the service does well: What has improved since the last inspection? The statement of purpose and service users’ guide have been revised. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 6 The call bell system has been upgraded and the corridors in the main care home have been redecorated. Fire exits have been alarmed. A ramp allowing access to the patio has been fitted. The medication trolley is secured when not in use. Care plans now include information on residents’ preferences in terms of activities, bedtimes, place in the home to access in the daytime and other day to day likes and dislikes. 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 H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 standard(s) 1,3,4 and 5. Information is available to prospective residents and their relatives to enable them to make an informed choice of home and needs are always fully assessed prior to admission. Importance is given to viewing of the accommodation before a choice is made to move in. EVIDENCE: The home’s statement of purpose and service users guide have been revised since the last inspection to include information on changes to the accommodation as both services are now registered as one home. The service users guide was clearly displayed in the reception area. A sample of residents spoken with confirmed that they had received written information prior to admission and that relatives had been able to view the accommodation on their behalf. One relative spoken with had viewed several homes before making a decision. The manager of the home undertakes a thorough assessment of needs before offering a place and only confirms an offer subject to prospective residents or a representative having visited. Choice of bedroom is offered if more than one is available at the time of application. The home has a number of double rooms in the nursing accommodation; prospective Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 9 residents are offered choice as to whether they wish to share if they do their decision recorded. The home does not provide intermediate care. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 and 11. The needs of residents are clearly documented and health care needs well met. Medication procedures need to be improved upon to protect the safety of residents. Care of residents near the end of their lives is given sensitively and wishes are respected. EVIDENCE: Care plans in both the Coach House and nursing home were inspected, they were found to be very comprehensive; sections included monthly reviews, nutritional monitoring, risk assessments and social activities and interests. Information was up to date with typed summaries so that information is easy to access and read. Health care needs are well documented and details of any medical appointments recorded. It was possible to clearly track where improvement in health had taken place from the care plans, for example in the case of weight gain or pressure sore healing and where concern was documented leading to contact with a GP. The manager said there are good links with local GP’s. Medication is administered by qualified nursing staff in the nursing home and care staff in the Coach House; the lunchtime medication round in the main unit was observed, the trolley was tethered just outside the dining room and staff Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 11 were seen to be correctly following procedures. MAR sheets were inspected, in both units gaps were found in the daily recording with no reason documented as to why a medication may not have been given. During the inspection those being assisted with personal care were seen to be treated respectfully by staff and to be responded to appropriately. Comments from residents regarding their personal care included “the carers treat me properly and with dignity” and “the care is excellent”. Samples of views on comment cards from relatives and visitors are “I am very happy to leave my mother in their care” and “mother is always clean and nicely dressed and we are made welcome”. A point raised by relatives visiting, from two residents who were spoken to and two comment cards was that it can take a while for call bells to be answered, although other residents stated that bells were answered promptly. Evidence was viewed on care plans of preferences regarding death and dying and staff are provided with training on bereavement. Relatives are able to stay at the home to be with residents who are near the end of their lives. Comments on thank you cards from relatives were complimentary about care given to relatives and support offered. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 and 15. Residents are supported in maintaining contact with friends and relatives and social and recreational activities are available. Residents enjoy good quality meals, which reflect choice. The dining area in the main unit does not provide a pleasing environment to eat in due to the poor standard of some furnishings, their cleanliness and the general décor. EVIDENCE: During the inspection a number of visitors were at the home and evidence was seen on care plans and from talking with residents that contacts are maintained and encouraged. The home’s activities coordinator has been in post for a year and has established a range of activities that are documented in a portfolio. Individual and group activities are on offer as well as trips out and visits by entertainers. Information and a questionnaire consulting residents on activities they prefer was seen. Views varied amongst residents, relatives and on comment cards as to the provision of activities; discussion with the coordinator showed that different abilities are catered for, although as the range of interests and abilities is quite varied it cab be hard to provide for all on a very regular basis. The home has a hairdressing area which is located in between the laundry and staff locker room which is not a very appropriate location, due to lack of Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 13 privacy. Although the area was not in use during the inspection, the manager advised it is a popular resource. Residents spoken with stated that the home gave them plenty of choices in respect of their daily lives, for example choice of meal, time to get up and go to bed and whether or not to take part in social activities. One resident commented that at weekends there can be less choice of bedtime; the manager will look into this issue. The lunchtime meal was partially observed in the main building; those on a soft diet and in bed are given their meal first. This does mean a rather long wait for others, some of whom eat in the dining room in the main building and others at tables in the adjacent lounge. The manager stated that residents take themselves to the dining room at times of their choice even though they may have to wait a while and enjoy having time for a chat. The meal was well presented, and portions appropriate, those assisted with eating were helped discreetly. Menus were inspected and offered daily choices with alternatives other than that on the menu recorded. The kitchen was inspected and food was seen to be stored properly in fridges with temperatures checked. Residents views on the meals included, food is “pretty good and enough” and “it is well presented, plenty of it”. One resident preferred not to eat meat, and found there was usually an appropriate alternative. The main midday meal is cooked at the nursing home and provided to residents in both units. The dining room at the Coach House provides an attractive setting for mealtimes. The dining room at the nursing home is in need of refurbishment and on the day of the inspection, which was warm, was quite stuffy with no fresh air and a stale smell. Tables were sticky and plastic and upholstered chairs were seen to have food stains on them; a number of plastic chairs were torn in places. Some square tables had been replaced with round ones following a recommendation from the last inspection to make them more suitable for wheelchair users. More of these are required. The general atmosphere in terms of décor was unwelcoming and not a pleasant environment in which to eat a meal. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18. Complaints are addressed within a given timescale appropriately and residents know who to complain to. Records of complaints need to be kept more securely. Adult protection policies and procedures are in place; staff have received training which is to be updated. EVIDENCE: The home has a complaints procedure; the complaints books in both the Coach House and the nursing home were inspected. There had been one complaint regarding the Coach House since the last inspection on 17th November 2004 and eight regarding the nursing home. These had all been resolved within the given timescale of 28 days and appropriate responses by the manager given. When a complaint is received verbally the complainant is advised that they or an advocate can put it in writing, if they do not wish to as they may feel it is resolved the manager records the issue in the complaints book so that evidence it has been made and addressed is available. The complaints book in the nursing home needs to be changed from a loose-leaf folder to a hardback book. Residents spoken with during the inspection said that if they were not happy with anything they would speak to the manager or other senior staff. There have been no adult protection alerts since the last inspection; the home has an adult protection policy and procedure. Staff are provided with adult protection training in their induction and updates are given. A number of staff are due update training; this is being addressed by the manager. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 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 standard(s) 19.20,21,22,23,24, and 25. Individual accommodation is of a good standard; some communal areas in the nursing home would be substantially enhanced by redecoration and better ventilation. Outside areas should be more easily accessible and radiator guards would enhance safety within both units. EVIDENCE: A tour of the premises took place during the inspection; both units were clean and maintained to a good standard with the exception of some furniture referred to under standard 15 in the dining room. Bedrooms are of varying sizes, bright and well decorated and many residents had personalised their rooms with their own furniture, pictures and ornaments. One resident was complimentary about the cleanliness of her room, residents spoken with in the Coach House and the main unit were happy with their rooms. One resident who had been unhappy in an upstairs room since a partner died, had moved downstairs and is now much more settled. Curtains providing screening in double rooms give sufficient privacy. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 16 Throughout the premises there is evidence of specialist equipment that enhances independence. Since the last inspection a ramp has been fitted to allow access to the patio off the dining room but it is not ideal and difficult to manoeuvre a wheelchair down. An alternative design will be looked into although the home had considered other options and so far found none suitable. Most of the radiators in both units have guards although some are still without them; the need for guards was noted at the last inspection. Communal areas and the kitchen, which are in the old part of the building, are to be refurbished, as the décor needs attention; this is scheduled for this year. There was an odour in the communal area of the main home of a generally stale nature possibly due to lack of fresh air and ventilation. One relative commented upon this. No windows were open for ventilation in the lounge and dining room area and the weather was quite warm. The home is well equipped with toilets and bathrooms, eight single and two double rooms have en -suite facilities and a number of upstairs rooms have access to a balcony area with pleasant views. l Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Staff are well supported and training is provided to increase skills. Recruitment practices are good and residents needs are met by an appropriate mix of staff. EVIDENCE: At the time of the inspection the deputy manager post was vacant; there were no other staffing vacancies and no agency staff had been employed for five months. Registered nurses and care staff are employed in the main home and two care staff are always on duty at the Coach House. In the main home there is a nurses station on each floor, staff are allocated a floor and residents to work with on a daily basis, the manager checks the list daily. This ensures that work is fairly distributed and staff deployed in correct numbers where residents require most care and where most rooms are occupied. Staffing files were sampled and evidence was seen of good recruitment procedures; of the two references taken up one is always followed up verbally. The information regarding CRB checks on the pre inspection paperwork showed that several staff that had been working at the home for varying numbers of years were awaiting CRB clearance; the manager checked this during the inspection and the list will be amended as it is not correct. Staff receive regular supervision and minuted staff meetings are held. Sixty per cent of the care staff have NVQ 2 or 3 in care which exceeds the ratio required, and more care staff are expected to be signed up for NVQ training soon. The manager holds substantial relevant qualifications, clarification is being sought as to whether she will need to complete the NVQ 4 management qualification. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 18 Update training is provided on topics such as nutrition, infection control and dementia care. One member of staff spoken with was very enthusiastic about the level of understanding the dementia course had equipped her with and was actively applying techniques learnt with one resident in particular. Throughout the inspection care and nursing staff were seen to treat residents appropriately, residents spoken with were complimentary about nursing and care staff and a comment from a relative on a comment card said “The staff are always pleasant and approachable”. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34 35 36,37 and 38. The home is well run with up to date policies and procedures. Staff are well supported, and the views of residents taken into account. Records are kept safely and securely. EVIDENCE: The views of staff and most residents spoken with were that the home was run in the best interests of residents and that the staff felt well supported. Comment cards received echoed this. Where views had identified areas of dissatisfaction it primarily related to parts of the environment and the response time to call bells. During the inspection the daily routine was seen to run smoothly and staff were confident in their roles. The position of deputy Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 20 manager had been vacant for a short while but this had not impinged on routines, the post is more care than managerially oriented. If residents are unable to manage their own finances relatives or other advocates assist them, the home does not undertake this responsibility. The view of residents and relatives are taken into account and user surveys undertaken. The manager meets with the home owner on a monthly basis to discuss financial, staffing and other business issues, minutes of these meetings were seen. Policies and procedures were sampled, they are easily accessible to staff and are in reception as well as the office. Evidence was seen of up to date maintenance checks, fire extinguishers had been tested in February and evidence of weekly fire alarm tests seen. A valid insurance certificate is clearly on display. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 3 3 3 4 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 3 3 3 3 3 3 Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 31 Regulation 9(1) Requirement A person shall not manage a care home unles he has the qualifications necessary . It is acknowledged that Mrs Ashley holds substantial qualifications and clarification is being saught on whether it is necessary to undertake NVQ level 4 in management. 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 measures are to be put in place to monitor and ensure that no gaps are left on MAR sheets. The registered person shall keep the care home free from offensive odours. In that the smell in the dining/lounge room area be investigated and furnishings that may harbour smell be replaced. Ventilation in these areas is to be improved. The registered person shall ensure that all parts of the care home are kept clean and reasonably decorated. In that chairs and tables in the dining room be regularly cleaned Timescale for action 31/10/05 2. 9 13(c) 31/10/05 3. 26 16(2k) 31/10/05 4. 26 23(2d) 31/10/05 Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 23 5. 25 13(4a) thoroughly and checked daily after the main mealtime. The registered person shall ensure that all parts of the care home to which service users have access are so far as reasonably practicable free from hazards to their safety. In that radiators must have guards of low temperature surfaces. 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard 12 16 19 19 20 20 29 7 19 27 Good Practice Recommendations It is recommended that information regarding activities be recirculated so that all residents and their representatives are aware of what is available. It is recommended that the complaints book in the main unit be in hard back form ,not loose leaf. It is recommended that redecoration of the older part of the building be actioned this year as planned. It is strongly recommended that the ramp to the patio be replaced with a model that is easier to negotiate so that residents can better access the grounds. It is strongly recommended that the remaining square tables in the dining room be replaced with round tables more easily negotiable by wheelchair users It is strongly recommended that torn ,broken and stained chairs in the dining room be replaced for the comfort and hygeine of residents. It is recommended that the list of staff CRB checked or awaiting the return of checks be kept up to date. It is recommended that dividers be used in care plans so that sections can be easily accessed. It is recommended that the area used for hairdressing be relocated . It is strongly recommended that a strategy be put in place to acknowledge call bells with an approximate time to be given of full response if the need is not urgent and staff are otherwise occupied. Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pilgrims Way Care Home with Nursing H56-H06 S26195 Pilgrims Way V231643 030805 Stage 4.doc Version 1.40 Page 25 - 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. 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