Inspection on 05/01/06 for Pembroke Hotel For The Retired

This inspection was carried out on 5th January 2006.

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 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 Rebecca Shewan Unannounced Inspection 5th January 2006 09:50 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.V274266.R01.S.doc Version 5.1 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.V274266.R01.S.doc Version 5.1 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.V274266.R01.S.doc Version 5.1 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 16th May 2005 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. 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. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the CSCI inspection year of 2005/2006. To gain a complete overview of the standards assessed it will be necessary to read both inspection reports for this inspection year. This unannounced inspection took place during the morning and early afternoon of the fifth January 2006. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took five and a half hours. A tour of the whole home was undertaken and the Registered Manager, two staff and eleven service users (known as Residents) were spoken with. There were sixteen residents living at the home at the time of the inspection. What the service does well: What has improved since the last inspection? The previous inspection requirement that the home provides fire training for all staff at suitable intervals and keeps a record of this available for inspection has now been met in full. The previous inspection recommendations that the home removes scaffolding from the side of the garden and that the home includes the time of the accidents in all accident reports have now been met in full. The previous inspection recommendation that 50 of care staff to have National Vocational Qualification (NVQ) level 2 in care by 2005, is currently being addressed and the home will have 50 of care staff trained to NVQ Level 2 by the middle of 2006. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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.V274266.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The home has suitable procedures in place for allowing potential new residents with the opportunity to visit the home. EVIDENCE: The Manager said that potential new residents are invited to stay at the home for a day and have a meal with the current residents. Trial periods of two to four weeks are offered to potential new residents as a matter of course. The Manager said that the trial period could be extended if required and with the agreement of all parties involved. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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 the following standard(s): 9 & 11 The home has to make some improvements in recording handwritten entries onto Medication Administration Record (MAR) sheets. The home has good processes in place to enable residents to self medicate. Resident’s dying/critical illness wishes are recorded in their care plan and staff are aware of residents choice in relation to this matter. EVIDENCE: The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home and drugs being administered. However, some improvement is required in ensuring that handwritten entries onto MAR sheets are dated, signed with an explanation of the reason for a handwritten entry being detailed. The implications of this were discussed with the Manager at the time of the inspection. Residents who are able are assisted to self medicate and it was noted that suitable risk assessments were in place to encourage independence with medication taking. The Manager said that the home records resident’s wishes in the event of dying or critical illness, where this information has been obtained and that Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 10 residents wishes to remain at the home would be respected until such time that the home is unable to meet the needs of the resident. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 & 15 The home provides a wide range of choice for the residents in order that they can maintain relationships and attend events within the local community. Residents are encouraged to have control over their lives and to exercise choice. The Manager was aware that there is a need for the home to address the issues raised relating to food during the inspection. EVIDENCE: The home has well-established links to local community events and activities. Residents said that they enjoyed the homes activities and that the staff were flexible in allowing residents to choose the level of activities attended. Residents are actively encouraged to maintain family contact and that visitors could attend the home at any time and in accordance with the service users wishes. Residents can entertain their guests in any of the homes communal areas or privately in their own bedrooms. Residents are encouraged to remain independent and those who are able attend the local community at a level of their choosing, residents who spoke to the inspector at the time of the inspection confirmed this. Two residents attend the Brunswick group. Two residents, who have difficulty with accessing Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 12 the local community to due mobility problems spoke of how they are supported to attend the local community within their limits. The homes menus are devised as a four-week rolling programme. Residents may have guests to stay for a meal at any time. The home’s Cook said that medical or therapeutic diets are provided as needed. Of the eleven residents spoken to at the time of the inspection, mixed responses were received relating to the food served by the home. Many residents felt that the food was good in content and quantity whilst some felt that the meals were hurried. This was discussed with the Manager at the time of the inspection and it was concluded that the Manager would speak with the Cook to address any issues highlighted by residents. The Manager said that monthly resident questionnaires relating to food are sent to all residents and that no issues were raised during the last questionnaire. The Manager felt that such comments may have arisen from the fact that staff courteously waiting for all residents to finish their meals before serving the next course, resulting in residents who eat slower feeling that there is insufficient time between courses whilst those who have to wait feel that there is too much time between courses. Therefore a recommendation has been made. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a suitable Complaints Procedure in place. EVIDENCE: The home has an established Complaints Procedure in place. There was a need for the home to ensure that the Complaints Procedure was updated to reflect that the CSCI can be contacted at anytime in the event of a complaint, this was rectified at the time of the inspection. Residents said that if they had any complaints then they knew that they could approach any member of staff or the homes management team. The home has received two complaints in the last twelve months, which had been addressed within the required timescales and resolved to all parties’ satisfaction. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23,25 & 26 The home provides a good quality of accommodation. Communal areas and bedrooms are maintained to a good standard, providing pleasant accommodation. The home as good facilities in place for residents to independently maintain their personal hygiene. Aids and equipment required to promote resident independence were in use throughout the home. EVIDENCE: The previous inspection recommendation that the home removes scaffolding from the side of the garden has now been met in full. There are ample toilet and bathroom facilities for residents. All bedrooms have en-suite facilities consisting of toilet, hand washbasin and a bath or shower. Additionally there is a walk in shower and medibath available if required. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 15 A passenger lift, grab rails, walk-in shower and specialist bath were evident in the home. Residents were also noted to have suitable mobility aids where required. There is a call bell system throughout the home. Resident’s bedrooms are pleasantly decorated. Residents are actively encouraged to bring in their own possessions and personalise their bedrooms. The home was clean and odour free throughout. An effective infection control procedure is in operation in the home. Residents are encouraged to launder their own personal clothes, however the home launders resident’s bed linen and towels. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 A competent staff team meets the service users needs. The home has a commitment to its staff achieving National Vocational Qualification (NVQ) level two and the recommended 50 has been met. Staff are trained to do their jobs. The home has clear procedures in place for the effective recruitment of staff. EVIDENCE: The Manager said that the home has two care staff trained to NVQ level two with a further three care staff are undertaking the training and two care staff due to commence training in mid January. The home hopes to achieve the required 50 of staff trained to NVQ level two by the middle of next year. Therefore the previous inspection recommendation remains unmet at the present time. Staff recruitment files were viewed and it was evidenced that these file contain all items required under the Care Homes Regulations 2001. Staff training files were viewed and it was evident that staff training in induction, Fire Safety, manual handling, Health and Safety, food hygiene, Protection of Vulnerable Adults and infection control are conducted. The staff induction-training package was viewed and this was found to be comprehensive in content. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,36,37 & 38 Effective Quality Assurance procedures are in place and appropriate action is taken to address issues highlighted by responses received by the home. The home has good arrangements in place for promoting the health, safety and welfare of both residents and staff. EVIDENCE: The Manager said that Quality Assurance questionnaires relating to food and are given to all residents on a monthly basis. It was evident that the home has taken the necessary actions to address any issues raised. Records were also viewed for the half yearly staff and service user meetings that are held. Suitable insurances policies and certificates were viewed and found to be on display where appropriate. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 18 It was evident from the staff files viewed that care staff are appropriately supervised. The Manager said that formal supervision of staff is conducted on a two monthly basis, records viewed confirmed this. The previous inspection requirement that the home provides fire training for all staff at suitable intervals and keeps a record of this available for inspection has now been met in full. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing, emergency lighting testing and water checks are carried out on a regular basis. From the records viewed it was evidenced that Portable appliance testing had been completed. Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 19 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 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 3 3 X 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X 3 3 3 Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13(2) Requirement That all handwritten entries onto MAR sheets are dated, signed and an explanation given for the entry. (This was an immediate requirement) Timescale for action 05/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard OP15 OP28 Good Practice Recommendations That the Manager liaises with the homes cook and residents to discuss issues raised during the inspection that relate to food. 50 of care staff to have NVQ level 2 in care by 2005 (This recommendation remains outstanding from the previous inspection) Pembroke Hotel For The Retired DS0000014222.V274266.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East Sussex Area Office 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 DS0000014222.V274266.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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