Inspection on 21/04/05 for Pembroke Lodge

This inspection was carried out on 21st April 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 08/12/09

Pembroke Lodge 05/11/07

Pembroke Lodge 12/03/07

Pembroke Lodge 03/10/05

Pembroke Lodge 04/10/04

Pembroke Lodge 08/07/04

Pembroke Lodge 09/03/04

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

CARE HOME ADULTS 18-65 Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle Unannounced 21st April 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 3 Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Name of service Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD 01722 742066 Address 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) Glenside Manor Healthcare Services Ltd Mr Denis Barry Mrs Anita Diane Smith Care Home with Nursing 14 Category(ies) of PD Physical Disability (14) registration, with number of places Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 5 SERVICE INFORMATION Conditions of registration: The Staffing levels set out in the Notice of Decision dated 18 November 2002 must be met at all times. Date of last inspection 4th October 2004 Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 6 Brief Description of the Service: The Glenside Centre for Brain Injury Assessment and Rehabilitation, known as ARC is a 14 bedded nursing assessment and rehabilitation unit for younger persons with acquired brain injury. The ARC is not for long term, permanent care but for rehabilitation, therefore following rehabilitation, the Service User will move on to another appropriate facility. The building was purpose built for the client group. All bedrooms and living facilities are on the ground floor, with wide corridors. The bedrooms are single with an en-suite facility, providing a good standard of accommodation. A team of nursing staff, physiotherapists, occupational therapists and rehabilitation assistants provide care and support the Service User group. The ARC is one of six registered care homes on one campus which are owned by Glenside Manor Health Care Services Ltd. Mrs Anita Smith is the Regsitered Manager. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10.30 am and was completed at 2.30 pm. The Registered Manager Mrs Anita Smith showed the inspector round the premises, including many of the bedrooms. Two Service Users and staff were spoken to. Care records were inspected, as were medication records. Several of the recommendations made from the previous inspection were not assessed by the inspector on this occasion as the information needed was held in the central office of the site. These recommendations will be assessed at the announced inspection. What the service does well: What has improved since the last inspection? The requirement made from the previous inspection relating to approved devices to be applied to fire doors has been fully addressed and many of the recommendations which were made had also been addressed. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 8 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. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4 A clear admission procedure is in place and all health care needs and rehabilitation needs are fully assessed prior to the placement taking place. Visits to the unit prior to admission are encouraged and take place where possible depending on the current healthcare needs of the Service User. EVIDENCE: All Service Users are fully assessed by the Registered Manager or a qualified nurse prior to admission, ensuring through the assessment process that the ARC is the appropriate facility to meet the rehabilitation and nursing needs of the Service User. A multi disciplinary team approach is taken for each prospective Service User admitted to the ARC, with involvement from social workers, health care professionals and next of kin. All admissions to the unit are planned and where possible depending on the health care needs and travelling arrangements of the prospective Service User visits to the unit are encouraged to view the range of facilities offered and meet with the staff before the placement takes place. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and7 The care plans fully address all aspects of rehabilitation treatment and care. Service Users are supported where possible to make decisions about their own lives. EVIDENCE: Individual care plans were based on assessed needs and contained clear information of the nursing care and support required by the Service User. A multidisciplinary monthly goal planning meeting takes place to assess the progress made by the Service User and to set goals and any further actions to be taken in line with rehabilitation needs and medical needs of the Service User. Personal decision making for Service Users during rehabilitation treatment is fully supported and encouraged by the care staff. However often due to the needs of the client group communication may be limited especially at the onset of treatment making decision making for Service Users difficult to do and express. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 12 Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 and 15 The unit is focused on providing rehabilitation to each Service User supporting personal development. Contact with family and friends is also supported and encouraged. EVIDENCE: Service Users are admitted to the ARC for rehabilitation who have an acquired brain injury to enable them to develop and learn appropriate independent living skills. Occupational therapy is very much part of the treatment provided at the unit to support Service Users with learning independent daily living skills. The staff encourage and support links between Service Users and their families and friends. Families are also encouraged to participate in areas of treatment where appropriate to do so. During the inspection a Service User was leaving the unit as treatment had been completed. The family were fully involved in the discharge programme. A leaving party was held for the Service User and Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 14 many other Service Users from other homes on site were seen at the party, it was evident friendships had been made. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Healthcare needs of Service Users are clearly recorded and monitored and appropriate action taken when healthcare needs change. Medication procedures are safe and all medication is kept under review. EVIDENCE: All Service Users are registered with a local GP and other relevant health care professionals are involved with the treatment programme. The nursing staff closely monitor all health care needs and any changes in care needs or medical needs are quickly actioned. Care records clearly identify all aspects of health care needs. Monthly care reviews take place. Nursing staff are responsible for the administration of medications due to the high needs of the Service User group. The method of administration was safe as was the storage of all medication. Medications were reviewed on a regular basis and change according to changing needs. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There is a complaints policy and procedure in place. A vulnerable adults procedure is also in place and staff are aware of the local procedures and how to use it. EVIDENCE: There is a complaints procedure in place, a copy of which is situated in the entrance hall to the unit for any interested party. Service Users are provided with a copy of the complaints procedure. The unit has not recently received any formal complaints. An “Abuse” policy and procedure is in place and abuse awareness is inclusive as part of the induction programme for all new staff. All staff have been given a copy of the “No Secrets” document. A “Whistle Blowing “ procedure is also available for all staff. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 and 30 The unit is well maintained providing a safe and homely environment for Service Users. Improved house keeping is needed to ensure Service Users live in a clean environment. EVIDENCE: The ARC was purpose built and designed to meet the needs of the Service User group. The unit offers spacious, comfortable and modern accommodation. The communal rooms are decorated and furnished in a domestic style. The corridors are wide to suite wheelchair users. The décor of the home and the building is well maintained providing a safe environment for Service Users to live in. The bedrooms are all single with an en-suite facility. The bedrooms seen were homely and personalised with many personal items around. Appropriate equipment was provided in the bedrooms to meet the needs of the Service Users. Glenside Centre for Brain Injury Assessment & Rehabilitation Version 1.30 Page 18 D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc The unit did not have a domestic assistant at the time of the inspection and some areas of the home needed more attention to good house keeping ensuring a clean and hygienic environment is provided for the Service Users. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The home is able to meet the needs of the current Service User group with the staffing levels in operation and with the additional rehabilitation staff. EVIDENCE: The operational staffing level provided appears to support the needs of the Service Users with additional staff such as rehabilitation assistants to support areas of the rehabilitation treatment. A qualified nurse is on duty at all times to supervise care staff and support the nursing needs of the individual Service User. The unit was busy but well organised and positive interaction between the staff and the Service Users was seen and heard. Communication with Service Users was very limited therefore the inspector was not able to gain the views of the Service Users regarding the performance of the staff team. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The quality assurance system is effective in gaining the views of all people involved in the service that the unit provides. Training for staff and health and safety checks in the unit mean that Service Users live in a safe environment. EVIDENCE: The unit has an organisational audit system and quality audits are undertaken mainly with visitors and relatives to the home. Where able Service Users are given opportunity to participate in quality audits. Fire records indicated that weekly testing of the fire system was taking place. The fire training records for the care staff were not available in the units fire record but it was reported by the Registered Manager that these records were held in the central office. It will be required that all fire training records are held in the fire log of the unit to provide evidence of fire training taking place. All fire exits were clear and as required from the previous inspection approved devices have now been applied to fire doors. The unit is well maintained, and Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 21 all lifting equipment used by the Service Users is regularly serviced ensuring the safety of the Service Users. Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 2 Standard No 11 12 13 14 15 16 17 3 x x x 3 x x Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Glenside Centre for Brain Injury Assessment & Rehabilitation Score x 3 3 Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x Version 1.30 Page 23 D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc 21 x Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 24 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 YA 30 Regulation 18 (1,a) Requirement The Registered person will ensure that appropriate housekeeping staff are employed. The Registered person will ensure that a record of all staff fire training is maintained in the units fire log. The Registered person will ensure the communal bathroom floors are deep cleaned to remove all water stains. Timescale for action By 1st June 2005 By 1ST June 2005 By 1st August 2005 2. YA 42 17 3. YA 30 16 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 Good Practice Recommendations Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Glenside Centre for Brain Injury Assessment & Rehabilitation D51_D01_S47643_GLENSIDEBRAININJURY_V203296_210405_Stage4.doc Version 1.30 Page 26 - 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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