Inspection on 15/11/06 for Pembroke Hotel For The Retired

This inspection was carried out on 15th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pembroke Hotel For The Retired 05/01/06

Pembroke Hotel For The Retired 16/05/05

Pembroke Hotel For The Retired 04/10/04

Pembroke Hotel For The Retired 09/06/04

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 Pembroke Hotel For The Retired 2 Third Avenue Hove East Sussex BN3 2PD Lead Inspector Merle Blakeley Key Unannounced Inspection 15th November 2006 09:30 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 Pembroke Hotel For The Retired DS0000014222.V317651.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. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pembroke Hotel For The Retired Address 2 Third Avenue Hove East Sussex BN3 2PD 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) 01273 323900 Mrs Susan Brand Ms. Elaine Darby Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum service users to be accommodated is 18 Service users should be aged 65 years or over on admission Date of last inspection 5th January 2006 Brief Description of the Service: Pembroke Hotel is a care home registered to provide services for 18 people over the age of 65. The home does not provide nursing care. The property is a detached Grade 2 listed building situated in a conservation area close to the seafront and the main shopping centre of Hove. All local amenities and transport routes are close at hand. Accommodation is on four floors accessed by a lift. All rooms are en-suite and have an intercom system. There is a comfortable lounge, an activities room and a spacious dining room. The garden is accessed by via a flight of steps or a path around the side of the building. Paid parking is available in the street. The home has achieved the Investors in People Award, and the Residential Domiciliary Benchmark Star Rating Award and also holds the Clean Food Award. Pembroke hotel aims to offer freedom and independence with discreet care to retired people who wish to maintain an independent lifestyle. The current fees range from £475.00 to £650.00 a week for a single en suite room. Additional fees are charged for hairdressing, chiropody, private phone line and newspapers. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of eight hours on the 15th November 2006. As well as this site visit information was also gained from a returned pre-inspection questionnaire, seven returned resident feedback questionnaires, informal talks with seven residents, three staff and the manager. The site visit consisted of a tour of the premises, looking at the needs of four particular residents, lunch with the residents, document reading and observing staff interactions with residents. The inspector was also able to informally chat with three relatives who were visiting the home during the day. What the service does well: What has improved since the last inspection? One requirement was made during the last inspection, which indicated that all handwritten entries on the medication sheet must be clearly signed and dated. This is now being carried out. Newly refurbished training rooms have been completed and paving has been installed outside the back garden to assist the residents with their mobility scooters. A small lean to has also been provided for the storage of these mobility scooters. New flooring has been laid in three of the bathrooms and temperature valves have been fitted to baths. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home carries out a thorough pre-assessment check before any prospective resident moves into the home. EVIDENCE: Pre-assessment checks were viewed for a resident who had recently moved into the home. Records showed that a visit had been made to the person whilst they were in hospital and an assessment of their needs had been carried out. Information was also taken into account from the ward sister and from a relative. This information formed the basis of the residents care plan. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 9 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. Care plans are informative and up to date. Resident’s healthcare needs are being met. Medication is being appropriately administered. Residents were seen to be treated with respect and dignity EVIDENCE: Five care plans were viewed and the information they contained was informative and up to date. Care plans are being reviewed on a six monthly basis and more frequently if someone’s needs change. Records also indicated how resident’s healthcare needs are being met. Residents have access to a number of local health professionals and at the moment two residents are receiving visits from a district nurse and a physiotherapist. All residents retain their own GP. Personal care is carried out in the privacy of resident’s rooms. Medication records were checked and they are being administered and stored correctly. The controlled drugs are also being correctly stored and accounted Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 10 for. Several residents self medicate and the home has carried out risk assessments to ensure that these residents are suitable to manage their own medicines. It was noted that one resident who self medicates is now becoming forgetful and the home must ensure that the well being of this person is maintained by carrying out more frequent risk assessments. During this eight hour visit to the home staff were observed interacting with residents. They all treated residents with great respect and dignity. Six residents who were spoken with also stated that the staff treated them very well and their privacy and dignity was always maintained. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 11 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 excellent This judgement has been made using available evidence including a visit to this service. The home provides residents with a range of enjoyable activities. Family and friends are made welcome in the home. Residents are given choice and control over their lives. Residents enjoy a well balanced diet EVIDENCE: Seven residents were asked about the lifestyle the home offers and all seven said they found it very much to their liking. During the week French classes, Tai Chi and board games are offered. The home has also offered residents movement to music, which was not quite so successful. Minibus outings, the pantomime and theatre are also ongoing activities during the year. A cocktail party and Christmas lunch are being organised for December and both residents and their family and friends are invited to attend. A mobile library service also operates throughout the year. Several residents remain very independent and they go out by themselves to visit friends or go shopping. Several residents have purchased mobility scooters to help them retain their independence so that they can get out and about. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 12 Visitors are made very welcome at Pembroke Hotel and there are no visiting restrictions. During the day the inspector was able to speak with three visitors who had come in to visit their relatives. They all stated that they were always made to feel very welcome in the home. They also stated that the manager and staff were very caring and kind and went out of their way to be helpful and supportive. Six residents were asked as to whether they felt they had choice and control in their lives. All stated that they did feel they had choice in their lives about most things, some did feel they had less but they felt this was because their mobility and general health had deteriorated somewhat. All stated that if they were not happy about something then they would have no hesitation in going to the manager to discuss it with her. Many enjoy the freedom and flexibility the home has to offer. The inspector was able to spend an enjoyable lunch with some of the residents in the dining room. The quality of meals was discussed with several of the residents and all stated that they were generally very happy with the meals that were offered. The cook who is employed for 34.5 hours a week is currently studying for the NVQ Level 3 in catering, she was attending college on the day of the inspection so another staff member was cooking the lunch. Residents receive a copy of the monthly menu and the cook talks to all residents about their likes and dislikes. The menus appeared well-balanced and included fresh vegetables and other produce. A brief visit was made to the kitchen and it appeared clean and tidy and generally well organised. A new cooker has recently been purchased. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 13 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 an effective complaints procedure. The home is aware of its responsibilities to protect all vulnerable adults. Staff have attended training in this subject. EVIDENCE: The home has produced a complaints policy and procedure, which is displayed on the notice board and is also contained in the service users guide. Four in house complaints had been made and these records were viewed. Three minor complaints had been dealt with immediately and one other complaint required more investigation and overall the outcome was very positive. Three residents were asked if they knew how to make a complaint and they all stated that they knew who to go to. Two said they had made a complaint in the past but were very satisfied about how it had been dealt with by the manager. The home has produced a policy and procedure regarding the protection of vulnerable adults. Records showed that there were no adult protection issues within the home. The three staff who were spoken to all stated that they were aware of the procedures to follow should any adult protection concerns arise. All staff have attended training in adult protection. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 14 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 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is maintained to a very high standard and was found to be very clean and tidy. EVIDENCE: Pembroke Hotel for the Retired has a very warm and pleasant environment. All areas within the home are very well maintained and tastefully decorated throughout. The home is comfortable and spacious and the two bedrooms that were viewed appeared very comfortable and homely. A maintenance person is employed for one day each week. Some of the original sash windows have become a little draughty over the years and some are currently having additional beading installed around the frames. As at the sister home Pembroke Lodge none of the radiators are covered. The owners have stated Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 15 that a special electronic device has been fitted to the boiler, which does not allow the radiator temperature to go above 43°C. These radiators are kept on 24 hours a day to maintain constant heat. Some resident’s were asked if the home was cold during the winter and all stated that it was not cold in the home. The home will be required to make sure that each radiator has a risk assessment carried out with particular regard to radiators in residents bedrooms, as this is where the risk of falling against a radiator at night can occur. Two housekeepers are employed and they ensure that the home is kept very clean and tidy. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 16 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 excellent This judgement has been made using available evidence including a visit to this service. The home employs a very experienced and stable staff team. 50 of staff have obtained NVQ qualifications. The home carries out suitable recruitment practises and provides staff with an excellent level of training. EVIDENCE: The home employs a very stable staff team who are very knowledgeable about each resident’s individual needs. There are suitable numbers of staff on duty to meet the needs of residents, which are currently quite low. Many of the staff team have been working at the home for number of years and they are very experienced in their work. They were seen to work very well together as a team and provide residents with friendly and caring support. Two housekeepers are also employed each morning plus the cook and the homes administrator. Currently 50 of the staff team have obtained NVQ qualifications in care and two other staff have just started their training. The cook is also undertaking the NVQ Level 3 in Catering. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 17 Four staff recruitment files were viewed and they contained all the required information. CRB checks are always carried out before a new employee commences work in the home. The home offers a very good level of training and recently one of the top floor rooms has been refurbished and is now a dedicated staff training room. Three staff were spoken to and asked as to whether they felt they received adequate training to support them in their roles and all said that they were offered a good level of training. All the staff team appeared up to date with their core skills training. The home produces a yearly staff-training plan. Recently the Pembroke Group in association with Fireco Ltd have produced a Fire Training Manual and Video to rationalise the new Fire Safety Order, which came into force on 1st October 2006. Staff in both Pembroke homes have already received this important training. Staff are also due to receive training in bereavement and a health & safety officer is coming to the home to talk to staff in December. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35 & 38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is run and managed by a very experienced and dedicated manager. The home has a good quality assurance system. Residents manage their own finances. The home continues to maintain the health & safety of residents and staff. EVIDENCE: The current manager is running in the home in a very friendly yet professional manner. Both residents and staff spoke very highly of the manager and said that she was ‘very supportive’, ‘firm but fair’ and ‘always got things done’. Residents said they would have no hesitation in going to the manager if they had any queries or concerns. It was evident from observations made during Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 19 the day that the home is running very smoothly and is very well organised. The manager has thirteen years experience of working in the care industry and she has obtained the NVQ Level 4 and Registered Managers Award (RMA) and she is also an A1 Assessor for the NVQ Level 2 qualification. The home has produced a quality assurance programme, which includes sending out confidential satisfaction questionnaires to residents several times a year to gain information about how residents feel about certain aspects of care within the home. A business plan has been produced and the home is involved with the Residential Domiciliary Benchmarking Award, which involves an annual assessment of the service. This year the home received 5 Stars. The home has also received The Investors in People Award. The majority of residents handle their own finances with the help of family and friends. The home does hold small amounts of money for two residents and these financial records were checked and found to be in order. A health & safety check was carried out on the home and no major issues were identified. Fire drills, safety checks of equipment, hot water temperatures, emergency lighting and the intercom system are checked regularly. A fire risk assessment has also been carried out. All staff have received training in food hygiene, manual handling, infection control, first aid and health & safety. The only item the home will need to look at is providing risk assessments on the radiators that may pose a risk to particular residents in their bedrooms, as mentioned previously. Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 20 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 N/A 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 21 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 OP25 Regulation 13(a) Requirement To ensure that no unguarded radiators in the home pose a risk to service users. Timescale for action 15/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Hotel For The Retired DS0000014222.V317651.R01.S.doc Version 5.2 Page 23 - 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!