Latest Inspection
This is the latest available inspection report for this service, carried out on 12th January 2010. 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 Pilgrim Wood.
Annual service review
Name of Service: Pilgrim Wood The quality rating for this care home is: The rating was made on: two star good service 2 3 0 1 2 0 0 9 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: Suzanne Magnier Date of this annual service review: 1 8 1 2 2 0 0 9 Annual Service Review Page 1 of 8 Information about the service
Address of service: Pilgrim Wood Sandy Lane Guildford Surrey GU3 1HF 01483573111 Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Mrs Jean Ann Walker,Mr John Albert Flexer Number of places (if applicable): Under 65 Over 65 35 0 0 35 The maximum number of service users to be accommodated is 35. The registered person may provide the following category of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia - (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: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Pilgrim Wood is located in an elevated position overlooking the North Downs within a few miles of Guildford town centre. The home provides accommodation and care for up to 35 older people, 6 of who may also have dementia. The accommodation is arranged over 4 floors, with the first and second floors being reached by stairs or passenger lift, and the basement by stairs or stair lift. Most bedrooms are located on the ground and
Annual Service Review Page 2 of 8 2 3 0 1 2 0 0 9 first floor, with a small number on the second floor and 2 in the basement. All bedrooms have en suite toilet and hand basin and 5 bedrooms also have a shower fitted. There are ample bathing facilities located on all floors, with most having adapted toilets and baths to assist those with mobility problems. The home has a spacious lounge area that is able to be split into three areas and a large dining room. There are large, well maintained gardens around the home that are fully accessible to the service users, and parking for several cars to the front of the building. Annual Service Review Page 3 of 8 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for since the last key inspection or annual service review. This included: We looked at all the information that we have received, or asked for, since the last key inspection. This included: The annual quality assurance assessment AQAA that was 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 and numerical information about the service. Surveys were sent to people using the service and to other people with an interest in the service. Fifteen written surveys were received from residents, five from staff and three from health care professionals. The received comments have been included within this service review. Additional information is also about how the service has maintained standards, made improvements and plans for the future. Evidence has also been received about how the home manages any complaints and safeguarding concerns and what the service has told us about things that have happened in the home, these are called notifications and are a legal requirement. We looked at the previous key inspection details, the results of any other visits that we have made to the service in the last 12 months and any relevant information received from other organisations. What has this told us about the service? The home sent us their annual quality assurance assessment when we asked for it. It was clear and gave us all the information we asked for. We looked at the information in the AQAA and our judgement is that the home is still providing a good service. The AQAA advises that the home has a Statement of Purpose and Service User guide which are provided to prospective residents and their representatives prior to moving into the home. All prospective residents and their representatives are encouraged to visit the home and a trial period is arranged in order to ensure that the home is suitable for the resident. Residents are only admitted after a full assessment has been undertaken by trained staff, to ensure that the homes staff have the skills and abilities to meet the residents care and support needs. The home have identified areas of improvement that they have made over the last 12 months which has included the adaptation of the Statement of Purpose and Service User Guide in larger print and the homes staff are aware of the importance of good assessments in the home prior to a residents admission. An improvement which the home have identified to be met includes information in the form of photographs of all the staff which could be displayed in the hall in order to Annual Service Review Page 4 of 8 assist in improved communication to residents and their representatives about who the staff team are. The AQAA advises that all residents risk assessments are reviewed and kept up to date in order to ensure the safety and well being of the residents and any necessary changes made and documented. Health care services remain available to all residents. The home have maintained their professional relationships with outside health care professionals including links with the GP and district nurses and specialist health care professionals also visit the home as required. Comments received from health care professionals regarding the home included Residents are well cared for with excellent personal care. Residents are treated with respect and dignity. There are an increasing number of residents with high level medical and complex mental health needs and Pilgrim Wood will need to be able to respond to this changing demographic.All residents appear happy and content. Pilgrim Wood provides a welcoming and homely atmosphere, the food looks superb and the home offers good services and entertainment for residents. What they could do better is to always follow through on requests for things to be done, to understand the limitations of clients with high needs and need to have moving and handling updates. I would be prepared to trust them with a family member they are a unique and superb home The AQAA advises that the homes medication policies and procedures remain in place, all staff receive medication training and the local pharmacist audits the homes medication protocols, training and procedures to ensure medicines are administered safely. The AQAA advises that the staff provide meaningful activities for residents. Special seasonal events for example a Christmas parties and entertainment and garden fetes are held and residents family and friends are invited to attend. Letters to residents relatives and friends are sent advising them of the of activities held at the home and a monthly Tea at Three event is held to which residents families and friends are invited. The home have identified areas of improvement that need to be made which consist of appointing an activities organiser which will also include the development of an activity programme which would be tailored to the residents individual preferences. The home would like to develop relationships with residents of the village and various companies for on going support. Written comments received from residents or their friends and relatives about the home included The home provide good food, comfortable accommodation, care and great kindness. Although entertainment is provided I think the home should encourage activities such as creative art. they care well for the elderly, provide nice surroundings including the garden, have nice fresh flowers and hold parties for residents. What they could do better is to provide hotter baths. Food, cleanliness, kindness, thoughtfulness, respectful of my dignity. They make it feel like home and encourage us to use it as our home for example they welcome our visitors and give refreshments and invite them to lunch etc. What they could do better is to make a longer more interesting walk round the garden and provide more activities. There is a
Annual Service Review Page 5 of 8 good choice of food and staff are very caring more entertainment and outings would be good and to keep families notified of entertainment and outings so family visits dont coincide.A very well kept home in lovely grounds but shame about strong smell of sewage sometimes. The atmosphere is always pleasant. Visitors are invariably made welcome at any time of the day. Food is prepared on the premises using good quality ingredients and is always appropriate to my requirements. The home is very friendly and makes visitors very welcome. The presentation is very clean and homely and the staff are approachable and supportive.Very clean,good choice of meals, always helpful,its a safe comforting environment with lovely rooms. More interesting activities and maybe more days out for the able bodied residents would be an improvement. Very good care, home is always clean and warm. The home is very welcoming, the staff are friendly and helpful, the home is kept very clean and the food is very good. My room is kept beautifully clean, and everywhere else is clean and lovely smell, toilets are always clean. The staff try to learn every member of the communitys idiosyncrasies and treat them as individuals, there are always sufficient staff on hand. The owners take trouble to make sure the little things are not missed like a cheerful display in the flower beds and planters outside, a vase of flowers in the hall the dining tables properly laid and the other impressive thing that the managers office is off the main lounge and not tucked away and good staff morale leading to low staff turnover. The manager and her deputy and heads of department are exceptional people. They are always available to a relative without an appointment. I never fail to leave without having a cheery word with one of them because they manage by walkabout. The home has a formal complaints procedure. The AQAA advises that no complaints have been received by the home within the last 12 months. The AQAA advises that the home has been subject to two safeguarding vulnerable adult referrals the outcome of which has not been notified to the commission and which notification is requested to be made in writing following receipt of this annual service review. Residents can have access to an advocacy service who need help or advice in matters in their life. Recruitment and selection of staff ensures that all appropriate checks are made to make sure that residents are protected and safeguarded from any harm or abuse. All new staff have received the Skills for Care Induction programme and the home have maintained a planned mandatory training programme. Twelve members of staff out of nineteen have achieved their NVQ Level 2 award. Written comments received from staff included Pilgrim Wood is a very nice home yet we are sometimes short staffed, I think we treat the residents well It would be nice to give every resident the right to have meals in their rooms because only some are allowed. The residents are varied, being quite a small home this is workable. The grounds are delightful which means in the summer months the residents can enjoy everything that it gives. we treat residents as individuals and on the whole act accordingly as their comfort comes first. There should be a give and take attitude between the manager and carers. Its the best place to work because we have a good team The manager is very good and she does her best to keep the standards of Pilgrim Wood high, we have good training and treat the residents with respect and visitors as well. more activities for residents would be good. I have worked in a number of care homes but I have never come across a home like Pilgrim Wood it provides a high standard of caring. Standards are very good and the home is well equipped to meet the residents needs, its very clean, the food is good and residents
Annual Service Review Page 6 of 8 nutritional needs are met, very professional staff who are well trained. The best interests of the residents are the priority The AQAA advises that improvements in the homes environment over the last twelve months include the reorganisation of two bedrooms, improved facilities for four of the bedrooms, reorganised the office space, radiator covers have been fitted throughout the home, some French doors and windows have been replaced with double glazing, several rooms have had new carpets, some bedroom showers have been fitted with seats, the dining room has been decorated and various parts of the garden have been reorganised with shrubs and flowing plants to give colour and pleasure to the residents who also have the facility to grow plants and vegetables if they wish. The home have maintained a Quality Assurance process in order to seek the views and opinions of residents and their representatives and others associated with the home. The management of the home has remained consistent and the home continues to let the commission know about things that have happened since the last key inspection and they have shown that they have managed issues well. They work well with us and have shown us that their service continues to provide good outcomes for the residents who use it. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and will do a key inspection by the 31st October 2010, however we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 7 of 8 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:
Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 8 of 8 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
