Inspection on 03/02/06 for Pembroke Lodge

This inspection was carried out on 3rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pembroke Lodge 14/08/08

Pembroke Lodge 14/09/06

Pembroke Lodge 15/08/05

Pembroke Lodge 01/02/05

Pembroke Lodge 02/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pembroke Lodge 8/10 Aymer Road Hove East Sussex BN3 4GA Lead Inspector Elizabeth Dudley Unannounced Inspection 10:30 3 February 2006 rd 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 DS0000014224.V277920.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 DS0000014224.V277920.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 8/10 Aymer Road Hove East Sussex BN3 4GA 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) 01273 777286 Mr L Brand Mrs Susan Brand Joanne Lea Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19). Service users should be aged sixty-five (65) years or over on admission. 15th August 2005 Date of last inspection Brief Description of the Service: Pembroke Lodge is a privately run care home registered for up to 19 older people. It offers hotel style accommodation to people aged over 65 who are independent and mobile. It does not provide nursing care. The detached building is situated close to the seafront and town centre of Hove, with all local amenities and transport routes conveniently nearby. Accommodation is on three floors with access via a lift: all rooms are en-suite. There are two lounges, the larger one located on the ground floor and another, smaller one on the first floor. Paid parking is available in the streets around the home. The service is aimed at retired people who wish to maintain an independent lifestyle and continue to live their lives to their maximum potential. The home has achieved various awards, including the Clean Food Award; Investors in People and Residential Domiciliary Benchmark star rating. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 3rd February 2006 over a period of five hours and was facilitated by Ms V Stock, deputy manager. During the course of the inspection, documentation including care plans, medication charts, personnel files, health and safety certificates, training plans and catering records were examined. The provider, six members of staff, four community nurses and twelve residents were spoken with. Very positive comments were received from all residents, the community nurses and staff. What the service does well: What has improved since the last inspection? Most of the requirements and recommendations made at the last inspection have now been addressed. Staff are receiving supervision and some staff have now commenced their NVQ 2. Minor maintenance issues have been addressed. There is a training schedule and this shows regular attendance for core training sessions. All residents who are able now sign for their personal allowances. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pembroke Lodge DS0000014224.V277920.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 DS0000014224.V277920.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): 1,2,3,4,5. The home provides sufficient documentation to ensure that prospective and existing residents have the information to make an informed choice over whether they wish to make Pembroke Lodge their home. EVIDENCE: The home produces a combined service users guide and statement of purpose, which meets this standard. Residents confirmed that they have received a copy of the service users guide. All residents receive a copy of the terms and conditions at the point of entry into the home, this needs to identify the fee breakdown in order to meet this standard and this was discussed with the provider. All prospective residents are assessed by the manager prior to their admission into the home, and this preadmission assessment forms the basis of the care plan. New residents spoken with confirmed that the manager had come to visit them prior to their admission, or they had come to the home and been assessed there. All residents stated that both they and their relatives or representatives had the opportunity to visit and meet staff and other residents prior to making the decision to move into the home. Pembroke Lodge DS0000014224.V277920.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): 7.8.9.10.11 Care plans need to address the care to be given in more detail, but otherwise are good, addressing the assessed needs of the residents. Some aspects of ensuring residents fitness to self medicate, needs addressing. EVIDENCE: A random selection of ten care plans were examined and were seen to have been reviewed on a monthly basis, to show participation by the resident or their representative and to include care planning relative to the assessed needs of the resident. It is recommended that care plans show more detail in addressing how care is to be given, and must address any change in the needs of the resident, due to illness, GP or nurse recommendations or other. A full plan of care must be included to address these new needs rather than the needs being detailed in the medical care notes. This was discussed with the deputy manager and the provider. Nursing care is provided by the District Nurses, and four that were visiting the home were spoken with. They felt that the residents were well cared for and that any instructions they gave in respect of residents care, were followed. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 10 They stated that they were called in as appropriate and one said that the home appeared to be “a good place”. Residents stated that they were “ well looked after” and “ they always call the doctor straight away”, and residents appeared well cared for. The clinic room was clean and all medications were seen to have been signed following administration. The storage and recording of controlled drugs was good and it is recommended that a drug counting triangle is obtained to avoid the handling of drugs when counted. The risk assessment for self-medication requires reviewing on a regular basis and the policy or procedure document may need reviewing. It was noted that two residents tablets in their rooms, which were not locked away, and the manager must address this, as it could be a safety hazard for other residents. Residents spoken with stated that the staff were “ Very good”, “ Are always polite and cheerful” and “They respect us and our privacy”. Pembroke Lodge DS0000014224.V277920.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): 12,13,14,15 The standard of catering and the activities provided by the home enable residents to enjoy a good quality of life. EVIDENCE: There is an activities programme and some outings and activities are arranged. Most residents are able to take themselves out, but the home arranges outings in conjunction with its other home. There is no activities organiser but activities are arranged by the care staff and include music and video afternoons. Residents stated that they were happy with the outings and activities provided and questionnaires returned by residents to the CSCI affirmed this. Residents spoken with stated that they had choices in the activities of daily living and could rise and retire when they wished. There is open visiting and a minister of religion visits to hold a service once a fortnight. Residents are encouraged to take part in the civil process by postal votes, and the staff said that some of them treat this as a matter of importance and raise concerns if their voting form does not arrive. The menu is varied and includes fresh fruit and vegetables. All residents have the choice of a cooked breakfast each day. The menu at lunch time shows only one choice but the cook states that vegetarian meals are available and that if a Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 12 resident does not want the menu of the day, other food can be provided. There is a choice of four options at suppertime, which includes soup, sandwiches, and a cooked option. Most cake, pastry and desserts are home made and residents said they have cakes on most days. Residents stated that a good diet was provided and that the standard of catering was good, comments such as ‘ The food is lovely’ and ‘its all home cooked’, being made. The meal of the day was Fish, chips and peas, followed by rice pudding or homemade banana whips. The kitchen was clean and records of fridge and freezer temperatures were in place. All staff involved in the handling of food have attained the food hygiene course. Pembroke Lodge DS0000014224.V277920.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): 16,17, 18 The home has a suitable complaints policy and residents were aware of to whom to make a complaint and were confident that this would be dealt with in a fair manner. Staff were aware of their duties relevant to the protection of those within their care. EVIDENCE: The home has a complaints procedure which is displayed in the entrance hall and a copy of this is included in the service users guide. No complaints have been received by the CSCI and the complaints file kept by the home shows that only minor complaints have been received. These have been appropriately dealt with. Staff have attended adult protection training and staff spoken with were aware of their responsibilities towards those in their care. The POVA procedure has not been required to be invoked for any resident at the home since the last inspection. Residents are able to participate in the civic process by postal voting and solicitors and advocates are accessed for residents should they require this facility. Staff spoken with were aware of the whistle blowing policy within the home. Pembroke Lodge DS0000014224.V277920.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): 19,20,21, 23,244,25,26 The home provides a pleasant and well-maintained environment for residents. Some issues need attention and these were discussed with the provider. EVIDENCE: Pembroke Lodge is a large detached building situated on three floors, all of which are served by a shaft lift. It has a large garden, which is well maintained. The standard of decoration and maintenance within the home is good and notes are kept of necessary maintenance issues, which are dealt with as they occur. The home has a large lounge/ dining room on the ground floor and a further smaller lounge on the first floor. All are well decorated and comfortably furnished. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 15 The first floor lounge and room 14 require a window restrictor or risk assessment, and individual water outlets should be tested to ensure they are within the recommended parameters. It is recommended that this be done on a monthly basis whilst baths are tested prior to use, or at least weekly. Radiators do not have radiator guards but temperatures are tested daily to ensure that these are within a safe range. All bedrooms are single and have en-suite facilities, some also have a bath. This is in addition to the two communal bathrooms. Rooms are well decorated and residents have a lockable facility in their rooms, they also said that keys to their rooms are available if they wish to have them. The home is in the process of having a bath hoist fitted in one of the two communal bathrooms. The home has a suitably equipped laundry although the statement of purpose identifies that the home does not do personal laundry and the laundry room is only used for laundry generated from the running of the home. Disposable aprons are provided in the kitchen and staff must wear these when entering the kitchen. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 16 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): 27, 28,29,30 Staff receive sufficient training and have the experience to meet the assessed needs of residents. EVIDENCE: Duty rotas showed that the home employs sufficient staff to meet the needs of the residents. There are two care staff and a cook and a domestic on duty in the mornings, 2 care staff in the afternoon and evening and one sleeping night staff. There is always a senior member of staff on duty and managers give on call support. Residents said that there were enough staff on duty and that they did not feel that the staff were overly busy. Staff also stated that they felt that they were adequately staffed. Training files showed that staff have attended a variety of training including mandatory training, and new staff commence with an induction course. Some staff have now commenced NVQ2 Personnel files were seen to include all documentation as required by the regulations, all staff also having a statement of terms and conditions and a copy of the GSCC code of conduct. Pembroke Lodge DS0000014224.V277920.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): 31,32,33,34,35,36,37,38 The management and ethos within the home is good providing a good atmosphere for residents. Some health and safety issues need attention to ensure resident’s safety. EVIDENCE: The manager, Ms Joanne Lee has obtained the NVQ4 and is studying for the registered managers award. She has obtained her NVQ assessors award and is registered by the CSCI. She has been in post for twenty months following many years experience in care. The ethos in the home is good. Staff turnover is low and some staff have worked in the home for several years. Residents said that “ there is so much kindness here, staff work well together and everyone gets on so well”, “ the staff are very good and there is a sense of fairness in the home, everyone likes everyone”. Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 18 Staff stated that the management of the home was “excellent” and that they enjoyed working in the home. The home sends out a resident questionnaire at regular intervals and the answers are evaluated. The CSCI questionnaires were returned and these identified that residents were happy living within the home and had no concerns. The home has achieved its “Investors in People Award” again this year. The homes financial position and the way it deals with residents finances were examined at the last inspection and found satisfactory. Some policies and procedures need to show evidence that they have been reviewed on a regular basis. Staff supervision is now taking place at intervals recommended by the standard. Regulation 26 provider visits have taken place, although there is no evidence that these had been received by the CSCI since September 2005. This may have been in agreement with the previous inspector to the home. The provider comments on this will be welcomed. The majority of certificates relating to maintenance of equipment and mandatory training were in place but the annual Landlords Gas certificate was not in place. Pembroke Lodge DS0000014224.V277920.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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 3 3 3 x 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 2 2 Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? no 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 OP9 OP25 Regulation Reg 13(2) Reg 13(4) Requirement That regular review of service users fitness to self medicate is in place. That the water temperature from service users outlets and communal bathrooms are tested and recorded on a regular basis and maintained within recommended parameters That window restrictors or risk assessments are put in place for those windows identified and all other windows are checked. That up to date gas and electric certificates are obtained That a method of ensuring safety in case of fire is found for those residents who wish their doors to be left open. Timescale for action 10/03/06 01/03/06 3 OP25 Reg 13(4) 01/03/06 4 5 OP38 OP38 Reg 13(4) Reg 23(4) 01/03/06 01/03/06 Pembroke Lodge DS0000014224.V277920.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 Refer to Standard OP2 Good Practice Recommendations That information regarding the amount of money payable by all service users including those funded by Local Authority is included in the statement of terms and conditions That care plans show the care to be given in more detail That a triangle for counting controlled drugs is obtained. 2 3 OP7 OP9 Pembroke Lodge DS0000014224.V277920.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Lodge DS0000014224.V277920.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. 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