Latest Inspection
This is the latest available inspection report for this service, carried out on 31st December 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Hornsey Rise Memorial Home.
Annual service review
Name of Service: Hornsey Rise Memorial Home The quality rating for this care home is: The rating was made on: two star good service 0 4 1 2 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Keith Charlton Date of this annual service review: 3 0 1 0 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Hornsey Rise Memorial Home Wellsborough Nuneaton Leicestershire CV13 6PA 01455290851 01455292867 wellsborough@pilgrimhomes.org.uk www.pilgrimhomes.org.uk Pilgrim Homes Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 0 0 0 14 10 38 1. The registered person may provide the following category/ies of service only: Care home only Code PC 2. The maximum number of service users who can be accommodated is: 38 To service users of the following gender: Either to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Old age, not falling within any ca whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP Mental Disorder, excluding learning disability or dementia Code MD Dementia Code DE Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Annual Service Review Page 2 of 6 Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 0 4 1 2 2 0 0 8 The fees for 2008 were £484.00 to £572.00. Please check with the home regarding current fees. The last report is available from the office. Pilgrim Homes (Hornsey Rise Memorial Home) is a care home registered to take thirtyeight residents in the categories of dementia, mental disorder (excluding learning disability or dementia) and old age. The home is situated in the rural village of Wellsborough, close to the towns of Nuneaton in Warwickshire and Market Bosworth in Leicestershire. It is owned by Pilgrim Homes, a 200-year-old Christian charity that was founded in 1807 as the Aged Pilgrims Friends Society with a vision to care for older Christians that needed personal care. Accommodation can be found on two floors, which is accessed by a shaft lift. There are thirty-two single and three double bedrooms, nine of the rooms are en-suite. There is a large lounge and dining room on the ground floor and a further two lounges on the first floor. Peoples rooms are served by a call system. There is also sheltered accommodation for some people who can access services such as meals from the main body of the home. The rear of the building overlooks magnificent views of open countryside and extensive grounds which are well maintained and accessible. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? The home has been registered with the Care Commission since 2004 and is a large size residential home, managed by Mrs. Sally Willis. The home was found to provide good outcomes for residents when it received its last key inspection. No regulatory action has been taken against the provider to indicate that the provider is unfit to manage a care home. The registered provider has complied with the responsibilities of a registered provider within this service. We looked at all the information that we have received, since the last key inspection or annual service review. This included: Information we have about how the service has managed any complaints: The Manager reported that there have been six complaints made to the organisation in the last twelve months, four of them being upheld. This appears to be a relatively high level of complaints we requested an explanation as to why this has been the case. The Manager replied that the service operates a climate of openness so that issues can be dealt with and that of the four complaints that had been upheld, we were given detail as to how they were followed up to ensure that peoples welfare needs were protected in the future. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement: There have been a number of notifications regarding relevant issues sent to the CQC, which have been dealt with in a satisfactory manner. The previous key inspection. No other visits have been made to the service in the last twelve months. Information has been received from other relevant organisations as there have been two incidents where there have been safeguarding incidents. The annual quality assurance assessment, (AQAA), has been sent to us by the service. The AQAA is a self assessment that focuses on, how well outcomes are being met for people using the service. It also gives us some numerical information about the service. Surveys have been sent out to residents and staff and we received back eight surveys from people who live in the service and five from staff. What has this told us about the service? The AQAA was detailed and well recorded and gave us the information we asked for. This included regarding essential policies and procedures that need to be in place for the proper running of the home and contained practices to ensure that residents needs are the primary focus of the homes work. However some policies had not been reviewed for up to four years. The Manager replied that these have now been reviewed. Annual Service Review Page 4 of 6 There is also evidence that all care staff had now received training in tissue viability, needed because of the findings of one of the safeguarding investigations. Surveys from people living at the home and staff were very positive in general regarding the care that the service provides: It gives me the choices that I prefer and understands how I feel. Gives me the care I need and require. It creates a loving atmosphere. We give privacy, dignity, and independence. (The home does well) at general care and maintenance. Our clothes are very well cared for. There was one adverse comment: More staff needed at times. (The Manager said that staffing is constantly reviewed to ensure that it meets peoples needs, which we would expect of a good service provider). Regarding the two incidents where there have been safeguarding incidents, we have now been informed as to what has been put in place to deal with the issues that were highlighted in terms of pressure area care, risk assessments to bed rails, slings and hoists, communication between the home and relevant professionals, and Care Plans updates. Taking into account all the information we have our judgement is that the home still recognises how to provide an good service and has identified improvements that the home intends to make. The AQAA outlined how the service focuses on the welfare and quality of life for people who live there and the improvements that are to be made to make peoples lives better. What are we going to do as a result of this annual service review? We requested an Action Plan from the Registered Provider as to the issues raised above and received a detailed reply that issues have been progressed. We therefore do not need to do a random inspection to look at the issues raised in this review or to bring forward our next key inspection. The next key inspection of this service will be based on the Fees and Frequency Regulations 2007 and the assessment of risk of the service. Further clarity will become evident as the new registration and inspection system under the Health and Social Care Act 2008 is confirmed. Annual Service Review Page 5 of 6 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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