Inspection on 14/09/06 for Pembroke Lodge

This inspection was carried out on 14th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pembroke Lodge 14/08/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pembroke Lodge 8/10 Aymer Road Hove East Sussex BN3 4GA Lead Inspector Merle Blakeley Key Unannounced Inspection 14th September 2006 10:00 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.V306835.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 Lodge DS0000014224.V306835.R01.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 Mr L Brand Mrs Susan Brand Joanne Lea Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19). Service users should be aged sixty-five (65) years or over on admission. 3rd February 2006 Date of last inspection 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 lift: all rooms 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 the Clean Food Award; Investors in People and Residential Domiciliary Benchmark star rating. The current fees are from £350.00 to £520.00 per week. Chiropody, hairdressing and complimentary therapies are additionally extras. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of seven hours on September 14th 2006. As well as this site visit information was also gained from a pre-inspection questionnaire, feedback survey forms from residents, informal talks with seven residents, one visitor, three staff and the manager. The site visit consisted of a tour of the premises, looking at the needs of five residents, lunch with residents, document reading and observing staff interactions with residents. There are currently thirteen residents living at Pembroke Lodge. What the service does well: What has improved since the last inspection? The home has addressed the requirements that were made during the last inspection. Residents who self medicate are having more frequent and regular reviews carried out. Hot water temperatures are tested regularly and window restrictors have been installed in certain rooms. Fire safety door guards have been fitted to doors in the corridor, dining room, kitchen and several resident’s bedrooms. Up to date gas and electric certificates have been supplied. A new manual hoist has been fitted in the ground floor bathroom and new carpet has been laid in three of the bedrooms. The manager has successfully completed the Registered Managers Award (RMA). Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pembroke Lodge DS0000014224.V306835.R01.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.V306835.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out an assessment on all prospective residents. EVIDENCE: All prospective residents have an assessment carried out on them before they move into the home. This is to ensure that the home can meet their needs. Assessments are carried out either at the care home or in the person’s own environment. This assessment will then form part of their plan for continuing care. The homes service users guide has just recently been updated in September 2006. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are informative and up to date. Resident’s healthcare needs are being met. Medication is being appropriately administered. Residents are treated respectfully. EVIDENCE: Several care plans were viewed and they were found to be informative and up to date. Recent reviews had been carried out on 1st September 2006. Resident’s healthcare needs appear to be well met and written records were viewed. Residents who were spoken with stated that the home would ‘get the doctor in’ if necessary and make sure they have access to all healthcare facilities. District nurses visit when necessary. A chiropodist visits the home on a regular basis. All residents are registered with their own doctor. Medication records were checked and the home is competently administering medications. One resident self medicates and a risk assessment has been carried and is reviewed on a regular basis. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 10 During the day staff were observed interacting with residents. Residents were seen being treated with dignity and respect. All the residents that were spoken to on the day stated that they got on well with the staff team and felt they were treated well by them. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are happy with their current lifestyles in the home. Visitors are welcome in the home. Residents are able to make their own choices. Most residents are happy with the meals that are provided. EVIDENCE: Residents are able to be involved with a few indoor activities such as board games, bingo etc. A member of staff was organising more activities but there was not a lot of interest from the residents. Several stated that they were happy with their own company and did not wish to participate in activities. Several residents go out on their own and during the week others go out with friends and family members. Visitors are made very welcome in the home and they can visit at most times of the day. There are no visiting restrictions and visitors are invited to stay for meals if they wish. During this site visit a visitor was spoken to and they said that the home was ‘very friendly’ and they felt that their relative was being ‘well cared for’. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 12 Several residents were asked as to whether they felt they could make choices and decisions about their lives and they all responded that they could. The home has a reasonably flexible routine, so residents can make daily choices about how they wish to spend their day. Some also said that staff would help them if they had any difficult choices or decisions to make. Residents were asked about the food that the home offers and the majority stated that they were very happy with the meals and felt they had choices about what they eat. Some did say that they found some of the dishes a little too rich for them. A tour of the kitchen was carried out and the inspector had a brief chat with the cook. Meals are cooked freshly each day with local seasonal produce. Vegetarian meals are available and these are also cooked fresh each day. Cakes and deserts are also all home made. Most of the staff team have attended training in food hygiene. The kitchen was clean and well organised. The inspector was able to join residents for a very enjoyable lunch. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an efficient complaints procedure. There is an adult protection policy and procedure. EVIDENCE: The homes complaints record was viewed and a number of minor in-house complaints had been made. These were minor issues between residents, which had been dealt with quickly and efficiently by the home. The home has produced an adult protection policy and procedure and a ‘whistle blowing’ policy. All staff have attended training in the protection of vulnerable adults. There are no current adult protection issues. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. 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 home has a very comfortable and relaxed atmosphere. The home is well furnished throughout and has a very pleasant rear garden area. All bedrooms are en suite and they are maintained to a good standard and residents are able to bring in their own small pieces of furniture and other possessions. A manual hoist has been recently fitted into the first floor bathroom and new carpets have been laid in three of the bedrooms. Window restrictors are installed in certain rooms. During this visit the home was found to be very clean and tidy. The home employs a full time domestic worker. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 15 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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs adequate staff. Three staff hold NVQ care qualifications. A good level of training is offered. Some staff recruitment files do not contain all the required information. EVIDENCE: The usual staffing pattern for the home is two care staff, the cook and domestic employed for the morning shift, two care staff in the afternoon and one sleeping in night staff. Current residents needs are quite low and most only need assistance with bathing. There is one staff vacancy at present and during this visit to the home there were two staff away on annual leave/sick leave, so the home was using two agency staff as cover. If the home does use agency staff then they like to keep the same people who know the residents and both agency staff were familiar with the home. An agency cook is also being used at present but he is due to become part of the permanent staff team. Three staff have obtained NVQ care qualifications and two other staff members are due to commence NVQ training later this year. Records showed that staff are receiving a good level of training, which has included moving and handling, fire safety, first aid, care & control of medicines, managing relationships and protection of vulnerable adults. A yearly training programme is displayed and further training this year will include skills for life, visual impairment awareness, and communication and infection control. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 16 Recruitment files were viewed and some were missing certain pieces of information. One file did not contain proof of identity, one did not contain two references and another did not have a recent photo of the staff member. Regular supervision sessions are being carried out. Two staff members were spoken to during the day and both stated that they were happy working at Pembroke Lodge and felt well supported by the manager and proprietors. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a fully qualified and competent manager. A quality assurance programme is in place. Resident’s finances are safeguarded. The home continues to promote the health & safety of both residents and staff. EVIDENCE: The manager has fifteen years experience of working in the care industry and has obtained the NVQ Level 4 qualification in care. In May 2006 she successfully completed the Registered Managers Award (RMA). The manager spends a lot of time with the residents and knows them all very well. Residents stated that they trusted and liked her and felt they had a good rapport with her. They also said that they could approach the proprietors who were very helpful. The manager also said that she felt well supported by the proprietors. The home appears well run and organised. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 18 The home has a quality assurance programme, which involves sending out surveys to residents to ask about their feelings on food, housekeeping, care and activities. The home would also benefit from sending surveys out to relatives and friends who could also provide feedback about how the home is being run. Regulation 26 Visits are carried out by the proprietors to ensure the home continues to meet its aims and objectives. The proprietors and the manager also carry out internal quality audits and the home has been credited with the Investors in People Award. The vast majority of residents manage their own finances with the help of relatives or friends. One resident has a staff member as an appointee and her finances were checked and found to be in order. Residents are supported and encouraged where possible to maintain their own finances. The pre-inspection information revealed that all health & safety checks are being adhered to. Regular fire drills are carried out and hot water temperatures and emergency lighting are checked very regularly. The only issue raised was that none of the radiators within the home are covered. This matter has been discussed before with previous inspectors and the proprietors have 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. 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. The home will be asked to continue to ensure that all radiators and pipe work remain ‘cool touch’ and do not present any risk to residents. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP29 OP38 Regulation Schedule 2 13(4)(c) Requirement That all staff recruitment files contain the required information. That the home ensures that all radiators remain as ‘cool touch’ and are risk assessed where necessary. Timescale for action 12/10/06 12/10/06 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. Refer to Standard OP33 Good Practice Recommendations To include relatives and friends in the homes feedback surveys. Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Lodge DS0000014224.V306835.R01.S.doc Version 5.2 Page 22 - 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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