Inspection on 30/05/07 for Pembroke House

This inspection was carried out on 30th May 2007.

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 House 10/02/06

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 Marion Weller Key Unannounced Inspection 30th May 2007 09:45 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.V330204.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 House DS0000037718.V330204.R01.S.doc Version 5.2 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 Lillian 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.V330204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 44 bed spaces are suitable for the accommodation of service users requiring nursing care, The remaining 6 bed spaces to accommodate service users with social care needs only. 10th February 2006 Date of last inspection Brief Description of the Service: Pembroke House provides residential and nursing care to former Royal Naval Ratings, other ranks from the Royal Marines, their wives and widows. The Royal Naval Benevolent Trust, a charitable non-profit making organisation owns and manages the home. Pembroke House is a large detached property located in a residential area of Gillingham, Kent and within walking distance of shops and a large local park. Public transport, offering rail and bus links are located approximately half a mile away. The home was originally built in the 1920s, and was extended and modernised in the year 2000 and now offers accommodation for up to fifty service users. All residents’ rooms have en suite toilet facilities and are fitted with television and telephone points. Resident accommodation is arranged over three floors and is served by two passenger lifts. 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, which overlook the extensive rear gardens. The home’s gardens are all wheel chair accessible. On the top floor there is a large day room, known as The Bridge, which provides impressive views over the river. There is dedicated parking to the side of the home for visitors. The home employs registered nurses and care staff working a roster, which provides 24-hour cover. A full time activities co-ordinator and ancillary staff for administration, catering, domestic duties, garden and property maintenance support them. As from the 1st May 2007 fees range from £368 to £399 for residential care and from £557 to £652 for nursing care. Charges are made according to assessed personal need. Please contact the manager for more information. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector between 09:45 am and 5:30 pm. During that time the inspector spoke with some residents, relatives, the manager, one of her deputy managers, the home’s administration manager and some of the staff on duty. Some judgements about the quality of life within the home were taken from observations and conversation. Some records and documents were looked at. In addition, a tour of the building was undertaken. Survey responses regarding the service provided at the home were received by the Commission following the inspection. Responses from residents, relatives and health professionals indicated they were generally very satisfied with the standard of care the home provided. Statements on comment cards included: “We are very happy with Pembroke House and grateful for the care and help received” “The home provides a good level of care” And “An exceptional level of love and care is unstintingly offered. Opportunities for residents to take part in activities outside the home are regularly arranged which makes all the difference.” The manager and staff gave their full co-operation throughout the site visit. What the service does well: This was a very positive inspection with the home able to demonstrate throughout the day the provision of good care practices and a firm commitment to meeting the needs of people living in the home together with the promotion of their independence and dignity. The manager continues to maintain an above average staff to resident ratio, which is clearly to residents benefit. The home has shown considerable investment and a high level of commitment to providing staff with sufficient skills and knowledge to ensure that residents are well cared for. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 6 The service provides a very comfortable and homely environment internally with extensive and attractive outside areas that stimulate and meet people’s needs. The property continues to be well maintained and is nicely decorated with ongoing maintenance and refurbishment programmes in place. Activities remain a high priority within the home and a full time activities coordinator is employed. Activities are aimed at promoting and meeting the specific interests of those people living in the home. The involvement of the residents and their relatives or representatives is actively encouraged in all matters relating to the running of the home which ensures the service is provided and developed with residents best interests to the fore. Where areas for improvement emerge in quality assurance exercises the home recognises and manages them well. The home has a sustained track record of high performance. What has improved since the last inspection? The home is surrounded by its own gardens and a major project undertaken during the last year has been the landscaping of the walled garden and approaches to it. This has now been transformed into a really beautiful and tranquil area where service users can walk, sit and spend their time when the weather is good. Residents on the nursing service floor now have automatic door closures fitted to their bedroom doors linked directly to the fire alarm system. This enables them to decide if they wish to keep their doors open during nighttime hours for instance without compromising their safety. The home has plans to extend this facility to all residents’ bedroom doors. A new hoist with ceiling tracking has been fitted to one of the nursing floor communal bathrooms. It is proposed that this system, which is designed to assist with residents moving and handling transfers, will be further extended throughout the home. Residents Pre admission assessment documentation has been further developed to support the senior staff efforts in clearly identifying prospective residents care needs before admission and which subsequently assist them to appropriately plan for that person in advance of their arrival at the home. Following a good practice recommendation made at the last inspection the home now ensures that offices on each service floor are left secure if the room is unoccupied to protect service users information. A committee involving residents, management, care staff and catering colleagues has been set up to look specifically at the food offered in the home and to improve the dining experience. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 7 The home has recently revised the staff induction programmes to ensure content meets fully with the good practice guidance issued by The Skills for Care Council and reflects the specific nature and uniqueness of the home and its stated aims and objectives. 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 House DS0000037718.V330204.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 123456 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service largely have all the information they need to make an informed decision about whether the service is right for them. The personalised pre admission assessment means that residents’ diverse needs are identified and planned before they move into the home and they are given a contract that clearly tells them about the service they will receive. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. The home’s Information documents are reviewed and regularly revised to ensure that information provided is kept up to date. Both documents could be improved upon by the introduction of a printed review date to evidence they are current. Content met all the requirements of regulation however; a minor change Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 10 needs to be made to the list of key personnel in the Service User Guide as some recent changes have taken place. Due to the diverse geographic nature of the prospective service group catered for by the home, they may find that other information formats could also be beneficial to people accessing the service. Such as a video or photographs being included in information documents together with comments and experiences of people already in receipt of services. The home has a clear process for undertaking pre admission assessments. The manager or other qualified member of staff visits the prospective resident to make a decision about whether the home can meet the person’s needs. Information is also obtained from other parties, including relevant health care professionals and care management assessments undertaken before a final decision is made and shared with the prospective resident. Pembroke House is the only older peoples nursing and residential service owned and operated by the Royal Naval Benevolent Trust nationally. They may from time to time have individuals referred to them from other agencies across the country dealing with the needs of ex service personnel and their families. In this instance geographic distance may prevent the home’s staff from visiting the prospective resident and initial interviews are carried out over the telephone. The manager stated that this can sometimes prove to be problematic but the same process for obtaining sufficient additional information from other parties is undertaken and a trail visit to the home would be arranged for the person. The manager stated trial visits are always enabled to ensure that prospective residents and their relatives and friends have an opportunity to assess the quality, facilities and suitability of the home before a firm decision to stay is made. Significant time and effort is spent by the staff making admission to the home personal and well managed. Survey respondents evidenced that a high value is placed on responding to individual need for information, reassurance and support by the home. Pre admission assessments and additional information gained form the basis for all residents care plans in the home. Additional assessments are made when the person is admitted to ensure their needs will be fully met. Each residents or their representative is provided with a contract between the home and themselves. Contracts are comprehensive with fees to be charged in evidence. The home’s contracts clearly state the responsibilities of the home and the rights of the resident. Intermediate care is not offered at Pembroke House. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 11 Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 12 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 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are clearly set out in their care plans ensuring that these needs will be met. Residents are protected by the home’s policies and procedures regarding medication and they can be confident that these will be regularly reviewed in light of good practice advice. The principles of respect, dignity and privacy are consistently put into practice in the home and people’s independence is promoted. Residents’ benefit from being consulted regarding their wishes concerning serious illness, end of life care and arrangements after death. EVIDENCE: Each resident has a care plan. Three were inspected in detail and were found to be comprehensive, detailed and contained consistent information based on Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 13 sound assessment. Care plans were signed by the resident or their representative to show their involvement with the formulation of the plan and their agreement to it. The format used includes residents’ social care needs and their choices and preferences in daily life. Care plans were seen to have been regularly reviewed and changes made where necessary to the main plan. Daily records were largely being maintained appropriately and reflected care plan demands. Some terminology used by nurses in daily records could be improved upon. This was discussed with the deputy manager who stated her intention to address this minor concern. Care plans included residents’ wishes for serious illness, end of life care and arrangements to be made after death. The home approaches end of life care and arrangements after death with great sensitivity, dignity and respect for the individual, their relatives and friends. Risk assessments were in place for a variety of aspects of care. Attention was paid to the prevention of falls, the management of pain, maintaining skin integrity and the moving and handling needs of residents, amongst others. Discussions with the manager and nursing staff clearly indicated that residents’ health needs are closely monitored and responded to. Some individual’s health care needs are quite complex; care plans evidenced timely input from other health care professionals involved with their care. Residents are weighed regularly and this is recorded as part of their ongoing assessment and review procedure. Staff from the local PCT regularly audited care plans maintained in the home for comprehensiveness and consistency. The manager welcomed their involvement and honest and constructive feedback. The home has three medication stores. A monitored dosage system for dispensing medication is used for the residential service and trained care staff can administer these medicines. Trained nurses administer from dispensed containers on the nursing floor. Temperatures were regularly taken of medication storage areas, including cold storage and records were being maintained. Some discussion took place in regard to minor improvements that should be made to the way cold storage temperatures are being recorded. The home has designated lockable medication fridges. The one inspected was slightly iced and could have caused holding temperatures to be increased to the higher range limit. Medication fridges should be regularly defrosted. Some medication administration sheets were inspected. No gaps in recording administration to residents were found. The home had a current medication policy and nurses and care staff has access to additional guidance documents. Residents prescribed medication is reviewed by their GP regularly or upon request. Homely remedies available to residents are agreed individually with their GP. The home has a contract for the disposal of all waste medicine. Medication in the home was handled competently and professionally. The Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 14 inspector was confident that areas of good practice advice would be acted upon. Care plans contained information about how a resident might prefer to be addressed. Staff was observed to be respectful when speaking to residents and good interaction was seen between staff, residents and their visitors. Personal care is given in a way that clients are known to prefer. Following a good practice recommendation made at the last inspection residents’ privileged and sensitive personal information kept in service area offices is now kept securely at all times. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 15 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. Social activities and opportunities for mental stimulation are well managed and as much as possible provide daily variation and interest for people living in the home. Residents are enabled to maintain contact with friends and family who are always made welcome. Wherever possible residents are given opportunities to make choices, therefore allowing for an important level of control over their lives. The home is innovative in the way it supports residents to be involved in menu planning. EVIDENCE: Information about residents past work, interests and hobbies are noted on care plans. Daily living routines and preferences are also recorded if known. Routines in the home are flexible and varied to suit residents’ wishes where it Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 16 is practicable. The home operates a key worker system, which enables closer resident/staff relationships where likes, dislikes and needs are shared. Activities and opportunities for stimulation within the home and the greater community continue to be considered a very important part of residents’ lives. To this end they offer a comprehensive and varied activities programme and employ a full time dedicated activities organiser. Highlights of the activity programme have included a garden party at Buckingham Palace and a visit to St James Palace, both arranged by the Not Forgotten Association. There are numerous invitations received to social events offered by branches of the Royal Naval Association and others. In the summer, the All England Lawn Tennis Club provides centre court seats at Wimbledon. There is a plentiful supply of leisure/recreational amenities available to residents such as TV’s, videos, books, jigsaws, board games, snooker table, music cassettes, radios etc. Some residents’ choose not join in formal activities or are too frail to consider it, others prefer to keep to their rooms, and this decision is respected by the home. The activities programme however provides meaningful and stimulating opportunities for those wishing to take part. The home has its own minibus donated by the Royal Naval Association. This is replaced with a new one by the association every four to five years. This year the RNA has also donated a smaller car adapted for residents use which is suitable for more individualised outings and can for instance be used for residents who need to attend medical appointments. It can accommodate three people and has wheelchair facilities. Visits out to places of interest are arranged for residents as well as regular shopping and library trips. Visits to local Churches, covering all religious denominations also take place. Family and friends said they always felt welcome and knew they could visit the home at any reasonable time. Relatives are asked to avoid meal times if at all possible. There are areas within the home, which residents may use to receive and entertain their guests as well as utilising the privacy of their own rooms if they wish. The home’s policy is to encourage the involvement of residents’ relatives who are known as ‘Friends of Pembroke House’. Volunteers generously help out with planned functions, trips out and regular activities. There are regular residents and relatives meetings with minutes kept. The manager emphasised how important maintaining good communication was in the home. The home’s catering staff are experienced in cooking for older people and considered to be important members of the care team. Residents were aware of their right to make menu choices and how to organise that with staff. A visitor said, “my relative is given a choice of what they are having next day and a menu is always on display.” The home is currently seeking ways to Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 17 improve food offered to residents with swallowing difficulties and who require a specialist diet. A current review of menus is underway with a committee set up that includes some residents, care and catering staff, and management and is known as ‘The committee for improving the dining experience.’ Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 18 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. Residents are protected from potential abuse and have access to a clear complaints procedure which they or their representatives understand and know how to use. They further benefit from having their views and concerns listened to informally and acted upon without delay. EVIDENCE: The home has received three complaints since the last inspection. Two were substantiated and one partly substantiated. All were dealt with appropriately and professionally within the 28-day timescale published in the home’s complaints procedure. Records are kept of investigations undertaken and clear outcomes are detailed including any action that has been taken as a result of a complaint. Staff training records for attendance at adult safeguarding courses were in evidence. The home’s induction procedures for new staff provide a comprehensive overview of adult safeguarding issues and information on ‘whistle blowing’. There are procedures in place for responding to suspicion or evidence of abuse and neglect to ensure the safety of residents. The manager and deputy manager evidenced a sound knowledge of adult safeguarding procedures. The home has a copy of Kent & Medway’s revised adult protection Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 19 policy document and bases its own safeguarding procedures on this. Staff spoken with was aware of how important it is to listen and pass on any concerns at an early stage to ensure residents feel safe and secure in the home. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 20 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a safe, well maintained, and clean environment in which good standards of décor and furnishings are maintained. EVIDENCE: The home’s layout and location is suitable for its stated purpose. A partial tour of the building was undertaken with the deputy manager. All residents’ bedrooms have en suite toilet facilities and are fitted with television and telephone points. Resident accommodation is arranged over three floors and is served by two passenger lifts. 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, which overlook extensive and attractive rear Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 21 gardens. The home’s gardens are wheel chair accessible. On the top floor there is a large day room known as The Bridge, which provides impressive views across the River Medway to the Thames estuary and beyond. The room is well used by people who live in the home. The environment continues to be well maintained. Both communal areas and residents’ bedrooms are nicely decorated and very clean. The bathroom on the nursing floor appears a little clinical in appearance however the manager has plans to make some areas more homely. Bathrooms were well equipped. A new mobile hoist with ceiling tracking has been installed in the communal nursing floor bathroom, which will benefit residents. The manager has plans to extend the tracking elsewhere in the home over time. Mobile hoists for the safe transfer of residents were in evidence elsewhere. Staff were properly trained in their use. Residents had individual mobility equipment, which was also being well maintained. No unpleasant odour was present anywhere in the home. There is sufficient domestic staff employed. One-survey respondents said, “I find the cleaning staff to be very good indeed.” Residents and relatives spoken with liked the home and felt that it fully met their needs. One resident said, “It is an exceptional and quite unique place” The home’s manager, administration manager and handyman are effective in ensuring functionality, safety and the effectiveness of plant and specialist equipment in the home. Regular maintenance and servicing plans are arranged and adhered to. The home has an infection control policy, which is closely adhered to. Paper towels and liquid soap were in evidence in all communal toilets and bathrooms. The home has a long-term problem with an uneven floor in the entrance/ reception area of the home. The manager explained that this will soon be resolved, the work required is now out to tender. The home has recently invited the Health & Safety Executive to advise them on actions they can take to limit any risk to residents and visitors in the meantime. An officer visited and gave advice, but was not unduly concerned and felt the home was already managing the situation well. The home was originally built in the 1920’s and therefore some major refurbishment work will need to be done in the not to distant future. For instance, there has been a recent drain and roof inspection completed. Work required will be undertaken as necessary and on a rolling programme of refurbishment. The manager stated there is currently no need for immediate work to be done. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a dedicated substantive staff team who are well supported and supervised. They would further benefit by agency staff who are used being fully aware of their identified needs and care plan content to ensure continuity of care. The home continues to effectively train and develop its staff to ensure residents’ needs are met at all times. Residents are protected from any potential abuse by the home’s robust recruitment procedures. EVIDENCE: Staff rosters are well planned and appropriate cover is generally well maintained in the home. Commendably the establishment’s current staffing levels exceed that recommended by The Department of Health’s residential staffing formula. The manager said that on occasions vacant roster hours have to be covered by the use of agency staff. A number of survey respondents felt that agency staff are sometimes not well informed of residents needs and are not sufficiently aware of the content of residents care Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 23 plans. Responses have been discussed with the manager and in line with other minor shortfalls the inspector is confident that the home will resolve the matter to the residents benefit and relatives satisfaction. The home provides agency staff with a comprehensive general induction to the home and they, as other permanent staff, continue to be led and supervised by trained nurses during their practice. The home must ensure however that the process is further developed and agency staff are made aware of the residents individual needs before they are deployed on specific service floors. They must fully understand the content of the care plans for the individuals they are caring for. The home is dedicated to maintaining a well-trained and supported staff group. Induction procedures for all staff are in line with Skills for Care standards and foundation training for staff is arranged by the home. Obtaining National Vocational Qualifications in care for all staff is actively encouraged. The home has some staff nearing retirement that are reluctant to gain the qualification. New staff are however expected to satisfactorily complete the course. The home just exceeds 50 of trained care staff. A number of the staff group are obviously trained nurses, which adds to the current quality of the care provision. Some catering staff has commendably completed NVQ in catering Level 2 and are applying for Level 3. Staff records were being comprehensively maintained. Supervision and annual appraisal records were in evidence for staff. Formal and informal supervision practices are in place in the home. Training certificates gained were seen in staff files. The home could evidence safe and robust recruitment procedures. All staff had a current CRB and POVA check in place. The senior staff responsible for recruiting understands the importance of making sufficient checks and follow sound interview processes to protect their residents from any potential for harm. In line with a good practice recommendation made at the last inspection the manager recognises people who use services should be actively and positively involved in the choice of new staff and their subsequent training. She would like to include some residents in future recruitment drives and this was discussed on the day of the site visit. The manager continues to gain support for this process to be established at Pembroke House with the home’s provider. Residents and their relatives spoke highly of the permanent staff team and felt they understood the specific nature and uniqueness of the home. Survey responses indicated that staff were kind, caring and skilled. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 24 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 36 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from an experienced and competent manager who is able to discharge her responsibilities fully and therefore provides an excellent role model. Residents further benefit from a strong permanent staff team that receive regular formal and informal supervision and identification of their training needs. Residents’ financial interests are protected and their welfare promoted through regular maintenance and equipment safety checks. Policies, procedures and systems of work are in place, which support the best interests of residents. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 25 EVIDENCE: Throughout the inspection the manager evidenced that she clearly understood her responsibilities to regulation and was able to discharge her duties appropriately. She was open and transparently honest and was seen to communicate a clear sense of leadership and direction to staff. She is well supported by two deputy managers and a recently appointed administration manager. There are clear lines of responsibity and accountability within the home and with external management. The RNBT has recently appointed a new Responsible Individual for Pembroke House. The manager is in the process of formally notifying the Commission. Residents and relatives responses said they felt the manager to be very approachable, understanding and professional. The manager is a trained nurse with many years experience in both the health care arena and management. She is qualified to NVQ Level 4 in management and care and has managed Pembroke House effectively for many years. Her personal investment and commitment to developing the home and her staff has been commendable. Staff indicated that they felt part of an effective and efficient team and this was due to the way the home was managed. The manager is commendably able to lead by example and much of the home’s current good practice comes from her sound leadership skills. The home is dedicated to maintaining a welltrained and supported staff group. Supervision and annual appraisal records were in evidence for staff. Formal and informal supervision practices are in place in the home. Training certificates gained were seen in staff files. The home’s record keeping is effective and efficient with reviews of policies, procedures and systems of work being undertaken annually or more regularly if situations demand it to ensure they reflect current legislation and up to date good practice guidelines. Records were seen to be kept in a manner that preserved confidentiality and safeguarded residents’ rights and best interests. The manager is instrumental in quality assuring the service and understands the principles of equal opportunity and diversity and applies the concept to her practice with residents and staff. She was able to evidence a high level of commitment to ensuring the health, welfare and safety of residents, visitors and staff. Residents or their representatives are encouraged to manage their personal money and valuables without the home’s involvement. Where they are unable to or prefer the home to keep allowance money for safekeeping, there are Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 26 sound records maintained of money that is kept in the home’s safe - i.e. for hairdressing etc. This is however minimal. Neither residents nor their families expressed any concerns about the home’s management of monies or valuables. Records evidenced that staff had regular fire training and participated in fire drills at the required frequency. Fire exits were kept clear of obstructions and fire fighting equipment regularly serviced and maintained. The home has plans to extend automatic door closures linked to the fire alarm system to all residents’ bedroom doors. They are currently fitted to doors on the nursing floor only. The manager evidenced within comprehensive pre inspection data supplied to the Commission and on the day of the site visit, that all records of maintenance and safety checks were up to date in the home. Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 3 X 3 Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 28 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 Home’s 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 OP28 Good Practice Recommendations It is strongly recommended that the use of agency staff does not prevent service users from receiving a continuity of care that fully meets their identified needs. The home must establish a process, which ensures agency staff are made sufficiently aware of residents needs and the content of their care plan. It is a good practice recommendation that the home considers involving service users in the choice of new staff appointed and their opinions gained during the process are acted upon. 2. OP29 Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pembroke House DS0000037718.V330204.R01.S.doc Version 5.2 Page 30 - 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. 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