Care Home: Pilgrims Lodge Residential Home For The Elderly

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What the care home does well It is evident through the inspector talking to members of staff that the emotional health of the residents is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. The inspector visited the home at 9:00AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with a few residents who expressed satisfaction with the care offered and given. Quality assurance was discussed and the views and opinions of many of the residents relatives sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. Feedback was received in the way of completed comment / survey forms which expressed a good level of satisfaction with regard to care provided. The home benefits from a activity coordinator who also works as a carer. Residents are encouraged to take park in a variety of activities as their interest and capacity allows. The home has sought the views of residents and considered their varied interests and abilities when arranging activities. The home employs a dedicated cook who prepares and cooks freshly food for the residents. The Inspector viewed residents eating their midday meal. From observation, records viewed and comments made by residents it was evident that residents had been offered a choice of menus that met their dietary needs and individual preferences. What has improved since the last inspection? Good progress had been made with all the matters raised by the last inspection. In some cases well in advance of the receipt of the report and timeframes set. This was judged a good use of the inspection process. What the care home could do better: The maintenance of the building requires continual investment, and the laundry arrangements could be improved. Shortfalls were noted with regard to hazards found within the garden which could have the potential to cause injury. The home was requested to review its environmental risk assessments and review its health and safety procedures to ensure that all elements of safety are inspected and maintained to ensure the safety of residents and that the home meets with the standards. CARE HOMES FOR OLDER PEOPLE Pilgrims Lodge Residential Home For The Elderly 10-12 Pilgrims Way Canterbury Kent CT1 1XT Lead Inspector Robert Pettiford Unannounced Inspection 4th April 2008 09:00 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 Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilgrims Lodge Residential Home For The Elderly Address 10-12 Pilgrims Way Canterbury Kent CT1 1XT 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) 01227 760199 01227 760199 canterbury.thelodge@virgin.net Mr David Barzotelli Mrs Margery Ann Martin Care Home 26 Category(ies) of Dementia - over 65 years of age (22), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (3) Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th May 2007 Brief Description of the Service: Pilgrims Lodge (the Service) is registered to provide accommodation and personal care for 26 older people (residents). Of this number, 22 of the residents may experience a reduction in aspects of their comprehension due to having a dementia-like disorder. The Service can also accommodate three older people who do not have these special needs. A further resident can be accommodated who has a learning disability. The Service is located in a residential part of Canterbury, which is not far from the city centre. The premises comprise of two houses, which have been joined together to form one building. The accommodation for the residents is provided on both the ground floor and the first floor. The property does not have a passenger lift or a stair lift. This means that residents accommodated on the first floor, need to be able to use the stairs. There is provision for 22 of the residents to have their own bedroom. There are four shared occupancy bedrooms. Each of the bedrooms has a private wash hand basin. None of the bedrooms have their own toilet or bath. There are gardens to the rear of the building. There is a small amount of off-road parking. The Registered Provider gives information about the Service to prospective residents through a variety of routes. These include the provision of a Residents’ Guide. This is a brochure, which outlines the principal features of the facilities and services available in the Service. There is also a document called a Statement of Purpose. This gives a more detailed account of the provision in place than does the Guide. The Registered Provider ensures that a copy of the most recent Inspection Report from the Commission is available for reference in the Service. The range of fees charged currently for each of the residents’ residence in Pilgrims Lodge, runs from £377.00 to 475.00 per week. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection took place at 9:00AM on 4th April 2008. The Inspector agreed and explained the inspection process with the Registered Manager present during the inspection. The focus of the inspection was to assess Pilgrims Lodge in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an annual quality assurance assessment questionnaire, which was received on time. This provided the Inspector with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. Survey questionnaires were sent to the home prior to the inspection. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, menus, rota’s, training records and recruitment records. In addition a full environmental tour took place. The Inspector identified three residents for case tracking, speaking with one of them and assessing the available information held in the home pertaining to the care provision for both. In addition the Inspector met with the other Residents, which gave him a good opportunity to observe the quality of care within the home and quality of life enjoyed. What the service does well: It is evident through the inspector talking to members of staff that the emotional health of the residents is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 6 The inspector visited the home at 9:00AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with a few residents who expressed satisfaction with the care offered and given. Quality assurance was discussed and the views and opinions of many of the residents relatives sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. Feedback was received in the way of completed comment / survey forms which expressed a good level of satisfaction with regard to care provided. The home benefits from a activity coordinator who also works as a carer. Residents are encouraged to take park in a variety of activities as their interest and capacity allows. The home has sought the views of residents and considered their varied interests and abilities when arranging activities. The home employs a dedicated cook who prepares and cooks freshly food for the residents. The Inspector viewed residents eating their midday meal. From observation, records viewed and comments made by residents it was evident that residents had been offered a choice of menus that met their dietary needs and individual preferences. What has improved since the last inspection? What they could do better: The maintenance of the building requires continual investment, and the laundry arrangements could be improved. Shortfalls were noted with regard to hazards found within the garden which could have the potential to cause injury. The home was requested to review its environmental risk assessments and review its health and safety procedures to ensure that all elements of safety are inspected and maintained to ensure the safety of residents and that the home meets with the standards. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed prior to admission. The home can demonstrate its capacity to meet the assessed needs of the residents who can visit the home; and there are trial stays before admissions are confirmed. This home does not provide intermediate care EVIDENCE: Residents confirmed feedback obtained at previous inspections, specifically that the decision to apply to this home was largely made on their behalf by relatives and was influenced more by its locality (i.e. close to where the resident or relatives lived), its reputation or the impression formed by previous contact, than by any public information produced by the home itself. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 10 The admission process is a systematic one, which also necessarily takes into account any assessments from any healthcare professionals and care managers involved. The resident, or their representative (relative, care manager etc) is invited to visit the home and there is a trial stay of eight weeks. There has been no overall periodic assessment of the premises by an Occupational Therapist; however, records confirm that individual residents are assessed by social services, as part of the admission and care planning processes, to ensure the home maintains its capacity to meet their needs. The assessment process recognises the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The inspector requested that the home reviews it equalities and diversity policy and considers amending the assessment process to ensure that each diversity groups needs are assessed. This is requested to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. This home does not provide intermediate care. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can feel confident that they will have good outcomes with regard to quality of care. Their health and care needs are fully documented. However work is not as yet complete to ensure all plans of care are reviewed embracing the principles of independence, choice, inclusion, equality and empowerment, which have a holistic model as its base. Residents can feel fully confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. Residents can feel assured that they will be treated with respect and dignity and their rights to make decisions about their lives is respected and they have the opportunity to be consulted on, participate in, all aspects of life within the home as they wish or their capacity allows. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector viewed and discussed with the manager the care records relating to three residents at the home. In the care plans viewed there was sufficient detail and guidelines in respect of the support needed to fully meet residents needs. The care plans were regularly updated. Assessments were in place that that identified areas of risk and measures taken to reduce such risk. No evidence was available that residents were involved in drawing up personal care plans in the documentation and that they are consulted in reviewing and amending such care plans. This was seen as a shortfall on evidence seen. However it is accepted that this may be difficult where the resident lacks the capacity to be fully involved. It was recommended that the home take steps to evidence where this is not possible and do more work where it is. The care planning system needs to be reviewed and introduce a centred planning approach to the care plans, which will have a holistic model as its base. The care planning approach for all residents needs move away from a task-orientated base to one, which includes social and personal goals including hopes and aspirations in more detail. The care plan should further evidence that equality and diversity issues have been considered with evidence that any needs are being supported. The manager stated that the system was currently under review and that all plans of care would be enhanced. No requirement has been made at this time. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed did confirm that residents had access to a range of health care inputs as and when required and as part of regular health checks. The home ensures that residents have access to their chosen Doctor where possible for medication reviews and health check up’s, Dentist, Optician in addition to identified specialist health care input. The documentation seen confirmed that all Residents have a Doctor and visits from other health professionals are arranged and enabled. The health care issues of the residents were seen recorded in the daily record. It was recommended that visits to health professionals are documented separately on its own page to enable the home to more easily document the outcomes for each visit. This was recommended to enable the records to be more easily understood and dispense with the need to read through all the daily notes to extract specific information re a visit to a certain health professionals. Risk assessments sampled were not sufficiently detailed with regard to identifying the risk and the control measures needed to minimise risks. The manager present recognised this and is committed to ensure that all residents have comprehensive risk assessments to minimise risk including access to the garden. Management of risk needs to take into account the age, specialist needs of people who use the service, balanced with their aspirations for Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 13 independence and choice. Where limitations are in place, the decisions have been made following consultation with the resident, relative where appropriate and social services care management. The inspector visited the home at 9:00AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with one relative who expressed a great deal of satisfaction with the care offered and given. They felt that the home offered an inclusive family atmosphere and that the manager was receptive to their comments and suggestions. The home has taken steps to ensure that resident’s personal clothing does not go missing and ensure that it is clearly marked. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets. The manager confirmed that all staff that dispense medication have received appropriate training. No residents currently manage their own medication and the home currently uses the Boot’s MDS system (Medicines are packed into separate compartments allowing the resident to be given the correct medicine, at the correct dose, at the correct time.) Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ social and recreational interest and needs are provided for with a range of activities organised and are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The dietary needs of residents are well catered for and their views and opinions are sought regarding the choice of meals served where possible. Residents feel confident that they are enabled to exercise choice and control over their lives. EVIDENCE: The home offers a programme of activities. This included art, signing, reminiscence and other activities. One resident said she enjoyed watching the television and talking to staff and visitors. Various other social events are arranged with families being invited. Occasional day trips are also organised. Relative’s and residents spoken with expressed satisfaction with regard to activities and opportunities for choice and participation. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 15 Family and friends are made to feel welcome within the home are very much seen as priority in maintaining emotional health and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. Residents are encouraged to exercise choice and control over their lives where possible, staff were willing to assist if necessary. Evidence seen confirmed residents could bring personal items on admission. The residents spoken with said the food was of good quality and that they had a choice. Three full meals plus snacks were available every day with drinks readily available. Evidence was seen that the residents were offered a choice at every meal and that it was well balanced and nutritious. The inspector viewed the menus, which offered a selection of fruit and vegetables on a daily basis. Specialist diets could be provided when advised by health care professionals or residents, including any cultural food needs. The home was requested however to consider providing a viable alternative to the main meal rather than an omelette or salad. Small amounts of money belonging to several of the residents are handled and receipted by the home. Records were seen to be in place. However no audit took place on this occasion. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints system in place, families are aware of its contents. Residents are protected by robust adult protection policies and procedures EVIDENCE: The home had a written complaints procedure, which was seen in the foyer. From the completed survey comment forms received by the Commission, this confirmed that relatives with were aware of the contents and felt free to voice their concerns. The home has received no formal complaints since the last inspection. The home had also received compliments from families regarding the level of care offered. The inspector viewed and discussed copies of the Home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided in abuse. More courses are planned to ensure all staff receive the training required to protect residents from abuse. Criminal Record Bureau Checks (CRB) have been obtained for all staff. The Registered Manager is aware of her obligations with regard to ensuring the Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 17 safety of Residents and protecting them from abuse. The manager stated that additional training is being looked into with regard to residents who may express challenging behaviours and be a physical risk to themselves or others. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s do not wholly benefit from living in a home that provides for a homely environment with safe access to outdoor communal areas. The standard of internal decoration, furniture and fixtures and fittings were found to be of variable quality. EVIDENCE: The service does not wholly provide a homely environment. Fixtures and fittings and general decoration were seen to be of a variable standard / quality. The kitchenette area within one part of the home and bathrooms were found to be in need of refurbishment to ensure standards of infection control are maintained. The home was requested to produce an action plan that provides for a rolling programme of maintenance and redecoration and ensure that it is actioned within the timescale stipulated in this report. There are sufficient Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 19 bathrooms and toilets to meet the needs of the residents. Residents are encouraged to bring their own possessions to the home and many have personalised their rooms with pictures and ornaments. Furniture within some of the bedrooms viewed were found to be of variable quality with some pieces in need of repair or replacement. Outside communal areas were found to contain some hazards that could put residents at risk. This was brought to the attention of the manager at the time of inspection who immediately instructed a member of staff to ensure the area was safe before the inspector left. This is highlighted later in the report. During the inspection it was noted that the home does not have a washing machine with a sluice facility to ensure that hygiene standards are met to meet the needs of residents. Some parts of the home were found not to be as clean as others, some tops of wardrobes and shelves in residents rooms were in need of cleaning. Generally however the home was found to be clean. The home was requested to review its environmental risk assessment to ensure that all risk are minimised and that it meets the standards with regard to suitable washing facilities following consultation with professional advice from an Infection Control Nurse. No requirements has been made at this time. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can feel confident that their care, social and emotional needs are fully promoted by the employment of care staff in sufficient numbers to meet their needs at all times. However a number of staff are working long hours which could compromise residents safety. Residents cannot feel wholly confident that staff are fully trained to meet their needs. Residents are protected by the recruitment procedures within the home. However the record system is in need of review to ensure that all the required documentation is retained. EVIDENCE: The rota for the months of January to April 2008 were seen. It was evidenced on these rotas that up to four. With one member of staff working for a whole month without a day off. Another member of staff had also worked a whole month with only one day off. Whist no direct evidence was available that the standard of care had suffered as a result. It was not in the view of the inspector safe practice as it could compromise residents safety due to staff being tired. The manager was requested to consult with the local councils Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 21 Environmental Health Officer and be guided by his or her recommendations with regard to staffing hours of what staff actually work. The manager was requested to review the staffing levels to ensure that residents needs are met at all times and their health and safety protected. All staff are clear regarding their role and what is expected of them. People using the service report that staff working with them know what they are meant to do, and that they meet their individual needs in a way that they are satisfied with. The currently home provides four AM carers with the manager and two cleaners. The PM staff comprise of four carers and two staff who work a waking night. Additionally the staff are supported by the manager whilst working on shift should the need arise. Following discussions with the manager, a review of the rota and observations made during the inspection. The inspector is of the opinion that sufficient care staff were on duty to support residents to participate in activities, meet their personal needs. Observations at the time of the site visit confirmed that their immediate needs were being meet and that the residents spoken with were happy and content. Relatives spoken with confirmed this in that they felt that their relatives were adequately supported with their needs. The staff training records indicated undertaken training for staff. Staff have received the majority of the required core training according to the evidence seen. However some elements of staff training were in need of improving as not all staff had received training in fire, manual handling, first aid and other basic training. The manager was requested to review the staff training within the home and ensure that all staff were trained to meet the needs of the residents. The manager stated that 75 of care staff had obtained an NVQ level 2 or above. The manager confirmed that all staff receives structured induction training and foundation training to Sector Skills Council specification. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files were seen on the whole to include all the information as required under schedule 2 of the Care Home Regulations 2001 on information given. The home was requested however to review its staff files to ensure compliance. No requirement has been made at this time. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Quality in this outcome group is good Residents and or their relatives can be confident that their views and opinions effect how the home is run and that their best interest are safeguarded. Residents cannot always feel fully confident that their health and safety is protected and thorough risk assessments in place. EVIDENCE: Quality assurance was discussed and the views and opinions of many of the residents sought. A relative was visiting at the time of the site visit which gave an opportunity to discuss the standard of care within the home. Many comment cards / survey forms had been received by the Commission and along with the positive comments of those spoken with enabled the inspector Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 23 to make a judgement that the residents care needs were being met and that their views and opinions were valued by the staff and management. The manager confirmed that the home does undertake quality assurance by means of asking residents to complete questionnaires. The manager quality monitoring system also seeks the views of stakeholders in the community such as doctors, care managers and other professionals. This will enable the home to ensure it is meeting the goals they set out in their own Statement of Purpose. Standard 35 not inspected on this occasion. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements. The inspector viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The inspector was able to evidence that checks and servicing of fire safety equipment had been undertaken. Fire risk assessments were in place along with gas safety checks. Electrical wiring and PAT (Portable Appliance Testing) testing tests were evidenced, along with thermostatic control valves for hot water outlets. However some elements of staff training were in need of improving as not all staff had received training in fire, manual handling, first aid and other basic training. Shortfalls were noted with regard to hazards found within the garden which could have the potential to cause injury. The home was requested to review its environmental risk assessments and review its health and safety procedures to ensure that all elements of safety are inspected and maintained to ensure the safety of residents and that the home meets with the standards. No requirement has been made at this time. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 24 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 3 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2) Requirement The home shall have a rolling programme of repair, maintenance, redecoration, internal and external. This shall include the replacement and repair of furniture including fixtures and fittings. This is to meet residents individual and collective needs in a comfortable and homely way and shall be carried out with reference to relevant guidance and within timescale given. The home is required to ensure that its staff are trained to the required standards as provided for by the Sector Skills Councils Skills for Care training standards and per the needs of the residents within the home. Timescale for action 04/12/08 2 OP30 18(1) 04/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard OP27 Good Practice Recommendations The manager was requested to consult with the local councils Environmental Health Officer and be guided by his or her recommendations with regard to staffing hours of what staff actually work. The home was requested to review its environmental risk assessment to ensure that all risk are minimised and that it meets the standards with regard to suitable washing facilities following consultation with professional advice from an Infection Control Nurse 2 OP26 Pilgrims Lodge Residential Home For The Elderly DS0000023990.V361675.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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