CARE HOMES FOR OLDER PEOPLE
Pembroke Residential Home 81 Marine Parade Saltburn-by-Sea Cleveland TS12 1EL Lead Inspector
Stephen Smith Unannounced 18 April 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Pembroke Residential Home Address 81 Marine Parade, Saltburn-by-Sea, Cleveland. TS12 1EL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01287 625334 01287 625334 Mr Robert Andrew Finney Mrs Judith Ann Weedall Care Home 12 Category(ies) of OP Older People (12) registration, with number of places Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The registered manager (Mrs Judith Weedall) has, by 2005, a qualification, at level 4 NVQ, in management and care or equivalent. Date of last inspection 04/10/04 Brief Description of the Service: Pembroke Residential Home is located on Marine Parade in Saltburn in a pleasant location overlooking the sea. The home is situated within a row of large houses a short walk from the local shopping entre and public transport facilities. It offers long-term care for up to 12 elderly people. There are 8 single and 2 double bedrooms located on the ground and first floor with a stairlift to provide access to the upper storey. All rooms meet the size requirements of the Care Homes for Older People National Minimum Standards and have hand basins although none contain ensuite toilet or bathing facilities. Downstairs there is a large lounge and a separate dining room. At the rear of the property there is a patio and small garden area with another small garden at the front. The homes registered manager lives on the premises. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9:30 a.m. The inspection lasted for six hours and concentrated on Health and Personal Care, Daily Life and Social Activities, Complaints and Protection and the Environment. During the inspection five service users were spoken to, four as a group and one individually, one relative was spoken to and three staff members were interviewed as a group. The manager was interviewed during the inspection also and accompanied the inspector on a tour of the premises. What the service does well:
Pembroke is a home in which the people who live there are cared for well. The staff team are experienced and well trained and know the residents and their needs well. Residents spoken said “The staff are very good” and that they have a very good relationship with them. One said “We have built up trust with them over the years, we know we can rely on them.” It is noteworthy that there are no requirements and few recommendations made as a result of this inspection. The home provides particularly good health care for its residents and is helped in this by effective relationships with local health services. Residents’ records contain information about residents’ preferences and choices as well as needs and this helps to ensure that residents are provided with a consistent standard of care that meets their needs well. Relationships with the families of residents are very good and the home welcomes visitors and encourages them to feel at home. The manager and staff make a great deal of efforts to provide the residents with a range of activities both inside the home and on trips out and to encourage residents to take part. Residents are well protected by the home’s procedures. The home provides a very homely and comfortable environment that is well maintained and well decorated and this enhances the quality of life of the residents. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 standard(s) These six standards were not inspected but it was found that a recommendation about the home’s statement of purpose, made at the last inspection had not been addressed. EVIDENCE: Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 standard(s) 7, 8, 9 and 10 The home plans well for and is good at meeting the health, personal and social care needs of the people who live there. EVIDENCE: The home’s care planning system is comprehensive and the records viewed contained detailed information about the care provided. During the visit the inspector spoke to five residents who said that they are well cared for; they said, “The staff are very good.” Residents’ views and preferences are recorded in their plans of care and the signatures of residents were seen in plans. Residents spoken to said that they are treated with respect and provided with dignity, they said that most staff have worked at the home for a long time and that relationships between staff and residents are very good. The staff members spoken to know the people who use the service well and are experienced in working with older people. The way that they described working with residents was confirmed by the residents spoken to and reflects the home’s good practice in this area. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 10 Care plans examined contained records of all health treatments sought for residents and showed that the home works closely with health services to ensure that residents get the treatment they need. Residents said that their health needs are looked after and staff members and residents said that relationships with local doctors are very good. The home’s system for storing, administering and recording medication was seen to be effective, storage is safe and complies with the relevant regulations and records of medication received at the home, given to residents and returned to the pharmacy were seen to be accurate. Records of a controlled drug were well maintained. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14 and 15 Residents’ daily lives are enhanced by the social activities provided by the home and by the welcome it extends to residents’ visitors. Dietary needs of residents are well catered for. EVIDENCE: The people living at the home who were spoken to during the inspection said that activities are provided in the home including bingo, dominoes, and discussions about news items. They also said that an entertainer comes in on a monthly basis and clothes parties take place occasionally. They said that trips out are arranged but those spoken to said that they choose not to go out much over winter but would go out more in the summer. Discussion with staff members and the manager and reading of records showed that shopping trips and a trip to the theatre had taken place over the winter months. The home has recently started to organise sessions in which a staff member reads news items to a group of residents and then a discussion of the item takes place. The inspector was also told by the manager and staff that a group of people from a local church have started to visit the home and spend time talking to residents. The relative and residents interviewed said that the home welcomes and encourages visitors and a number were present during the inspection.
Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 12 The inspector noted the good relationships between staff and the visitors and the fact that visitors appeared to feel ‘at home’. The home arranges the service of a person who acts as an advocate and visits the home regularly and spends time with service users in order to help them express their views. All residents spoken to said that the food is good and reflects their wishes. They said that they can choose what they eat and that the menu is flexible based on their wishes. The inspector ate lunch during the inspection and found the food provided to be tasty and well prepared. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 standard(s) 16 and 18 The home provides effective arrangements to ensure that residents are enabled and supported to make any complaint they consider necessary. Staff are well trained in and understand adult protection issues; this helps protect residents. EVIDENCE: The home has a clear complaints procedure and information about how to make a complaint is displayed around the home including on notice boards in residents’ bedrooms. The relative spoken to said that she knows how to make a complaint but has not had to do so. She said that relationships with the manager and staff are very good and any day-to-day issues are sorted out quickly. Residents spoken to said that they had no complaints and that the home’s manager and staff are very good and listen to their views. Staff members spoken to understood the complaints procedure well. It was noted from discussion that some further work with staff would be helpful in order to ensure consistency in how staff would handle the initial receipt of any complaint. All residents spoken to during the inspection said that they feel safe at the home; the resident spoken to also expressed this view. The home has a clear policy and procedure in place and staff members have received training in adult protection. In discussion with the inspector three staff members demonstrated their understanding of the home’s procedure and knew the action that they would take if they suspected abuse might be occurring. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. EVIDENCE: A tour of the premises showed that the home is well maintained internally and externally. During the inspection the manager pointed out minor areas where work is planned to take place to enhance the environment and appearance further. Suitable communal space is provided for residents and these areas are decorated in a homely and comfortable manner, as are the home’s toilet and bathroom areas, which provide any aids needed by residents. The temperature of water tested was at a safe level and previous problems with hot water supply in the home have now been solved. Residents’ bedrooms are homely and personalised with many personal belongings being evident. All rooms visited were well decorated and furnished though the carpet in one room was noticeably faded in places and in need of replacement. The manager contacted the registered provider whilst the
Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 15 inspector was in the home and received permission to have the carpet replaced. The home is well lit and, at the time of the inspection, was comfortably warm. At the time of this unannounced visit the home was commendably clean and hygienic with good facilities and procedures for handling laundry and preventing odours or the spread of infection. Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These four standards were not inspected but it was found that a recommendation about staff records, made at the last inspection had been addressed. EVIDENCE: Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These eight standards were not inspected but it was found that a recommendation about the manager’s qualifications, made at the last inspection is being addressed but has not been completed. EVIDENCE: Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There were no requirements identified at this inspection. Timescale for action 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 1 Good Practice Recommendations The information within the statement of purpose relating to the organisational structure of the care home and the arrangements for consultation with service users should be developed further. This was identified at the last inspection of the home. It is recommended that some further work with staff take place in order to ensure consistency in how staff would handle the initial receipt of any complaint. The faded carpet in bedroom 2 should be replaced. The manager should continue to work towards achieving NVQ level 4 in Care by 2005. 2. 3. 4. 16 24 31 Pembroke Residential Home B51-B01 SN61528 Pembroke VN221237 180405 Stage 4.doc Version 1.20 Page 20 Commission for Social Care Inspection Unit B - Advance St Marks Court Teesdale Stockton-on-Tees. TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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