Inspection on 19/04/05 for Pembroke Lodge

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13/03/06

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 19 April 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 H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 32 Alexandra Road Reading Berkshire RG1 5PF 0118 926 6255 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 DCruz Charles DCruz Care Home 20 Category(ies) of Older Persons (OP) registration, with number of places PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28/9/04 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 – 7 single and 6 shared rooms. 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. “ PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over 5 hours covering a morning and lunchtime period. 9 service users were spoken to and all staff on duty were seen in private. In addition 3 visitors to the home were spoken to individually. The communal areas were seen and one service user was seen in private in their bedroom. What the service does well: What has improved since the last inspection? What they could do better: PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 6 There was evidence that the management approach of the home could be improved by the promotion of better relationships with senior staff. 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 H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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 standard(s) No standards under this heading were inspected on this occasion. EVIDENCE: PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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) 8 & 10. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. Personal support is offered in such a way which promotes and protects service users’ privacy, dignity and independence. EVIDENCE: There was considerable evidence from talking to service users and staff that health care needs are identified and acted upon swiftly and efficiently. A visiting District Nurse praised the standard of care provided in the home and confirmed that appropriate referrals are always made. Service users spoken to indicated that carers are warm and friendly and their personal care needs are provided for in private and in a sensitive manner. Staff spoken to in private indicated that the deputy manager sets high standards for care giving and provides guidance to staff in a professional and supportive manner. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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, 13 & 15. Some general activities provided in the home meet some needs however, these activities are not planned to meet individual needs. Visitors are welcomed in the home and contact with service users is encouraged and supported. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: There are some regular activities provided in the home including regular exercise and a visiting organ player. Some service users spoken to had particular interests and some made suggestions for occasional activities such as music sessions. It will be recommended that key workers explore these areas with individual service users and ascertain whether any of these suggestions can be acted upon. Although residents meetings have been held in the past it was acknowledged that one had not been arranged for some while. The senior carer spoken to undertook to arrange a residents meeting in the near future. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 11 The inspector was able to speak in private to two separate visitors. Both felt welcomed and were provided with appropriate information about their relative or friend. One visitor wanted to comment particularly on the good standard of care provided in the home. Generally, most service users commented favourably on the food provided in the home. The regular home baking came in for particular praise. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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 standard(s) No standards were inspected under this heading. EVIDENCE: PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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 standard(s) 19, 21,25 & 26. This home provides a good standard of décor and service users enjoy an attractive and homely place to live. There are adequate toilet facilities however, service users must be safeguarded from identified risks. The standard of cleanliness in this home is high and provides a hygienic and orderly place to live. EVIDENCE: This home is well maintained with an ongoing refurbishment programme in place. The communal areas are comfortably furnished and are warm and homely. Some action had been taken with regard to an excessively hot radiator identified during the previous inspection which is situated in an upstairs bathroom. However, this action was considered by the inspector to be PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 14 inadequate and the radiator remains a significant risk to service users and must be addressed. There was no evidence provided that a previous requirement relating to the risk assessment of radiators had been actioned. This will remain an outstanding requirement until evidence is provided by the home. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 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 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 & 29. The complement and competence of the staff team is well balanced and provides consistent care for service users. There are gaps in the systems for the recruitment of staff which places service users at risk. EVIDENCE: There was sound evidence that the home now had a staff team which was working well together. One service user described the staff team as well organised and gave examples of where staff worked in a complimentary way. Individual staff were spoken to and were generally happy with their management. All staff felt confident in referring concerns or issues to the deputy manager who was described as supportive and professional. Despite some major improvements in staff recruitment processes there was evidence that staff were being employed without appropriate checks being undertaken. This is being dealt with by separate correspondence and by the continuation of the previous requirement. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 16 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) 32, 35, 36 & 38. There is a lack of a planned and co-ordinated management approach to the running of this home which does on occasions adversely affect service users. Staff are well supervised by the senior staff team which enables consistent care to be provided for service users. Generally the health, safety and welfare of service users and staff are promoted. EVIDENCE: There was evidence provided from talking to staff and visitors that the senior staff team are not always adequately supported by the manager. His presence in the home is infrequent and some staff felt that issues raised by them had not always been appropriately dealt with. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 17 The introduction of formal supervision is progressing well. Almost all staff have received a recorded supervision session. Despite a previous recommendation no supervising staff have been offered formal training by the manager. There was no evidence available that previous requirements relating to several health and safety matters had been addressed. These have been dealt with under separate correspondence but two of the outstanding requirements will be recorded on this report. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 18 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x 1 x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 2 x x 2 1 x 2 PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 19 yes 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. 2. Standard 21 25 Regulation 23 23 Requirement To ensure that the excessively hot radiator located in an upstairs bathroom is made safe. That a risk assessment be undertaken on all communal radiators to identify and manage significant risk to service users. No new staff to commence employment until all legally required checks are undertaken. To consult with the Fire Authority regarding the fire safety arrangements in the home an specifically signage and risk assessments. Timescale for action 31/5/05 31/5/05 3. 4. 29 38 19 23 Immediatel y 31/5/05 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 12 37 Good Practice Recommendations To explore the introduction of further activities base upon service users interests and preferences. To ensure a copy of the relevant standards and regulations is available in the home. PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading 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 PEMBROKE LODGE H51-H01 11114 Pembroke Ldge V210815 190405 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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