Inspection on 03/10/05 for Pembroke Lodge

This inspection was carried out on 3rd October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pembroke Lodge 08/12/09

Pembroke Lodge 05/11/07

Pembroke Lodge 12/03/07

Pembroke Lodge 21/04/05

Pembroke Lodge 04/10/04

Pembroke Lodge 08/07/04

Pembroke Lodge 09/03/04

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

CARE HOME ADULTS 18-65 Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle Announced Inspection 3rd October 2005 09:00 Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 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 Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 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 Adults 18-65. 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. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD 01722 742066 Address Telephone number Fax number Email address 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) Glenside Manor Healthcare Services Ltd Mrs Anita Diane Smith Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The staffing levels set out in the Notice of Decision dated 18 November 2002 must be met at all times 21st April 2005 Date of last inspection Brief Description of the Service: Glenside Centre for Brain Injury Assessment and Rehabilitation is a 14 bedded nursing assessment and rehabilitation unit for younger adults with acquired brain injury. The centre is also known as the ARC. The ARC is not a long term care facility but based on rehabilitation, therefore following rehabilitation, the Service User will move on to another appropriate facility. The building was purpose built for the client group. All bedrooms and living facilities are on the ground floor, with wide corridors. The bedrooms are single all with an en-suite facility providing a good standard of accommodation. A team of nursing staff, physiotherapists, occupational therapists and rehabilitation assistants provide care and support to the Service Users group. The ARC is one of six registered care homes on one campus which are owned by Glenside Manor Health Service Ltd. Mrs Anita Smith is the Registered Manager. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection commenced at 9.20am and was completed at 1.30pm. There were nine service users in the home. The registered manager Anita Smith assisted the inspector. The inspection included a tour of the premises, visiting each bedroom, speaking with service users and staff and inspecting a number of records. Inspection of staff recruitment and training records took place on the 5th October 2005. Mary Collier, pharmacy inspector also visited the home on this date and assessed the medications. What the service does well: What has improved since the last inspection? What they could do better: Where a care need has been identified in the care plan the staff must ensure the need is fully addressed. Recruitment procedures need to be more robust as not all of the required documents relating to staff were in place. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A clear admission procedure is in place and all needs are fully assessed prior to admission. Visits to the unit by service users prior to admission are encouraged. All service users are provided with written contracts. EVIDENCE: All service users are fully assessed by the Registered Manager or the Operational Manager for the Glenside group prior to admission, ensuring that through the assessment process the home is able to meet all nursing and rehabilitation needs of the individual service user. A multidisciplinary team approach is taken for each prospective service user admitted to the ARC, with involvement from social workers, health care professionals and family. The pre admission assessment is a comprehensive assessment of physical and mental health needs, social needs and rehabilitation needs. All admissions to the Arc are planned and where possible service users and families can visit the centre prior to admission depending on health care needs and travelling arrangements. Service users are provided with written contracts which are inclusive of all terms and conditions of the centre. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Comprehensive care plans are provided which fully involve the service user. Service Users are supported by the home as part of their rehabilitation programme to take risks. EVIDENCE: Comprehensive individual care plans are provided for each service user. The care plans involve the nursing needs of the service user and a detailed plan of rehabilitation needs and progress made. The plans are regularly reviewed in line with a monthly multidisciplinary goal planning meeting which is held for each service user. Evidence of service users involvement with the care plan was available. However the home should ensure that if the care plan has been implemented with a direct instruction such as to weigh a service user weekly or monitor blood pressure weekly that these areas of care are carried out weekly. The Arc is aimed at providing a good rehabilitation programme based on an outcome of service users leading an independent lifestyle where possible. The home will support service user to take risks within a risk assessment framework. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The ARC provides a comprehensive rehabilitation programme, however basic social activities are limited. The food provided by the home is enjoyed by service users and is supported by a varied and balanced menu. EVIDENCE: The ARC is very focused on providing a detailed and positive rehabilitation programme, which is inclusive of occupational therapy. However speaking with two service users who were sat in the communal area, both wished to do more day- to- day social activities. Plans for a day centre to be developed on site are currently taking place, which will provide more daily activities and social interactions with other service users living on site. At the time of the inspection only four service users were able to eat a normal diet, the other five service users were being fed via a PEG system. The four service users able to eat a normal diet were observed eating together in the dining area. The hot meal of the day was well presented and all four, service users were complimentary of the food provided. However a weekly menu was not displayed and service users when asked were unsure what was for lunch. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 11 Some supplement food products were out of date and food was not dated stored in the fridge. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Healthcare needs of service users are clearly recorded and monitored with appropriate action taken when healthcare needs change. The systems of handling medication are good and service users individual needs are met. EVIDENCE: Care records indicate that health care needs are monitored and assessed and appropriate action taken when health care needs change. All service users are registered with a GP who visits the home weekly or more if needed. Clear entries are made in the care records of other visiting health care professionals. A large team of specialists are employed to support all areas of care needed including speech and language therapist, physiotherapist and a psychologist. The home has a comprehensive medication policy and up to date homely remedies list. All records are appropriately kept and medication stored securely. Records are made of all medication which leaves and returns to the home with service users who spend time away form the site. A disposal system for medication is in place, in line with current legislation. Links are maintained with the hospital and some medication remains under the control of the consultant. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A complaints procedure is in place. As far as possible, service users are protected from possible abuse, although recruitment practices need to improve. EVIDENCE: A complaints procedure is in place, a copy of which is situated in the entrance hall to the Arc for any interested party. Service Users are also provided with a copy of the complaints procedure. No complaints have been received by the CSCI and no serious complaints had been received by the home. A policy regarding protection of vulnerable adults is available and all staff receives mandatory training in abuse awareness. Recruitment procedures need to be more robust with regard to obtaining CRB checks and references. Findings are detailed in the “Staffing” section of this report and there are three statutory requirements relating to this. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The ARC provides a good standard of accommodation which is clean and well maintained meeting the needs of the service users. Infection control measures are in place. EVIDENCE: The ARC was purpose built and designed to meet the needs of the Service User group. The ARC offers a spacious, comfortable and well maintained environment for service users to live in. The communal rooms are furnished in a domestic style and the corridors are wide to suite the needs of wheelchair users. The bedrooms are all single with an en-suite facility. The bedrooms are homely and personalised depending on the individual service user. The home is fully equipped with a range of specialised equipment to meet the needs of the service users. A large well-equipped physiotherapist treatment room is situated within the ARC. The home was cleaned to a good standard of hygiene throughout and odour free. Infection control measures were in place and clinical waste was dealt with appropriately. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The staff receive appropriate training to meet the needs of the service users. In some instances, recruitment procedures do not fully protect service users. EVIDENCE: A selection of staff recruitment records for all of the Glenside units was reviewed. In the main appropriate documentation was in place, however in one instance a CRB check had not been obtained for a staff member who had been employed for almost two years and in two other cases, references from previous employers, one of whom had been a care provider, had not been obtained. Should a person with a criminal record be employed, full details of any convictions should be on file. It is also desirable that written evidence of a risk assessment process, indicating their suitability for employment, be available. Records indicated that staff had received induction, foundation and mandatory training. Further training in relevant subjects such as dementia care and cognitive rehabilitation therapy is also provided. NVQ training is provided and training manager stated that on most units had up to 50 of staff with an NVQ. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users live in a well managed home. Health and safety checks are appropriate providing a safe environment for service users to live in. EVIDENCE: The Registered Manager Mrs Anita Smith is a registered nurse who shows a good understanding and knowledge of the service users group, all of which have complex health care needs. Mrs Smith is supported by the Glenside Operations Manager and weekly meetings are held for all of the registered managers. Fire records indicated that weekly testing of the fire system was taking place and staff had been provided with fire training. All fire exits were clear. All accidents are recorded and records audited regularly. The home is well maintained and equipment used by service users is regularly serviced ensuring the safety of service users. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X 4 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 15/11/05 2 3 4 YA17 YA17 YA34 5 YA34 6 YA34 The registered person will ensure that where a care need has been identifed and recorded in the care records that the care need is fully addressed. 13(1,C) The registered person will ensure that all food supplements are in date. 13(1,C) The registered person will ensure that all food stored in the fridge is correctly dated. 19(1,a,b,I)Sch2 The registered person is required to ensure that all staff have undertaken a Criminal Record Bureau check. 19(4,C)Sch2 The registered person is required to ensure that two written references, including, where applicable, a reference to the persons last employment, be obtained for all new staff. 19(1,a,b,I)Sch2 The registered person is required to ensure that details of any criminal offences of which a staff member has been convicted are recorded. DS0000047643.V254708.R01.S.doc 03/10/05 03/10/05 03/10/05 03/10/05 03/10/05 Glenside Centre for Brain Injury Assessment & Rehabilitation Version 5.0 Page 19 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 YA12 YA17 Good Practice Recommendations The Registered person should consider providing more daily activities. The Registered person should consider displaying a weekly menu so that Service Users are informed and reminded of the weekly menu available. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V254708.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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