Inspection on 14/08/08 for Pembroke Lodge

This inspection was carried out on 14th August 2008.

CSCI found this care home to be providing an Adequate service.

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 14/09/06

Pembroke Lodge 03/02/06

Pembroke Lodge 15/08/05

Pembroke Lodge 01/02/05

Pembroke Lodge 02/08/04

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Pembroke Lodge 8/10 Aymer Road Hove East Sussex BN3 4GA Lead Inspector Judy Gossedge Unannounced Inspection 14th August 2008 10:10 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 Lodge DS0000014224.V369274.R02.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 Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 8/10 Aymer Road Hove East Sussex BN3 4GA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 777286 01273 779069 admin@pembrokelodgeresthome.co.uk Mr L Brand Mrs Susan Brand Anura R Ponnamperumage Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number to be accommodated is nineteen (19) Date of last inspection 14th September 2006 Brief Description of the Service: Pembroke Lodge is a privately run care home registered for up to 19 older people. It offers hotel style accommodation to people aged over 65 who are independent and mobile. It does not provide nursing care. The detached building is situated close to the seafront and town centre of Hove, with all local amenities and transport routes conveniently nearby. Accommodation is on three floors with access via a passenger lift: all bedrooms are en-suite. There are two lounges, the larger one located on the ground floor and another, smaller one on the first floor. Paid parking is available in the streets around the home. The service is aimed at retired people who wish to maintain an independent lifestyle and continue to live their lives to their maximum potential. The home has achieved various awards, including ‘5 stars on the doors’ awarded by Brighton & Hove Environmental Health Department; Investors in People and Residential Domiciliary Benchmark star rating. The current fees are from £425.00 to £525.00 per week. Chiropody, hairdressing and complimentary therapies are additionally extras. At the time of the Inspection a copy of the homes Statement of Purpose/ Service User Guide was available for reference. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Since the last Inspection an Annual Service Review has been completed. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key Inspection. The Provider had been asked to complete an Annual Quality Assurance Assessment (AQAA) used for the Annual Service Review, and the Manager updated the information in the AQAA during the Inspection, which is quoted in this report. This unannounced Inspection took place over five and a half hours on 14 August 2008. A tour of the premises took place to look at communal areas and a selection of resident’s bedrooms and care records were inspected. Eleven people were resident and three were spoken with individually in their bedroom and a number were spoken with as part of the Inspection process. The care that three of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. Eight residents surveys were sent out and six came back completed. Two care workers; the cook, the domestic support, the provider and the Manager were all spoken with. Six care workers surveys were sent out and three completed surveys were returned. The home has been through a period of change with a number of staff changes and a new Registered Manager working with staff to implement a number of changes to the policies and procedures followed. What the service does well: The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident in the home. Residents spoke positively about their experiences at the home. The staff was observed to deliver care with dignity and respect. The three residents spoken with felt the care provided respected their privacy and dignity. Four residents surveys stated they always received the care and support they needed and two stated usually, and one comment received from a resident was,’ I have lived here for many years and am very happy.’ Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 6 100 of care workers have achieved NVQ Level 2 in care. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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 Lodge DS0000014224.V369274.R02.S.doc Version 5.2 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 Lodge DS0000014224.V369274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is information available for residents and/or their representatives to view, although it must be ensured that it details all the required information. Potential new residents are individually assessed prior to an admission to ensure that their care needs can be met in the home. Intermediate care is not provided in the home. EVIDENCE: The Statement of Purpose/Service User’s Guide and was read during the Inspection. Currently these documents do not detail all the information to be included and as detailed within Schedule 1 of the Care Standards Regulations and are in need of review. The AQAA details a copy of the last Inspection report is available to read in the home. Four residents surveys stated they had received enough information prior to moving in, one had not and one did Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 9 not answer the question. Comments received were, ‘everything of interest was given to me,’ and ‘we had a general look around, but were given no details on laundry etc.’ The AQAA details that the pre-admission procedure has been improved since the last Inspection having been reviewed to get more information about the potential resident. The Manager stated that he visits new residents prior to any admission. This is to ensure individual resident’s care needs can be met in the home and to provide staff with information on the care to be provided. A detailed pre-admissions format has been put in place, and for one new resident admitted to the home since the last Inspection there was detailed preadmission information viewed, which had been completed. Intermediate care is not provided in the home. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 9. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by a detailed individual plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care, which needs to be provided. Supporting risk assessments need to be further developed. Medication policies and procedures are in place, but evidence that all staff have received medication training should be in place. EVIDENCE: The Manager stated a new detailed care plan format has been introduced in to the home and all care plans have been updated. Four of the residents individual care plans were viewed and are kept in well-structured folders. These were detailed and gave clear guidance to staff of the care to be provided, resident’s health care requirements, dietary needs, and social and leisure interests. Supporting risk assessments were also viewed and where there are any identified risks the recording detailed how these will be Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 11 managed. Risk assessments need to be further developed to fully demonstrate all residents have a falls risk assessment completed. A number of residents go out independently from the home and supporting risk assessments were not in place. All these documents had been reviewed. The three staff surveys responses varied and stated they always, usually and sometimes have up-todate information about residents care needs. The AQAA details that the home maintains and promotes residents health and help them access health care services to meet their needs. Records viewed evidenced residents are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Residents spoken with confirmed good access to their GP and one visited the dentist during the Inspection. Five resident’s surveys stated they always received the medical support they needed and one usually. The AQAA details the home has a policy for the handling of medication which includes receiving, recording, storage, handling, administration and disposal of medicine. Residents are free to self medicate under the management risk assessment framework. None of the residents self medicated at the time of the Inspection, though staff confirmed that the home had only recently taken over the administration of one resident’s medication. Medication is stored in a locked trolley, or in the office and sample of the recording of medication administered was viewed. Changes in the requirements for the storage of control drugs was discussed with the proprietor and the Manager and a Requirement made for the necessary changes to be implemented. The record was viewed of the pharmacist last visit. The care worker spoken with confirmed they had received medication training. The Manager was not able to evidence all staff had received medication training and stated he was looking into opportunities to ensure staff had received up-to-date training if required. The three resident’s spoken with felt that their medical care needs were met in the home. The staff was observed to deliver care with dignity and respect. The three residents spoken with felt the care provided respected their privacy and dignity. Four residents surveys stated they always received the care and support they needed and two stated usually, and one comment received from a resident was,’ I have lived here for many years and am very happy.’ Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible residents are enabled to exercise choice in their lives whist resident in the home, there are some opportunities to participate in social and recreational activities provided which would benefit from further development, residents are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: Residents social interests are recorded on their individual care plans and the AQAA detailed that it is planned to arrange outings for residents and organise external activity programmes. On the day of the Inspection there were no activities arranged in the home. The resident’s surveys were varied and stated that activities were always, usually or sometimes arranged. Comments received were,’ there are usually activities, but I am happy to stay in my room,’ ‘I would welcome more activities’ and ‘ I enjoy music, singing and company.’ Several residents go out on their own and others go out with friends and family members. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 13 The AQAA details that residents are free to have visitors at any reasonable time. The three residents spoken with confirmed there was flexible visiting, that staff are very welcoming and they could see their relative/friend in private if they wished. The care and support provided was observed to enable residents where possible to exercise choice whilst at Pembroke Lodge. The four residents files viewed, staff and the three residents spoken with confirmed this. The cook was spoken with, who works four days a week and stated she holds a basic food hygiene certificate. A further cook works three days a week and there is a seven day supper cook. A rotating menu is place, which the cook stated is drawn up monthly, and takes into account residents likes and dislikes. It does not identify that choices available at all meals, but staff and residents all confirmed if they do not like what is on the menu there are always a range of alternatives. Lunch on the day was roast lamb with fresh vegetables and trifle. Special diets are catered for. On the day some residents were observed eating their lunch in the dining room and others in their bedroom. It was a relaxed environment taking into account the different length of time that individual residents would need to finish their meal. All the residents spoken with stated they had enjoyed their meal. Records are kept of food consumed individually by each resident to ensure they are receiving an adequate diet. Three residents surveys stated they always liked the meals and three usually. Comments received were, ‘I enjoy the variety of meals,’ ‘the meal was lovely today,’ and ‘the meat is sometimes chewy.’ Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to enable residents or their representatives to raise any concerns about the care being provided and to ensure that residents are protected from abuse. But these should be followed to protect residents. EVIDENCE: There is a detailed complaints policy and procedure in place. The AQAA detailed that a copy of the procedure is given to new residents and that two complaints had been received at the home during the last year. The CSCI have not received any concerns in relation to the care provided at Pembroke Lodge. Feedback from the residents surveys all stated they were aware who to talk to if they were not happy and how to make a complaint. One commented, ‘can speak to anyone if I have a problem.’ All the staff surveys stated they knew what to do if a resident had any concerns The AQAA detailed that there are policies and procedures in place in relation to the safeguarding of vulnerable adults. The Manager stated that a copy of the new East and West Sussex County Council, Brighton and Hove safeguarding adults’ procedures is available to reference in the home. The Manager was not able to evidence all staff had received safeguarding adults training and stated Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 15 he has undertaken ‘train the trainer’ training in safeguarding adults and is aware of the need to ensure staff had received up-to-date training if required. The two care workers spoken with confirmed they had attended this training and demonstrated an awareness of the policies and procedures. As discussed under Standard twenty-nine of this report resident’s are not always safeguarded, as staff is not being fully vetted before working at the home. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 16 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 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides residents with a pleasant and well-maintained environment. The home is clean and tidy. EVIDENCE: The AQAA detailed there is an ongoing external and internal maintenance programme serviced by the homes maintenance person or external contractors. That new external security lights have been installed, further window restrictors provided, a new emergency call system has been installed and a shower room. Some ceiling areas have been damaged, and the Manager stated that this was due to problems with the tiling on the roof, which was about to be repaired after which the ceilings would be redecorated. A tour of the building was made. The home is decorated and furnished in a homely style. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 17 There are sixteen bedrooms on all floors in the home; all were being used as single bedrooms at the time of the Inspection. A number of bedrooms were viewed and displayed resident’s individual styles and interests. The Manager stated there is an ongoing work redecorating and replacing carpets where required. All bedrooms have an emergency call bell system. All of the bedrooms have en-suite facilities of a toilet and wash-hand-basin. Bathroom facilities are provided throughout the home. Residents are able to control the temperature in their own bedrooms. The homes recording of the testing of the hot water temperatures was viewed and detailed that water at the outlets accessed by residents is being maintained at close to 43 º C. The three residents spoken with confirmed there is adequate heating and hot water in the home. A passenger lift is available from the ground floor to the second floor. There is one lounge and a dining room on the ground floor and a smaller lounge on the first floor. Residents have access to a private and well-stocked garden at the rear of the home. Two residents spoke of their enjoyment at sitting out in the garden. The AQAA details that there is a policy in place for managing infection control and that Department of Health Guidance has been used to assess current infection control management. The home was clean and free from offensive odours at the time of the Inspection. Feedback from the resident’s surveys was that the home was always fresh and clean. The domestic assistant was spoken with and who stated he had received training/guidance in infection control or the control of substances hazardous to health regulations (COSHH). The AQAA detailed that infection control training has been facilitated and it is planned more staff will be able to attend this training. Staff confirmed that there was good access to protective clothing, liquid soap and paper towels. Recording was viewed of routine fire checks that had been carried out in the home. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 18 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): 26, 27, 28 and 29. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are recruitment policies and procedures in place, but these need to be followed to protect residents, staff are provided with opportunities for training to develop their skills and ensure the individual care needs of service users can be met, but it should be ensured staff receive training updates as required. The induction training provided to care workers at the start of their employment should be reviewed to ensure it meets current induction standards. EVIDENCE: Staff spoken with and rotas viewed confirmed that one member of care staff is deployed to work in the home during the morning and one during the afternoon. Two domestic staff was on duty during the morning of the Inspection. The Manager stated one of the domestic staff as well as undertaking domestic duties, provides general support not including personal care to the residents. The Manager was also working in the home at the time of the Inspection. At night the home deploys one ‘sleeping in’ member of staff. Staffing levels were discussed with the Manager and the need to ensure the health, safety and welfare of the residents is being met. The Manager stated that staffing levels in the home is kept under review to enable the residents care needs to be met and will be adjusted where required. A morning and Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 19 supper cook is also employed seven days a week. All six of the residents surveys stated staff always listen and act on what residents say. Four stated they always receive the care and support needed and two usually. Comments received were, ‘staff are good to me,’ and ‘everything satisfactory.’ Care workers surveys stated there was always, usually and sometimes enough staff to meet residents needs, and all stated they always the right support and experience to meet individual residents care needs. When asked what the home does well, comments received were, ‘it supplies a comfortable and homely, supporting surroundings: for the residents that come for respite,’ ‘helps its residents through long or short-term health weakness,’ and ‘resident’s can take personal discreet decision on whether they want to mix and talk with others or not.’ The Manager updated the information in the AQAA detailed that all of the care workers holds an NVQ Level 2 in care and this equates to 100 of the care workers. The AQAA detailed that new staff working in the home had satisfactory preemployment checks. The documentation was viewed for the three new members of staff, who had been recruited since the last Inspection. All demonstrated the completion of an application form, all had two written references in place, but for one member of staff a verbal reference had been sought, but the written reference had not been received until after the member of staff had commenced working in the home. All had completed a Criminal Records Bureau check (CRB)/and a Pova First check, but for two members of staff a POVA First check had not been received prior to staff commencing work in the home. The Manager was not also able to demonstrate that all staff working in the home have had a CRB check undertaken. A sample of staff documentation was viewed and all had had a check completed. The Manager stated that this information will be able to be viewed for future Inspections as further documentation is being put in place. The Manager stated that induction training for new members of staff is in place, but that this had not been checked to ensure it meets the requirements of the General Skills for Care induction standards. The Manager agreed to reference these standards and implement any requirements as necessary, so a Requirement was not made on this occasion. The three care workers surveys stated the induction covered everything they needed to know very well. The Manager stated he is currently updating staff records and ascertaining staff training needs. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 20 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 and 38. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team have strived to create an atmosphere within the home, which is open, relaxed, homely and caring, however shortfalls in some key management responsibilities means some practices do not promote and safeguard the health, safety and welfare of residents. Quality assurance systems are being developed to enable ongoing feedback about the care provided in the home and systems are in place to ensure a safe environment for staff and service users. EVIDENCE: Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 21 There is a Registered Manager in place in the home, who has had previous experience of being a Registered Manager and stated has completed the Registered Managers Award and NVQ Level 4 in Care. Feedback received was that the running of the home was open and transparent and there were opportunities for staff, residents and their representatives to affect the way in which the service is delivered. A quality assurance system is in place. It was evidenced that feedback about the service provided has been sought from residents through residents meetings and surveys. The minutes form the last residents meeting in November 2007 and it was discussed with the Manager to ensure residents have regular opportunities to participate in this forum. Feedback from the outcome of the quality assurance process undertaken in the home has not been collated and should be and available to read in the home. The AQAA detailed that policies and procedures are in place but had not been reviewed. This was discussed with the Manager who stated he was in the process of updating all policies and procedures and this would be completed by the end of the year. Not all the required policies and procedures are in place and this was discussed to also be addressed as part of the review. Records of a monthly visit by a proprietor of the home to meet Regulation 26 were viewed. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. The Manager reported that they do sometimes hold small amounts of money for a few residents, and a sample of the recording for two residents for whom money is kept was viewed and was adequate. Supervision for care staff is in place to meet the requirements of Standard 36. The Manager evidenced a plan for supervisions to be completed during the year and that detailed records are kept. The Manager stated that training records were being updated, and that he is working with all staff to ensure they have received the required training/updates in moving and handling, basic food hygiene, first aid and infection control within the required timescales. That there has been some delay in staff accessing this training due to a period of staff changes and pressures in the home. The care worker spoken with had not attended all the required training updates A detailed check of the environment had been completed and the AQAA detailed that the maintenance of equipment and services has been carried out. The Manager was also able to update the AQAA as further checks have been carried out since its completion. There were records of regular testing of the hot water temperatures at outlets accessed by service users to ensure these are being maintained at close to 43 º C. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 22 None of the radiators within the home are guarded. This matter has been discussed before at previous Inspections and the proprietor has stated that they have installed a specific valve, which does not allow the radiator temperatures to go above 43°C. It was also stated that radiator temperatures were checked on a daily basis by staff. Records viewed during the Inspection did not evidence these had been maintained, which was discussed with the proprietor who stated she would ensure these checks were maintained once the heating system is put on. The Inspector was unable to evidence how this system works, as the radiators were not turned on during this visit due to the weather still being very warm. A Requirement has been made that further guidance is sought from Environmental Health and acted upon to ensure current controls in place are adequate to protect residents. A fire risk assessment in place undertaken by an external agency in 2006. This has not been reviewed since and the Manager agreed to seek advice from the East Sussex Fire and Rescue Service as the required frequency of any review. So a Requirement has not been made on this occasion. Records were viewed of regular checks of the fire procedures in the home Records evidenced that some staff had attended a fire drill in June 2008, but that prior to that no further drills or training had occurred for fifteen months. The proprietor and the Manager stated that this training had not been maintained, but it will now be ensured regular fire drills and training is arranged for staff to meet requirements and that fire training will be facilitated before the end of the year. So a Requirement has not been made on this occasion. The two of the care workers spoken with, one stated they had attended the fire drill and the other stated fire training had been covered in their induction. Recording was viewed of incidents and accidents. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 24 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 OP1 Regulation 6 (a) Requirement That the Statement of Purpose/Service Users Guide is updated to ensure prospective residents/representatives have accurate information to refer to. That the recorded risk assessments in place include a falls risk assessment for all residents and a risk assessment is in place for where residents go out of the home independently. To protect residents and staff. That suitable storage and recording is in place for control drugs to meet the new requirements. To protect residents and staff. That a thorough recruitment and selection process is in place and staff do not commence work in the home before a satisfactory POVA First /CRB check and two written references has been received. To protect residents. That the information gathered for quality monitoring is reported on and made available to interested parties with recorded evidence of action taken in DS0000014224.V369274.R02.S.doc Timescale for action 30/09/08 2. OP7 13(4)(c) 30/09/08 3. OP9 13 (2) 30/11/08 4. OP29 19 (1) (a) (b) 31/08/08 5. OP33 24 30/10/08 Pembroke Lodge Version 5.2 Page 25 response to demonstrate ongoing review and improvement to the quality of care and services in the home. 6. OP38 23 (4) (d) That all staff have received the required training/updates in moving and handling, basic food hygiene, infection control, fire training, protection of vulnerable adults and first aid and this can be evidenced. To protect residents and staff. That further guidance is sought from Environmental Health and the Health and is acted upon to ensure the required controls are in place in relation to the unguarded radiators. To protect residents and staff. 30/10/08 7. OP38 12 (1) 13 (5) 30/09/08 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 OP33 Good Practice Recommendations To include relatives and friends in the homes feedback surveys. Pembroke Lodge DS0000014224.V369274.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone 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. 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