Inspection on 16/05/05 for Pembroke Hotel For The Retired

This inspection was carried out on 16th May 2005.

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

The inspector 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 15/11/06

Pembroke Hotel For The Retired 05/01/06

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 James Houston Unannounced 16 May 2005 9:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Pembroke Home for the Retired Address 2 Third Avenue Hove East Sussex BN3 2PD 01273 323900 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Brand Ms Elaine Darby Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (OP) 18 of places Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is 18 2. Service users should be aged 65 years or over on admission Date of last inspection 4 October 2004 Brief Description of the Service: Pembroke Hotel is a care home registered to provide services to 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. Accomodation 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. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the sixteenth of May 2005. Before the inspection the inspector read papers held on the service by the Commission for Social Care Inspection and prepared for those sections of the standards that were to be assessed. The inspection in the home took 4.8 hours. A tour was made of the home, and the manager and three staff were spoken with as well as eight residents and a visitor to the home. An inspection of a number of policies and records was made. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4, and6. The home provides a detailed statement of purpose and service users’ guide to assist prospective residents and their families in deciding whether they want to move into the home. Residents are provided with a suitable contract. The home assesses fully prospective new residents. The home meets the needs of the current group of residents. Intermediate care is not provided. EVIDENCE: The home has a combined suitable statement of purpose and service users’ guide. One point of detail needed amending and this was done during the inspection. Residents are provided with a contract at the point of moving in. This sets out clearly the terms and conditions of accepting living in the home. Records inspected showed that the home obtains a copy of a care management assessment where this exists, and conducts its own needs assessment. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 8 Discussion with the manager, staff, residents, and a visitor and the reading of a range of records indicated that staff individually and collectively have the skills and experience to meet the needs of those currently living in the home. Intermediate care is not offered in the home. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,and 10. The plans of care are detailed and comprehensive. Health care needs of residents are attended to. Residents are treated with respect and dignity. EVIDENCE: All residents are asked if they wish to be involved in care planning. and are invited to sign their plans. Staff said that plans are regularly updated and plans inspected confirmed this. Staff said that they write updates and have had guidance about how to do this. Risk assessments are conducted as necessary and are updated. Records showed that the health needs of residents are attended to. Residents said that they either make appointments themselves or the manager will do so, and that their health care needs are attended to. The manager said that residents are encouraged to keep links with their community dentist, optician and chiropodist and some have done so. Residents are weighed regularly. Staff confirmed that they have been given guidance as to how to treat residents with respect. Residents said that staff respect their privacy and dignity for example by knocking before entering their rooms, and calling them by their chosen name. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Social activities are well managed – a wide range is offered - and residents choose what they do. Meals provide daily variation and interest for people living in the home. EVIDENCE: Residents said that they are free to rise and go to bed at times of their choosing, and whether or not they eat their meals in the dining room. Residents and staff said that a range of activities is arranged and residents said that they choose whether to participate or not. A French class took place during the inspection, and for example games and video afternoons are arranged. Some residents go out on their own. Outings are arranged regularly, with the destination for the outing due later in the week of the inspection being decided upon by residents. Residents said that they appreciate the food served in the home, and that they are given choices. Records inspected confirm this. The manager said that therapeutic diets are catered for. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 and 18. Residents’ rights to participate in the political process are upheld. The home’s procedures, processes and training for staff should protect residents in the event of any abuse or allegation of abuse. EVIDENCE: Residents said that they had either votes or postal votes, and several had voted in the recent general election. The home has both whistle blowing and adult protection procedures. The reporting procedures in the event of abuse or suspected abuse in the adult protection procedure had been amended to meet the requirement at the last inspection requiring this. The manager added a sentence to the procedure during the inspection to complete this. Staff have recently had training in adult protection. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20, and 24. The home provides a good quality of accommodation. Communal areas and bedrooms are to a good standard, proving pleasant accommodation. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is safe and well maintained, and all parts of the home and grounds are accessible to residents. The home’s owners arrange for items needing attention to be addressed. There has been no recent visit by the local Fire Safety officer. The environmental health officer visited recently and his report is awaited. The manager said that the only stipulation in the report has already been met. Outside the home has a large garden which is accessed either by a steep flight of steps at the rear of the house or by a level path around the side of the building. The steps cannot be altered owing to the home being in a conservation area. At the side of the garden is old scaffolding and the manager will arrange for this to be removed. A small piece of this scaffolding was on the ground near some steps and this was removed by the manager. The manager said that there are plans to enlarge the office. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 13 The home has a dining room and lounge, which are spacious, well furnished and decorated. There is also a large activities room on the lower ground floor. Residents said that they like their rooms. Rooms are all well furnished and decorated. Residents said that they have been offered a key to their rooms and to the front door, and that they use these. They said that they have been encouraged to bring in items of their own into their rooms and appreciate this facility. Records inspected showed that an inventory of furniture brought in is kept. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. A competent staff team meets residents’ current needs. The staff team is working towards but at present does not meet the recommended minimum ratio 50 trained members of staff to have NVQ level 2 or equivalent by 2005. EVIDENCE: The home has two care staff on duty during the working day, in addition to the manager. There are a number of part time ancillary staff including the cook, administrator, housekeeper, domestic and maintenance staff. The home does not have waking staff at night. The inspector noted from records that a resident had fallen during the night on two occasions and that Carelink had called the home to advise them of the situation. The manager advised that the resident had subsequently been re-assessed by her GP and the Social Services Occupational Therapist, and that the home can meet this residents’ needs. The manager said that extra staffing has been employed, and would be employed for periods when the needs of a resident or residents require it. Staff and residents confirmed that the staff group is currently stable with no new staff having been appointed since the last inspection in October 2004. The manager advised that two staff hold NVQ level 2 in care and three staff are doing it. One staff member is doing NVQ level 3 in care. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,37,and 38. The manager is competent and experienced to run the home and meet its stated purpose. Residents benefit from the ethos and management approach of the home. Residents and/or their representatives control their finances. Records are well kept and residents can access their personal records. The manager ensures as far as is reasonably practicable the welfare of staff and residents. More regular fire training for staff should be arranged. EVIDENCE: The manager has several years’ relevant experience, and has recently completed her NVQ level 4 in care. She hopes to have completed her Registered Managers award by June 2005. She has a suitable job description. One point required amending and this was done during the inspection. Records inspected showed that the manager undertakes periodic training to update her skills. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 16 Staff said that the manager holds very regular staff meetings. Staff said that these are minuted and that the manager is open to new ideas. These minutes were made available to the inspector. The record showed that staff sign to note their presence and the manager said that the minutes are brought to the attention of any staff that were not able to be present. Residents said that there are regular residents’ meetings at which they feel free to raise a wide range of topics. These minutes were made available to the inspector. Residents said that they find staff and the manager approachable and helpful. The manager said that no monies or valuables are not normally held on behalf of residents, but should the need arise over the short term the facility to do exists. Those records inspected were well kept. Residents said that they are aware that they can access their own records, but that to date they have not chosen to do so. Records inspected confirmed that the home ensures regular servicing of electrical and gas systems. Staff said that they have recently had training in moving and handling and first aid and records inspected confirmed this. Fire drills are held six monthly. Staff have fire training as part of their induction, and the next fire drill will be held on May 24th 2005. Some staff have not had fire training for longer than six months and a requirement has been made about this. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 3 3 x x 3 x 3 2 Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 18 NO 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 38 Regulation 23(5)(e)& Sch 4 14. Requirement Provide fire training for all staff at suitable intervals and keep a record of this available for inspection. Timescale for action 30 June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 19 28 37 Good Practice Recommendations Remove scaffolding from the side of the garden. 50 of care staff to have NVQ level 2 in care by 2005 Include the time of the accidents in all accident reports. Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Hotel for the Retired H59-H10 S14222 Pembroke Hotel V216925 160505 Stage 4.doc Version 1.20 Page 20 - 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. 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