Inspection on 29/11/07 for Pembroke Lodge

This inspection was carried out on 29th November 2007.

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 27/06/06

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 Andrea Leverett Unannounced Inspection 29th November 2007 12:15p 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.V354668.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 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 0118 941 4200 enquiries@pembrokelodge.net www.pembrokelodge.net Mr Charles D`Cruz 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.V354668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 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. There is also a large patio area to the front of the garden with an awning to provide shade on those sunny days. The communal L-shaped lounge is light and airy with the communal TV not dominating the room. The manager informed the inspector that the scale of charges range from £550.00 and £700.00 a week. Any health care requirements that involve supporting people to attend appointments outside the Home are not included in the standard charge. However this service can be provided with an additional charge of £10.00 an hour. Additional charges are made to residents for hairdressing, chiropody, private telephone costs, and newspapers. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 12:15pm and was in the service for 9 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner/manager, and any information that CSCI has received about the service since the last inspection. This unannounced Key inspection took place on the 29th of November 2007. 9 people who use the service were spoken with as well a 1 relative, 3 staff, a senior carer and the owner manager. A partial tour of the premises was undertaken during the site visit and 4 people who use the services files were inspected as part of a case tracking process. Judgements about quality of life and choices were taken from direct conversations with and observations of people who use the service, followed by discussion with support staff, the manager and evidencing records held at the home. Feedback from people spoken to have been taken into consideration and comments have been reflected in this report. Feedback from people who live at Pembroke Lodge was very positive about the care and support provided by staff although many comments showed that improvements are needed in some areas. The Home is decorated and furnished to a good standard and a good standard of food is provided. The inspector concluded that people are given an adequate service at Pembroke Lodge. The Home needs to make improvements in a number of key areas such as assessment and care planning, staff training and supervision and the provision of social activities. Progress towards meeting requirements and recommendations made at previous inspections has been slow. It is acknowledged that the owner prior to this site visit has noted many issues identified in this report and plans are in place to address them. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: More needs to be done to ensure that prospective service users have accurate information to make an informed choice about where they live. More needs to be done to ensure that people who use this service can always be confident that their needs will be assessed fully before they move into the Home and that the Home is registered to meet their needs. More needs to be done to ensure that people who use this service benefit from having comprehensive health, personal and social care needs set out in an individual plan of care. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 7 More needs to be done to evidence that staff are properly trained to administer medication safely. People living in the Home receive a wholesome and appealing diet in pleasing surroundings but more needs to be done to evidence that choices around meals are sought and that snacks and drinks are at times convenient to them. More needs to be done to ensure that People are protected from the risk of abuse by the home’s Adult Protection procedures. More needs to be done so that people who use this service cannot be confident that their needs will be met by sufficient number of staff that are trained and competent to carry out their role. 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. The summary of this inspection report can be made available in other formats on request. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 8 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.V354668.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, People who use the service experience poor quality outcomes in this area. More needs to be done to ensure that prospective service users have accurate information to make an informed choice about where they live. People who use this service cannot always be confident that their needs will be assessed fully before they move into the Home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner/manager informed the inspector that any health care requirements that involve supporting people to attend appointments outside the Home are not included in the standard charge. However this service can be provided with an additional charge of £10.00 an hour. At the time of the site visit this information was not included in the homes statement of purpose and service user guide and the need to update these documents and include this Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 10 information was discussed with the manager. The statement of purpose and the service user Guide also does not include information regarding the scale of charges. The need to explore how prospective service users needs would be met in terms of support to attend appointments should be covered in the homes assessment prior to being admitted to the service if this is not included in the standard charge was also discussed. In all other respects the homes statement of purpose included all the information required by this standard however improvements are needed key areas such as staff training and the provision of social and therapeutic activities for people who use the service to ensure that the service provision is in line with the statement of purpose. Assessment and care plans were looked at in detail for 4 residents including the most recently admitted person. It was noted that 1 person was admitted with a diagnosis of dementia, although the Home is not registered to care for people with these needs. The owner/manager agreed that the person does have dementia but he felt it was appropriate to admit the person because he thought the Home could meet his needs. He also stated that he was not aware that he needed to have a dementia registration to do this. A requirement has been made that the Home must not admit people that it is not registered to care for and the Home must now seek a registration variation from the commission to accommodate this person legally. Assessment information was limited to one word or one-line responses, which did not give enough information to guide the care plan and evidence that needs could be met. Given that most people admitted to the Home are funded privately and do not have Local Authority Assessments, the Home must ensure that its own assessment information is comprehensive and detailed. The owner/manager informed the inspector that he always visits people to carry out an assessment before a place is offered and would not admit someone who’s needs he could not meet. Discussion took place regarding the need to evidence this in the assessment documents. It was noted that care plans were more detailed. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience adequate quality outcomes in this area. People who use this service do not always benefit from having comprehensive health; personal and social care needs set out in an individual plan of care. More needs to be done to evidence that staff are properly trained to administer medication safely. People who use this service feel they are treated with dignity and respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessment and care plan documents were inspected in detail for 4 people who use the service. Information seen and discussions with people who use the service and staff evidenced that care plans are in place to cover most health and personal care needs but some gaps were noted and care plans were not always detailed enough to guide staff practice. For example one persons Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 12 bathing care plan stated that the person was difficult and needed 2 staff but did not detail how the person should be supported emotionally and physically and if any moving and handling equipment was needed. Another person’s health records showed that they suffered with nose bleeds but no care plan was in place to show how this should be managed. Documents included nutritional screening, weight charts, Moving and handling assessments and personal hygiene plans. No records were being kept to evidence that dental and eye care was being monitored although there was evidence that some people had seen an optician in the last 12 months. Records also showed that care plans and risk assessments are not being reviewed consistently on a monthly basis and requirements have been made regarding this. It was noted that some people had pressure alarm mats in their rooms, which are used during the night to alert staff when people get out of bed. Although the use of pressure alarm mats seemed appropriate to the inspector, care plans are not in place to evidence that consent has been sort from the person or those acting on their behalf. Assessments seen gave some information regarding peoples social and therapeutic needs but care plans are not in place to show how these are to be met and feedback from people who use the service evidenced that social activities are limited in the home. Feedback from people who use the service was generally positive about the care and support provided by staff and staff were seen supporting people in a respectful and dignified manner. Medication was observed being given and medication administration records and medication storage was inspected. Staff were observed administering medication appropriately and medication records were being kept up to date and were accurate. Care notes included information regarding homely remedies that had been agreed by the persons GP. The manager informed the inspector that the senior carer undertook staff medication training; although training records did not evidence that they were qualified to undertake this role. Typical comments included: “ You get very well looked after and you get a bath once a week.” “I get a bath once a week but wouldn’t mind more but you’ve got to be reasonable.” Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 13 “ I haven’t seen a dentist or optician since I’ve been here but get to see the Doctor if I need to.” “ Staff treat people respectfully and are very caring. It is generally well run, mom is well looked after. Staff help people more or less straight away.” “The Home is small and intimate, like a big family.” Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience adequate quality outcomes in this area. More needs to be done to evidence that the experiences of people who use this service always match their expectations and preferences in terms of social, cultural, religious and recreational needs. People living in the Home are supported to maintain contact with family but more needs to be done to evidence that they are fully supported to exercise choice and control over their lives. People living in the Home receive a wholesome and appealing diet in pleasing surroundings but more needs to be done to evidence that choices around meals are sort and that snacks and drinks are at times convenient to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with relatives, staff and people who use the service showed that organised activities are limited in the Home. Armchair exercises are provided most mornings and sometimes people play dominoes and cards. The Home also has a visiting library service. As stated previously assessments and care Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 15 plans do not give enough information to identify peoples needs in terms of social and therapeutic activities and daily care records do not generally refer to social activities undertaken. A requirement has been made regarding this. It is acknowledged that the owner/manager has identified the need to improve activity provision in the Home. On the day of the site visit both he and a staff member were attending an activities training course and a staff member has been allocated the responsibility for planning and facilitating activities in the future. The need to ensure that the social and therapeutic needs of people with dementia and memory loss are identified and met was also discussed. Feedback from people who use the service and a relative spoken to show that the Home supports people to maintain contact with families and friends and visitors are welcome at any time. Records seen and discussions with staff also showed that the Home communicates with families in the best interest of people living in the Home. Observation on the day of the site visit and discussions with people who use the service showed that generally their choices on a day to basis are respected. However improvements in assessment and care planning process are needed to evidence that their individual views and wishes are sort and acted upon. Discussions with people who use the service showed that they were generally very satisfied with the quality of the food provided. An inspection of the homes kitchen and food stocks showed that a broad range of good quality food is purchased. Records seen and feedback given also showed that people’s specialist dietary needs are catered for. The Home has its own cook and menu’s showed that a balanced diet was provided. The cook informed the inspector that he is currently developing new menus and will be seeking the views of people who use the service in this process. Feedback from people who use the service regarding choices offered around meals was mixed. Most people spoken to stated that they were not given any meal options and the homes menus only show one main meal option. More varied options were seen being offered for the tea time meal and the cook was observed going around asking people what they would like for tea. The Home does not have a late supper menu although it was clear that some people did have snacks in the evenings if they asked. The need to explore people’s preferences in terms meals and suppers and evidence in care plans that this has been done was discussed with the manager and a requirement has been made regarding this. The cook also informed the inspector that he does seek feedback from people regarding the food but does not currently keep any records to evidence this. A recommendation has been made that this should be done. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 16 The home dining area is decorated and furnished to a good standard, but it does not currently have enough room to accommodate all 16 people. Some people ate their meals in the lounge on the day of the site visit and although people spoken to were happy with this arrangement, the need to evidence peoples preferences in terms of where they eat meals was discussed with the manager. Typical comments included: “ They don’t ask us what we want to eat, how could they with so many of us, but it always tastes nice and is healthy food.” “ I loved the dinner, I like everything but no one has come to me and asked me if I liked it.” “ The food is good, they always come round and ask what we want. I generally find something I like, they are very accommodating.” “ I didn’t like the dinner today, I don’t often say that, most of the time I enjoy meals, they are very accommodating” “I don’t get a cup of tea in bed in the morning, I get a cup when I am brought down for breakfast. I have never been asked if I want a cup of tea in bed in the morning. Breakfast is cereal and toast. Tea is sandwiches mostly, but you can have something on toast or soup, they ask every day what you would like.” “ There are not many activities but sometimes there are exercises in the mornings.” “I play domino’s and cards sometimes but nothing organised I like reading and do exercises in the mornings.” “The Home is talking about doing more activities and quizzes, they do keep fit every morning.” Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience adequate quality outcomes in this area. On the whole people who use this service are aware of their rights with regard to making a complaint and can be confident that their concerns and complaints will be listened to and acted upon. More needs to be done to ensure that People are protected from the risk of abuse by the home’s Adult Protection procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure was not inspected on this occasion but the last inspection report stated that there is a complaints policy and procedure in place. The commission has received one complaint regarding the care of a person using the service. This was raised as a safeguarding adults alert and was investigated by the local authority, under the safe guarding adults procedure. This procedure has now been closed and concluded that the Home has taken appropriate measures in relation to this incident. People spoken with during the site visit felt they could raise concerns if they needed to and felt these would be acted upon. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 18 Training records seen and discussions with staff evidenced that not all staff have undertaken Safeguarding Adults training. The manager stated that staff has covered this in their NVQ training but the Home does not yet have training certificates to evidence this. A requirement has been made regarding the need to evidence that all staff have received this training. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People who use the service experience good quality outcomes in this area. People who use this service benefit from living in a Homely environment, which is well maintained and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the communal areas and the homes kitchen was undertaken at the site visit. No bedrooms were inspected on this occasion. The Home is decorated and furnished to a good standard and is clean and free from offensive odours. Maintenance records showed that the Home was being maintained appropriately. The kitchen was clean and records showed that temperature checks are being carried out regularly. The Home has an accessible well-maintained garden and people who use the service were seen taking advantage of this during the site visit. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 20 The communal lounge is L shaped and has just enough space to accommodate 16 people. Although the seating arrangements do not allow most people to have a view of the television, people spoken with did not mind this and stated that they could watch television in their rooms if they wished. As stated previously the dining area does not have enough space to accommodate everybody at one sitting and several people were observed eating their meals in the lounge area on the day of the site visit. People spoken with said it was their choice to eat in the lounge but assessment and care plan documents do not evidence that people’s preferences have been explored. A requirement has been made regarding this. The manager informed the inspector that he is planning to build an activities/resource room at the bottom of the homes garden and work on this should start in 2008. A recommendation has been made that the Home looks at ways of extending the homes dinning space. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. People who use the service experience adequate quality outcomes in this area. People who use this service cannot be confident that their needs will be met by sufficient number of staff that is trained and competent to carry out their role. People living in the Home are protected by appropriate staff recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from people who use the service and observation on the day of the site visit demonstrated that the Home had enough staff on duty during waking hours to meet people’s needs. The Home has 4 staff on in the morning and 3 care staff in the afternoon. In addition the Home has a cook and domestic staff. During the night the Home only has one member of staff on duty and feedback from people spoken to suggest that this was not enough to meet peoples needs. Care plans and risk assessments do not explore how peoples care needs would be met at night and a requirement has been made that the Home review and risk assess the night time staffing arrangements in terms of meeting general care needs, fire safety and the particular needs of people with dementia. It was noted that some people have pressure alarm mats that would alert staff if they get out of bed at night. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 22 Discussions with staff and some training certificates seen showed that over 50 of staff has undertaken NVQ training at level 2 or above. Staff files were inspected for 4 care staff including the most recently employed staff members. Records showed that the Home has appropriate recruitment procedures in place. All files contained application forms, 2 written references, employment history and evidence that Criminal Record Bureau checks had been undertaken before starting employment. The training records were looked at for 6 staff members. 3 staff training records evidenced that they had undertaken NVQ2, Fire safety, Health and safety, First Aid, POVA training, Moving and handling. Several staff had also undertaken training in care planning and anti discriminatory practice. 3 staff files did not have evidence of moving and handling, POVA training, or health and safety. This included a nighttime care worker who has recently started work. The manager informed the inspector that all his staff would have received moving and handling training. A requirement has been made that the Home must be able to evidence that staff have undertaken all mandatory training needed to carry out their role safely and that staff must not work unsupervised including at night without evidencing that this has been done. The manager also informed the inspector that his senior carer has a moving and handling training qualification and that she undertakes this training and medication training with staff. A certificate was seen to evidence that the moving and handling training course had been undertaken in 2005. The senior carer had also attended a basic moving and handling refresher course in 2007 although it did not evidence that their qualification to train had been updated and the need to do this was discussed with the manager. There was no evidence that the senior carer had any qualification to deliver medication administration training. A requirement has been made that the Home can evidence that staff receive medication administration training by a person qualified to do so. One person’s file showed that they had completed skills for care induction program and the manager informed the inspector that another staff member was currently working through it. The manager also informed the inspector that the homes in house induction procedure is in the process of being updated and records did not evidence that an in house induction had taken place for the 2 most recently employed staff members, including night staff. A requirement has been made regarding this. Staff do not have dementia training and it was evident that a number of people who use the service have dementia or memory loss. The manager stated that he had plans in place for all staff to undertake this training and a requirement has been made regarding this. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 23 There was no evidence in the staff file to show that the cook had undertaken food hygiene training, although the cook assured the inspector that he had undertaken this training with his previous employer. The manager stated that additional food hygiene training and nutrition training has been planned for the cook. Since the site visit the manager has contacted the inspector to say that moving and handling training has been planed for the 2 most recently employed staff members working on nights. Comments included: “You can hear bells going off for a long time during the night, night staff say they are rung unnecessarily.” “ They need more staff at night, there is only one person, not enough if something happened.” Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37 and 38 People who use the service experience adequate quality outcomes in this area. An experienced and qualified manager manages the Home but more needs to be done to ensure that the Home is run well. More needs to be done to ensure that the health safety and welfare of people living in the Home are promoted and protected and that the Home is run in their best interests. This judgement has been made using available evidence including a visit to this service. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 25 EVIDENCE: The owner manager has a qualification in Advanced Management of Care and has an NVQ 4 in care and the Registered Managers Award. He has been managing the Home since 1994. Feedback from staff spoken to and people who use the service showed that generally people felt supported by the manager. Records seen did not evidence that staff supervision was being provided and staff spoken to stated that they had not received supervision since the deputy manager left some time ago. The manager stated that all senior carers are going to undertake supervision training in addition to NVQ level 3 and that a supervision structure is going to be implemented shortly. Staff spoken to confirmed that they had been told about the new supervision arrangements and a requirement has been made that this should be done. A staff handover meeting was observed taking place between the morning and afternoon staff. Information was shared about peoples needs in an appropriate manner and plans for the following shift was discussed. Evidence was seen to show that the Home has sought the views of people who use the service using questionnaires distributed and collated by an independent person. Although there were no dates on the questionnaires a letter from the person carrying out the survey on behalf of the Home suggests that this was undertaken this year. The information showed that generally people were happy with the care and support provided by the Home but information suggested they would like more activities. Records seen and observation during the site visit showed that generally the Home was being maintained appropriately but shortfalls in risk assessments, care planning and staff training are undermining the safety and welfare of people who live in the Home. Care records showed that information was not always up to date and accurate and a requirement has been made that all care files are reviewed to ensure that information is kept up to date and accurate. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 26 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 1 X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 2 2 Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 27 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. Standard OP1 Regulation 4, 5, 6. Requirement The registered person must ensure that the homes Statement of Purpose and Service users Guide has up to date and accurate information to enable prospective residents to make a fully informed choice about whether or not the Home is suitable and able to meet the individual particular needs: In that statements regarding staff training, assessment and care planning and the provision of social activities accurately reflect the homes practice in these areas. In that the admission criteria to the Home must be in line with the homes registration: In that the documents include information regarding the scale of charges and that people are made aware that any health care requirements that involve supporting people to attend appointments outside the Home are not included in the standard Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 28 Timescale for action 10/02/08 2. OP2 5 3 OP3 14 4 OP7 15 charge but can be provided with an additional charge of £10.00 an hour. The registered person must 10/02/08 ensure that service users contracts/statement of terms and conditions includes information regarding fees payable and additional services to be paid for over and above those included in the fees. The registered person must 10/01/08 ensure that full and comprehensive assessments are undertaken prior to a place being offered. The registered person must 20/02/08 ensure that care plans and risk assessments are in place to cover all health, personal care and social care needs of service users and that these documents are reviewed appropriately. Requirements relating to this regulation outstanding from 30/09/06 The registered person must evidence that a person qualified to carry out this role provides medication administration training. The registered person must ensure that social and therapeutic activities are provided that are in keeping with people’s wishes and needs. 5 OP9 18,13 20/02/08 6. OP12 16 20/02/08 7 OP15 16 The registered person must 20/01/08 ensure that the Home can evidence that people are being offered drinks and snacks at such times as may be reasonably be required by service users: In particular that people are consulted about their preferences regarding evening Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 29 snacks/suppers and these preferences are recorded in the care plan and acted upon. 8 OP18 13 The registered person must ensure that staff receives appropriate training in the protection of vulnerable adults. Requirement relating to this regulation outstanding from the 31/12/06 The registered person must review and risk assess the night time staffing arrangements and ensure that sufficient staff are provided to meet peoples needs. The registered person must ensure that all staff receive appropriate training to carry out their role: In that the Home can evidence that staff have undertaken induction, Moving and handling, dementia, health and safety and were appropriate food hygiene training. The registered person must ensure that all staff is supervised appropriately. The registered person must ensure that all care records are kept up to date and accurate. 20/02/08 9 OP27 18,13 10/01/08 10 OP30 18 20/03/08 11 12 OP36 OP37 18 17 10/01/08 10/02/08 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 OP15 Good Practice Recommendations It is strongly recommended that the Home evidence more fully that they have consulted with people living in the Home regarding their meal preferences and seating DS0000011114.V354668.R01.S.doc Version 5.2 Page 30 Pembroke Lodge preferences when eating meals and that this information is recorded in the care plan and acted upon. Pembroke Lodge DS0000011114.V354668.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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