Inspection on 15/08/05 for Pembroke Lodge

This inspection was carried out on 15th August 2005.

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 14/09/06

Pembroke Lodge 03/02/06

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 James Houston Unannounced 15 August 2005 08:30 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 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 H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 8/10 Aymer Road Hove East Sussex BN3 4GA 01273 777286 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr L Brand Joanne Lea Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (OP), 19 of places Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is nineteen (19). 2. Service users should be aged sixty-five (65)years or over on admission. Date of last inspection 15 February 2005 Brief Description of the Service: Pembroke Lodge is a privately run care home registered for up to 19 older people. It offers hotel style accomodation 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. Accomodation 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. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the fifteenth of August 2005. Before the inspection papers held by the Commission for Social Care Inspection were read, and those standards to be inspected prepared. The inspection in the home took 5.6 hours. A tour was made of most of the premises. A variety of records including four care plans were read. The inspector met the owner, the manager, four staff and eight residents. Twelve residents were being accommodated on the day of the inspection. Since the last inspection the Commission for Social Care Inspection has registered Ms Joanne Lea as the manager of the home. What the service does well: 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. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 7 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 standard(s) 1,3,4,5 and 6. Full information is given to residents and their relatives/ representatives to assist with the decision about admission. The home fully assesses prospective new residents. The home meets the needs of the current resident group. Residents are encouraged to visit the home before admission to assist them with the decision about whether or not to enter the home. EVIDENCE: The home’s combined statement of purpose and service users’ guide were inspected. They contained the required and recommended elements. Minor aspects needing attention were amended during the inspection. A resident said that they had a copy of this document. Records inspected showed that the home obtained care management assessments in respect of residents (where these exist), and that the home conducts its own full needs assessment. Discussion with residents, staff, the manager and the reading of a range of records indicates that the staff individually and collectively have the skills and experience to meet the needs of residents. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 8 Residents said that they had visited the home prior to admission, or known of it. Staff said that a senior member of staff visits prospective residents in the setting where they then are before admission. Emergency admissions are made only rarely. The home does not offer intermediate care. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 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 standard(s) 7,8 and 9. Care plans are well constructed. The healthcare needs of residents are well met. The medication administration systems need early attention. EVIDENCE: Records inspected showed that residents are invited to participate in the process of drawing up and signing their care plans. The manager monitors the care plans weekly. Risk assessments have been drawn up. Records inspected showed that care plans are reviewed monthly. Staff make regular updates as needed. Those entries inspected were found to be up to date and well written. Staff said that they have had guidance as to how to write. Residents said that their health care needs are well met by the home. Some residents have been able to retain their own GP when moving into the home. Staff said that some residents still make their own contacts with their doctor. Residents said that where the home holds their drugs this works well. A pharmacist visits the home quarterly to inspect the home’s systems and the most recent report was satisfactory. Controlled drugs are held in accordance with the provisions of this standard. A resident self medicates. Arrangements must be made to ensure the secure holding of this medication. The medicine administration sheets were not fully recorded. Records inspected showed that staff have had suitable training. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12 and 15. Social activities are well managed and provide interest and variation for people living in the home. Food served is of a high standard. EVIDENCE: Residents said that they exercise choice in the routines of daily living such times of getting up and going to bed. Residents said that they are free to join in or not in the activities set up in the home, such as music and video afternoons, and in outings to local places of interest. Residents said that they are invited to events held at Pembroke Lodge’s sister home the Pembroke Hotel. A staff member said that she has recently been given the role of activities organiser and is reviewing provision. Arrangements are made for residents exercising their choice in relation to religious observance. There is an information table with brochures relating to various leisure and educational opportunities available in the area. Residents said that the food served is of a very high standard. The meal served during the inspection was well presented and with ample portions. Records are well kept, including menus, food served, alternatives offered, and recorded likes and dislikes. Individual diets are catered for. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18. The home has suitable arrangements to deal with complaints made to it. The home’s procedures and processes are designed to protect residents in the event of any allegations of abuse or allegations of abuse. EVIDENCE: The home has a suitable complaints policy, which is made available to residents. The log where complaints made to the home are held was made available to the inspector. This was well kept. No complaints regarding the home have been received by the Commission for Social Care Inspection. The home now has a suitable Adult Protection policy which has been linked with the home’s Whistle-blowing policy. Staff said that they are aware of these documents and records inspected showed that staff have had recent training in Adult Protection. The procedures have not had to be invoked for anyone resident at the home since the last inspection. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,20,24 and 26. The home provides accommodation to a high standard. Some items need addressing. Communal and bedroom areas are well appointed. Laundry arrangements are suitable. EVIDENCE: Pembroke Lodge is a large detached building in its own grounds. The home is on three floors all served by a passenger lift. It has a large well-kept garden area which residents said that they appreciate. The whole building is well maintained and equipped. The home has a system of noting items requiring attention and in the absence of a maintenance person at present the providers take the lead in dealing with items identified as needing attention. Two fire doors need adjusting so that they close onto their stops and a bathroom door needs an appropriate securing device for the privacy and dignity of residents. The home has a large communal area on the ground floor and a smaller lounge on the first floor. These are both well furnished and lighting is domestic in style. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 13 All bedrooms are single and have en- suite facilities (some with a bath). They are well furnished and decorated. Residents said that they liked their rooms and had been able to bring in their own furniture if they so wished. They said that keys to their rooms are available to them. The home has a suitably sited and equipped laundry. The home’s statement of purpose/service users guide makes clear that the home does not in general do personal laundry for residents, who the manager said either have help from their families or use a visiting laundry. The home was clean and tidy throughout. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. A competent staff team meets residents’ needs. The home has robust recruitment processes. EVIDENCE: A staff rota with staff roles was available for inspection. There are four staff on duty in the home in the morning and three in the afternoon. The home has a sleeping night staff member on duty in the home. If individual residents need particular support at night for a period this can be arranged at the resident’s expense. The administrative post is vacant at present and the manager said that this work is at present done by her and the providers. Residents and staff said that in general the home is adequately staffed and that staff turnover and the use of agency staff are low. The manager said that no one under the age of 21 is left in charge, and that she and the providers give on call support to the staff. Records inspected showed that the required paperwork is held on staff appointed. Staff confirmed that they have been given terms and conditions of employment, and the General Social Care Council code of conduct (copies of which were available in the home). Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,36 and 38. The home’s manager is able to discharge her responsibilities fully. The home has suitable financial procedures. Residents’ monies are in general well handled. Staff supervision needs some attention. Some core training updates are needed. EVIDENCE: Since the last inspection the Commission for Social Care Inspection has registered the acting manager as the manager. She obtained a suitable job description during the inspection. She holds NVQ level 4 in management and is an NVQ assessor, and expects to complete the registered managers award by the end of 2005. The home has a detailed business plan which was made available to the inspector. A suitable certificate of insurance was on display in the home. The providers keep a record of transactions made. Staff and the manager said that lines of communication within the home are clear. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 16 Residents said that they deal with their own finances, with support from others as needed. The manager said that she holds small sums for four residents, and the balance set out in the records matched the monies held in a record inspected at random. The home does not currently hold any valuables for residents, but has the facility to do so. The home offers supervision to care staff but records inspected showed that this was not at the recommended frequency of six times per year. The previous inspection contained a recommendation that core training updates should take place as planned. A number of updates and refresher courses were then due shortly and these dates have now passed. For some staff first aid refresher training has now arranged, but there are not yet dates in all cases. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x 3 3 2 x 2 Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 18 NO Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2)& Sch3(3)(i) 13(4)&18 (1)(c)(1) Requirement Keep securely medicines self medicated, and fully record administration of medicines held for residents. Core training updates take place. Timescale for action 31August 2005. 21October 2005. 2. 38 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. 3. Refer to Standard 19 35 36 Good Practice Recommendations Attend to identified physical items. Residents sign for their allowances if they are able. Supervise care staff formally at least six times a year. Pembroke Lodge H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex 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 H-59-H10 S14224 Pembroke Lodge V238862 150805 Stage 4.doc Version 1.40 Page 20 - 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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