Inspection on 13/03/06 for Pembroke Lodge

This inspection was carried out on 13th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pembroke Lodge 01/03/10

Pembroke Lodge 13/02/09

Pembroke Lodge 29/11/07

Pembroke Lodge 27/06/06

Pembroke Lodge 19/04/05

Pembroke Lodge 28/09/04

Pembroke Lodge 19/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pembroke Lodge 32 Alexandra Road Reading Berkshire RG1 5PF Lead Inspector Sally Newman Unannounced Inspection 13th March 2006 10:50 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 DS0000011114.V279766.R02.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. DS0000011114.V279766.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 32 Alexandra Road Reading Berkshire RG1 5PF 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) 0118 926 6255 Mr Charles D`Cruz Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000011114.V279766.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th July 2005 Brief Description of the Service: Extract from the Statement of Purpose.Pembroke Lodge is a large adapted Edwardian house, situated near the town centre of Reading. It has 14 bedrooms located over three floors. Toilets and bathrooms are located on each of the three floors, including a bath with integral hoist and shower being available on the first floor. A vertical passenger lift provides access to all floors. Unless the resident so wishes residents using the lift are always accompanied by a member of staff. There is a wheelchair access to the large secluded rear garden, which has well established trees and shrubs. Our experienced gardener ensures that the garden is well maintained throughout the year with a variety of colours and scents. Residents are encouraged to enjoy the garden especially in the warmer months of the year. There is also a large patio area to the front of the garden with an awning to provide shade on those sunny days.The large communal L-shaped lounge is light and airy with the communal TV not dominating the room. Here the residents can enjoy the company of others or retire to the quiet of their own bedrooms if they should so desire. DS0000011114.V279766.R02.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 conducted over the course of a late morning and early afternoon and covered a duration of 4 hours. The inspector was assisted by the deputy Manager and senior staff on duty. The inspector saw a range of paper records and spoke with 3 relatives and a G.P. who were visiting the home. In addition a range of records were seen and staff on duty and 6 service users were spoken to. The focus of this inspection was to follow up previous requirements made at the last inspection and a subsequent additional visit made on 15/7/05. Not all previously made requirements could be followed up because it was not possible to access the relevant paperwork. These requirements have remained and will be followed up at the next inspection. What the service does well: What has improved since the last inspection? The relationships within the management team have improved significantly resulting in greater contentment and improved morale amongst the staff team. DS0000011114.V279766.R02.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. DS0000011114.V279766.R02.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 DS0000011114.V279766.R02.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): Service users moving into the home do have their needs assessed and are assured that these will be met. EVIDENCE: Evidence was provided by the deputy manager which indicated that all new referrals are visited prior to a place being offered. Assessment documentation is completed and a blank format was provided for the inspector. It was noted that completed documentation for the two latest residents was not evident on their care plans. The deputy manager undertook to ensure this documentation was located and stored on the relevant file. There was no written record of the risk assessments undertaken in respect of individual service users, this will be subject to requirement. DS0000011114.V279766.R02.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): Service users health, personal and social care needs are mostly set out in an individual plan of care. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Evidence was provided from discussion with the deputy manager and from perusal of care plans. It was agreed that the recording of service users health care needs could be improved. The deputy manager was confident that sufficient information was maintained in relation to personal and social care needs and she had taken steps to ensure that all care staff were familiar with the specific needs of individuals. Evidence was also provided by discussions with relatives who were confident that the home met the needs of their relatives well. A G.P. visiting a service user confirmed that information provided by the home was comprehensive and appropriate and unnecessary requests for medical intervention had not occurred in his experience. DS0000011114.V279766.R02.S.doc Version 5.1 Page 10 A full audit of the arrangements for medication was not undertaken. The deputy manager confirmed that no current service users self medicate. All staff receive in house training before they undertake administration of medication. Staff records should contain evidence of this training. The deputy manager informed the inspector that she will pursue potential for regular pharmacy audits to commence and re-arrange a planned meeting with the local pharmacist. DS0000011114.V279766.R02.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): Service users are encouraged to exercise choice and control over their lives. EVIDENCE: Evidence was provided from discussion from staff, service users and from visiting relatives. This home prides itself on enabling service users to maintain their independence. An example was provided of a recent service user who had moved into the home with mobility difficulties. In a relatively short space of time the staff team under the direction of the deputy manager had supported this service user to regain some of her previously unused skills. This had resulted in greater self esteem for the service user. DS0000011114.V279766.R02.S.doc Version 5.1 Page 12 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): Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: There is a complaints policy and procedure in place. The complaints log was seen and no entries had been made since the last visit to the home. The deputy manager confirmed that comments and concerns are encouraged and acted upon. Discussion with relatives provided examples of when concerns had been raised action had been taken immediately and to the satisfaction of all. DS0000011114.V279766.R02.S.doc Version 5.1 Page 13 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): No standards under this heading were undertaken on this occasion. EVIDENCE: DS0000011114.V279766.R02.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): No standards under this heading were undertaken on this occasion. EVIDENCE: DS0000011114.V279766.R02.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): No standards were inspected under this heading on this occasion. EVIDENCE: DS0000011114.V279766.R02.S.doc Version 5.1 Page 16 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X DS0000011114.V279766.R02.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? yes 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 OP21 Regulation 23 Requirement To ensure that the excessively hot radiator located in an upstairs bathroom is made safe. No new staff to commence employment until all legally required checks are undertaken. Ensure that written general risk assessments and those applicable to individual service users are available in the home. Timescale for action 31/05/05 2. 3. OP29 OP38 19 12 13/03/06 31/03/06 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 OP3 OP37 Good Practice Recommendations To ensure that all relevant pre-admission documentation is accessible on service users files. To ensure a copy of the relevant standards and regulations is available in the home. DS0000011114.V279766.R02.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000011114.V279766.R02.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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