Inspection on 27/06/06 for Pembroke Lodge

This inspection was carried out on 27th June 2006.

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 13/03/06

Pembroke Lodge 19/04/05

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 Robert Dawes Unannounced Inspection 10:45 27th June and 3rd July 2006 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 DS0000011114.V292524.R01.S.doc Version 5.1 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 DS0000011114.V292524.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 32 Alexandra Road Reading Berkshire RG1 5PF 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) 0118 926 6255 Mr Charles D`Cruz Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 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 located over three floors. 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. Fees range from £550--£670 a week. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place over two days. Four service users, relatives of two service users, a District Nurse, three members of staff, the deputy manager and the manager were interviewed. The inspector also observed care practice, toured the premises and looked at the home’s records and files of the service users spoken with. The questionnaire was not returned nor were any service user questionnaires received before the site visit took place. The overall inspection was therefore based mainly on the site visit. Twenty-two standards were assessed of which 3 were exceeded, 14 were met and 5 nearly met. 6 requirements and 3 recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: To ensure the risk of injury to service users is as minimal as possible, all service users must have individual risk assessments. To ensure service users receive the best possible care, all staff must undertake training in key areas of Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 6 work and be offered the opportunity to attend additional training to increase their understanding of old age and skills to respond to the needs of the service users. To ensure the home is meeting the aims and objectives for the care of the service users a quality assurance and quality monitoring system must be developed. The Commission must be notified of any deaths and serious incidents that affect the health and welfare of the service users. To ensure all staff in any situation are aware of the current needs of the service users the individual plans must be reviewed every month and contain information about the service users’ health needs. 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 DS0000011114.V292524.R01.S.doc Version 5.1 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 DS0000011114.V292524.R01.S.doc Version 5.1 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): Number 3. Intermediate care is not provided so Standard 6 was not assessed. Quality in this outcome area is good. No service user moves into the home without having had his/her needs assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No service user has been admitted since the last inspection when it was concluded that service users moving into the home have their needs properly assessed. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Numbers 7, 8, 9 and 10. Quality in this outcome area is good. Service users receive a very good level of personal and health care; they are treated with respect, consideration and care; and they are protected by the home’s policies and procedures for dealing with medicines. The outcome for this area could be excellent if the individual plans were all reviewed as frequently as they should and the plans contained sufficient detail about the service users’ health care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the files seen had individual plans. None of the individual plans contained detailed information about the service users’ health needs and not all the plans were being reviewed every month. Service users said the personal and health care they receive is very good and they have no complaints. Doctors and health professionals are called promptly when required and a chiropodist comes every six weeks. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 10 Service users were observed to look clean and well dressed. Relatives complimented the deputy manager and her staff on how well they looked after the service users’ personal care and health needs. One relative said his wife’s physical and mental health has improved significantly since being admitted to Pembroke Lodge. A district nurse, who has been visiting the home at least once a week for several years, said she was very impressed with the standard of personal and health care. The deputy manager and her staff are knowledgeable about the service users’ health needs and call health professionals appropriately. No service user is suffering from bedsores. A service user told the District Nurse he is better off now than when he was in his own home. Staff are attentive and caring. Staff interviewed by the inspector were knowledgeable about service users health needs. They said service users are weighed at least every six weeks and offered the opportunity of joining in exercise sessions every day. Policies and procedures for dealing with medicines are in place. Records showed all staff receive in house training before they administer medication. Administration records were in order. No service user self medicates. The deputy manager has arranged for a pharmacist to visit at regular intervals to assess the storage, administration, recording and disposal of the medication. Service users said staff treat them well. ‘They are patient, caring and respectful’. ‘ We can remain in our rooms if we wish’. Staff said service users could have telephones in their rooms. Relatives said staff treat service users with respect and kindness. The inspector observed staff respond to service users in a considerate and caring manner. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Numbers 12, 13, 14 and 15. Quality in this outcome area is good. Service users daily routines and activities are flexible and varied to suit their preferences and capacities; they are able to have visitors at any reasonable time; they are helped to exercise choice and control over their lives; and they enjoy a wholesome appealing balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said various activities are made available, such as dominos and draughts. Those that are able go out for walks and occasionally entertainers come to the home. A mobile library calls regularly, a member of staff plays the guitar and sings for them, local clergymen and priests visit the home and staff organise clothes parties. The inspector observed staff playing board games with service users. Service users said their friends and relatives can visit at any reasonable time. Relatives said they are always made to feel welcome and involved in all matters. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 12 Service users said they were able to bring personal possessions with them and don’t have to do anything they don’t want to do. Service users said they enjoy the meals, there is a choice if they do not like the main meal and fruit (cut up for those who have difficulty eating) is always available. The menu showed nutritious and varied meals are provided. Staff said dietary needs are catered for, service users can have their meals where they choose, individual preferences are recorded and meals are discussed at service users meetings. Snacks and hot drinks are available in the evenings and service users are asked about their likes and dislikes. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Numbers 16 and 18. Quality in this outcome area is good. Service users and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the March 2006 inspection it was concluded that service users and relatives are confident that their complaints will be acted upon. No complaints have been made to the manager or the Commission since the last inspection. Staff interviewed said they would inform the manager or deputy manager if they suspected any service user was being abused. No allegation of abuse has been made to the Commission. No member of staff has undertaken vulnerable adult training. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Number 19 and 26. Quality in this outcome area is excellent. Service users live in a safe, well-maintained, clean and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home showed it is safe, homely, comfortably furnished, well decorated and well maintained. Service users also benefit from a large, very pleasant and well maintained garden. The excessively hot radiator identified at a previous inspection is now suitably protected. On the day of the inspection the home was clean, hygienic and free of any odours. Service users and relatives said the home is always very clean and free of odours. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Numbers 27, 28, 29 and 30. Quality in this outcome area is adequate. Service users needs are met by the numbers and skill mix of staff although it is recommended that the staffing numbers at certain times of the weekends should be reviewed. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. A number of staff have received training in key areas of work but basic training must be achieved by all care staff. Service users would also benefit from staff attending additional courses on subjects such as dementia and bereavement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed demonstrated a good understanding of the service users’ needs. A manager, deputy manager, nine full time carers, four part time workers who do not undertake personal care tasks, a cleaner and a gardener/maintenance person are employed to work in the home. The manager is not included on the duty rota. No agency staff are employed. Staff turnover has been low over the last year. Staff working overtime cover any vacant care hours. The duty rota showed the deputy manager plus four carers are on duty in the week day mornings, the deputy manager plus three carers in the afternoons, three carers in the evenings and one carer plus a ‘sleep in’ member of staff at Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 16 night. At weekends, between 7am and 10am, the deputy manager or a senior carer plus three carers (sometimes two carers) are on duty; between 10am and 2pm the deputy manager or a senior carer plus one or two carers; from 2pm to 8pm three carers are on duty. The proprietor/manager and part time carers assist with the cooking and non personal care tasks. Staff said the home would benefit from another member of staff at weekends to ensure the service users’ needs are responded to, i.e. taken out for walks. Two members of staff have a NVQ 2 or above in care. The inspector was also informed that four members of staff from abroad have equivalent NVQ3 qualifications. A letter from the recruitment agency stated that ‘the Home Office grants work permits to a foreign national only if they meet the minimum requirement which is NVQ3 or its equivalent’. The inspector has requested the manager provide the Commission with copies of the certificates of qualification and evidence that the training to achieve the qualifications covered similar training modules in this country’s NVQ 3 in care. Records for the last member of staff employed showed the home followed a thorough recruitment procedure. Records showed all staff undertook an induction programme when they started work in the home. The majority of staff have undertaken fire awareness and drugs administration training. Four members of staff have undertaken moving and handling training, two have undertaken food hygiene training, two have undertaken a first aid course and one has undertaken health and safety in the workplace training. The members of staff who have achieved a NVQ 2 or above in care have studied health and safety in the workplace and the protection of individuals from abuse. None have attended courses on subjects such as dementia or bereavement to increase their understanding of old age and skills to respond to the needs of the service users. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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): Numbers 31, 33, 35, 37 and 38. Quality in this outcome area is adequate. Service users live in a home which is run and managed by a competent and experienced person. There is no quality assurance and quality monitoring system in place to measure success in meeting the aims and objectives of the home. Service users’ finances are not managed by the home. Relatives, power of attorneys or advocates are responsible. The health, safety and welfare of service users are promoted and protected although there were no risk assessments on service users’ files. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 18 The proprietor/registered manager has been responsible for the home since it opened twelve years ago. He has achieved the Registered Manager’s Award and a NVQ 4 in care. The deputy manager, who has worked at the home for twelve years and been the deputy manager for four years, undertakes the day-to-day management of the staff and running of the home. Staff described her as being clear in her directions, having high standards, supportive, hard working and very committed to providing the best possible care for the service users. A hand over meeting was observed where the deputy manager was clear in her expectations and fully informed staff of the service users’ current needs. Service users’ meetings took place in February and June of this year and good communication takes place between the deputy manager, the senior carer and the other members of staff but there is no formal quality assurance and quality monitoring system in place to measure the success in meeting the aims and objectives of the home. The home does not handle any service users’ financial affairs or personal money. Relatives, power of attorneys or advocates are responsible. No regulation 37 notifications have been sent to the Commission since 2004. Records showed the registered manager ensures safe working practices take place except for ensuring a first aid trained member of staff is always on duty. All health and safety checks and servicing have taken place as required except for twice yearly fire drills. There were no risk assessments on any of the service users’ files looked at. A home’s fire risk assessment has taken place within the last year. The manager said regular health and safety checks of the home would be made and recorded. Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 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 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP7 Regulation 15 15 Requirement Service user’s plans must be reviewed every month. Service user’s plans must include how the service user’s needs in respect of his/her health are to be met. All staff must receive training in key areas of work including first aid and protection of vulnerable adults. A quality assurance and quality monitoring system must be developed to measure the success in meeting the aims and objectives of the home. Notifications of deaths, illness and other events as described in the regulation must be sent to the Commission. Risk assessments must be undertaken and recorded for all service users. Outstanding from 13/03/06 inspection. Timescale for action 31/08/06 30/09/06 3 OP30 18 31/12/06 4 OP33 24 30/09/06 5 OP37 37 31/07/06 6 OP38 38 30/09/06 Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 21 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 OP27 OP30 Good Practice Recommendations Review the staffing arrangements at weekends to ensure service users’ needs are met at all times. Provide staff with the opportunity to undertake training in additional areas of work to increase their understanding of old age and skills to respond to the needs of the service users. Fire drills take place twice a year. 3 OP38 Pembroke Lodge DS0000011114.V292524.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks 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 DS0000011114.V292524.R01.S.doc Version 5.1 Page 23 - 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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