Inspection on 10/02/06 for Pembroke House

This inspection was carried out on 10th February 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 House 30/05/07

Pembroke House 25/10/05

Pembroke House 21/03/05

Pembroke House 26/04/04

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 House 11 Oxford Road Gillingham Kent ME7 4BS Lead Inspector Anne Butts Unannounced Inspection 10th February 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 House DS0000037718.V283210.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 House DS0000037718.V283210.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pembroke House Address 11 Oxford Road Gillingham Kent ME7 4BS 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) 01634 852431 01634 281709 The Royal Naval Benevolent Trust Mrs Carole Lilian Mary Davis Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 44 bedspaces are suitable for the accommodation of service users requiring nursing care, The remaining 6 bedspaces to accommodate service users with social care needs only. 25th October 2005 Date of last inspection Brief Description of the Service: Pembroke House provides residential and nursing care for former sailors, Royal Marines, their wives and widows. The Royal Naval Benevolent Trust owns and manages the home and is a non-profit organisation. It is a large detached property located in a residential area of Gillingham, Kent and is within walking distance of shops and a large local park. Public transport, (rail and bus) are located approximately half a mile away. The home was originally built in the 1920s, and was extended and modernised in 2000 and offers accommodation for fifty service users. All rooms have en suite toilet facilities and are fitted with television and telephone points. Accommodation is on three floors and is served by two lift shafts. Each level has its own dining room and day rooms. On the ground floor the three day rooms can be opened up to provide a large function room with a purpose built bar. There is a library on the first floor and two conservatories, overlooking the gardens. On the top floor there is a large day room, which is known as The Bridge, which provides impressive views over the river. The gardens are wheel chair accessible, and there is parking to the side of the home. The home employs care and nursing staff that work a roster that gives twenty-four hour cover, and they are supported by a full time activities co-ordinator and staff for catering, domestic and maintenance tasks. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out by two inspectors, who were in the home from approximately 9.30 am until 2.00 pm. The manager was present throughout the inspection. During the course of the visit a full tour was taken of the home, care plans and some records were viewed. Staff, service users and some family members were spoken to. This was a positive inspection and the home demonstrated, throughout, good care practices and a commitment to supporting the people living within the home. What the service does well: What has improved since the last inspection? What they could do better: Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 6 The home continues to strive to improve any areas and are pro-active in identifying and addressing these. The home needs to ensure that the individual offices on the different floors that are used for service users records are secure if there isn’t a member of staff in the room. 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 House DS0000037718.V283210.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 House DS0000037718.V283210.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): 3, 4 and 5. Prospective service users benefit from an assessment process that ensures needs can be fully met. Service users and their families benefit from having the opportunity to visit the home prior to admission and can be confident that the home will support them. EVIDENCE: The home has comprehensive pre-assessment forms and these are undertaken by the manager either by herself or with a deputy. Prospective service users are visited prior to moving into the home and families are fully involved in this process. All the needs of the individuals are taken into account and the home places a high emphasis on their assessment process in order to ensure that they will be able to meet the needs of any prospective service users. Ongoing assessments are carried out on a regular basis and records demonstrated that the home can meet the ongoing and changing needs of individuals. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 9 The assessment findings are reflected into the care plans and detail action to be taken to meet needs and encourage independence. Part of the induction process for new staff includes making them aware of the different needs of the service users. Prior to moving into the home people are encouraged to visit and spend time meeting current residents. A family member stated that when her mum had moved into the home the family had been fully involved and the home had been extremely supportive through, what they felt to be, a difficult time in their lives. The manager demonstrated an awareness of how traumatic this period can be for both service users and their families and the home aims to support people through this time. There is a trial period in place – although this is flexible to meet individual needs. The home does not provide intermediate care. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 10 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): 7, 8 and 10. Service users benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Personal and healthcare support is offered in a way that promotes and protects service users’ dignity and privacy in their daily life EVIDENCE: Samples of care records were viewed and all contained comprehensive assessments and detailed care plans. They are person centred and cover all aspects of how the home supports service users with regards to their health, personal and social care needs and the risk assessments are detailed and informative. Records also showed that the care plans are reviewed monthly and updated as required and that service users and their families are involved in this process. Records are kept in the offices over the three floors – however it was noted that if the member of staff was not in the room then the doors were being left open. A recommendation is being made that these rooms are kept secure at all times. Experienced and well-qualified nurses are employed to provide nursing care where it is required and are supported by the community nurses. Care staff Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 11 are also well trained and ensure that care needs are met. Where more specialist intervention is required it is sought - records checked confirmed that contact with GP’s and other health care professionals are maintained. The staff also work closely with the GP and tissue viability nurse to ensure that pressure sore management is monitored and tracked and that appropriate intervention procedures are in place. Service users and a relative spoken to confirmed that they felt that all their healthcare needs were met. They also confirmed that there were regular visits from the a physiotherapist if needed and a family member described how the home had supported her mother as her condition deteriorated and that she had been kept fully informed of the healthcare needs. Service users rights to privacy and dignity are respected at all times. Care plans demonstrated how to support people with this and records were maintained in a sensitive and professional manner. Staff were seen to treat service users with respect and courtesy at all times and observation during the course of the inspection showed that service users and staff related well to each other and there was clear respect and regard demonstrated. Comments from service users also confirmed this and included “the staff have a hard job but they are always helpful and polite” and “staff are very supportive and nothing is too much trouble”. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 12 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): 12, 13 and 14 Social activities are provided with a wide range of choices available that are well organised, creative and provide stimulation and interest for people living in the home. Service users are supported to maintain contact with family and friends. EVIDENCE: The home and the organisation places a high emphasis on recreational interests and activities. There is a full time activities co-ordinator who concentrates on a full and varied programme. These include in-house activities such as arts and crafts, bingo, light exercises, quizzes and entertainment from singers. There are also a variety of external trips including going to concerts, trips to London and local sights. The home is fortunate in that many of the activities are supported and sponsored by the larger organisation and outside groups – as all service users have naval connections many activities are geared towards these interests. Service users spoken to confirmed that they lead a full and varied lifestyle and comments included, “There is always something going on and things to do”. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 13 “I am thoroughly spoilt here and really pampered and looked after” “This is a safe harbour”. The involvement of families and representatives is promoted and people can visit at any time. The homes policy is to encourage the involvement of families and family members known as ‘Friends of Pembroke House’ help out with functions and activities. Visitors can meet either in private or sit in one of the communal areas if they wish and also will arrange for visitors to have a meal with their relatives if they wish. One of the relatives explained of how the home involved them and described different functions they had been invited to. Evidence was seen of personal possessions in individual rooms and the manager stated that service users can bring in their own furniture if they wish. Records viewed, staff, service users and their families spoken to all confirmed that people are encouraged to make as many personal decisions and choices with regards to their daily living as possible. Most service users still manage their own finances and are actively supported in their daily preferences. Overall the atmosphere in the home was relaxed and welcoming and people clearly felt at home here. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 14 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): 17 and 18 Service users’ legal rights are protected and the home’s Adult Protection Policy and procedures protect service users from abuse. EVIDENCE: The home promotes the legal rights of the service users and they are supported with their right to vote. Policies and procedures are in place with regards to adult protection issues and the home is committed to safeguarding service users. The home also promotes the local authorities adult protection protocols. The home has an adult protection trainer and they are currently in the process of updating all staff in adult protection training. There are also policies and procedures on the management of challenging behaviour issues and staff are fully supported in their role. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 15 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, 20, 21, 22, 23, 24, 25 and 26 Service Users benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home; and benefit from having their own en-suite rooms with sufficient additional toilets and specialised bathrooms. EVIDENCE: The home is set out over three floors and provides a range of communal areas that service users can use at any time. There are two lifts and these provide safe and easy access to all areas of the home for all service users. All communal areas were very comfortably furnished and offer homely and pleasant surroundings. There is a large room on the ground floor that can be partitioned off into separate areas and is also used as a function room and has bar facilities. There is a large lounge area on the top floor that overlooks the river and offers a relaxing area for people to spend time. The home also offers smoking and non-smoking areas for service users. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 16 There are large gardens to the rear of the property and these are well maintained – some service users also spend time tending the gardens in the summer months and there are raised beds in place for easier access. The home is currently undergoing a large renovation project in part of the garden area and this is being transformed into an area where service users can spend time in the summer. This has been carefully planned and will include shaded areas, sensory flowers and plants, seating and a circular walkway. It will be wheelchair accessible and will enhance the rear grounds. All bedrooms have en-suite toilet and hand washing facilities and there are also staff and communal toilets available on each floor. There are also additional shower and bathrooms situated over the three floors and all are equipped with the appropriate equipment. The premises has been assessed by an Occupational Therapist and the home was observed to be wheelchair accessible and suitable aids and adaptation were situated around the property – but this does not detract from the homely feel especially in the communal lounge and dining areas. Bedrooms that were viewed by the inspectors were all seen to be comfortable and well decorated. Fixtures and furnishings were of a good quality and service users can bring in their own furniture if they wish to. The home was cleaned and maintained to a high standard and smelt clean and fresh throughout. There are separate laundry facilities and these were well maintained with systems and structures in place to maintain infection control procedures. There are sluicing facilities on all floors and these were seen to be clean and tidy, and appropriate hand washing facilities are in place. CoSHH regulations are adhered to and safe working practices are in place to promote hygiene and cleanliness. One family member stated that that whenever they “visit they have always found the home to be clean and welcoming and it is a joy to come here”. This is a large home that supports service users some of whom have high support needs, but it manages to retain a family orientated and homely atmosphere that service users clearly benefit from. One service user stated, “I did go to look at other homes but none came anywhere near to the standard of this one. I am very happy here”. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 17 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): 29 and 30 Service users can be confident that their care and support needs are met by trained and competent staff, who respect their preferences and choices. EVIDENCE: The manager talked through the recruitment process and was able to evidence that full checks are carried out. Application forms are completed and interviews take place with interview notes taken. A minimum of two references is obtained and full CRB / POVA checks are carried out. Part of the interview process also includes meeting service users – good practice would be to include a service user in the actual interview and a recommendation is being made that the home takes this into consideration. All staff are issued with a contract and there is a probationary period in place. Nurses pin numbers are checked and renewed as necessary. Staff training takes a high priority in the home, and there are a number of trained trainers in the home. The manager and her deputies support staff with their training needs and there is an extensive training programme in place. Training is either provided ‘in-house’ or the home will access accredited training from other organisations. The training programme is varied and comprehensive and covers areas that promote staff in supporting service users needs. New staff are supported through an induction programme. The home is also promoting ‘Leadership at the point of care’ to ensure developmental practice – they are pro-active and forward thinking in the support for staff. This ensures that service users are in receipt of the highest Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 18 quality care. They had also just supported two nurse-training placements and feedback provided at the inspection from the trainees was extremely positive. They both stated that “we have been extremely lucky in our placement, and this has been a very positive experience. Everybody has been supportive and this has been a lovely place to work”. The manager has continued to rotate staff through different areas in the home, and members of staff spoken to confirmed that this had been beneficial and also helped them improve their own practice. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 19 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): 31, 32, 35 and 36 Service users benefit from a manager who is clearly committed to safeguarding and promoting individuals independence, rights and choices and is assisted by a stable staff team who offer a good quality of support to the service users. EVIDENCE: The registered manager has a vast wealth of experience and continually undertakes periodic training to update her skills and knowledge. She is supported by two deputies and an administration manager and there are clear lines of management and accountability within the home. The manager and senior staff all demonstrated awareness and knowledge of the needs of the service users within the home and were familiar with conditions and diseases associated with old age. Overall the manager and senior staff are committed to ensuring that staff are supported and that meeting the needs of the service users are their highest priority. The management team were open and transparent and staff stated Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 20 that they felt well supported and were part of a team. Regular meetings are held with service users and views or ideas they have with regards to the running of the home and different aspects of their care are listened to and acted upon. One service user stated that “they are very supportive here and they always keep me informed of what is going on and I am very much part of this home”. Regular staff meetings are held and these are in a formalised setting which address specific issues affecting the home and care provided. There is individual supervision for staff and this is carried out either through direct observation of care practice or formal one-to-ones with actions, goals and outcomes recorded. Staff development reviews are also held and the home is also continuing to promote and improve it’s clinical supervision processes. Staff spoken to also confirmed that on a general daily basis they felt well supported by the management team. Service users manage their own money with the support from families where necessary. Small amounts of cash are kept on behalf of the service users and records showed that this money is kept securely and accounted for. All transactions are recorded and accompanying receipts were seen to be in place. Regular audits and checks are carried out ensuring that service users can be confident that their personal finances are looked after. Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 21 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 4 4 3 3 3 3 3 4 STAFFING Standard No Score 27 X 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 3 X X Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 22 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP7 Good Practice Recommendations It is strongly recommended that the home ensures that any rooms in which confidential records are stored are made safe and secure if there is not a member of staff in attendance. It is a good practice recommendation that the home considers including service users in the formal interview process. 2 OP29 Pembroke House DS0000037718.V283210.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House DS0000037718.V283210.R01.S.doc Version 5.1 Page 24 - 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!