Inspection on 17/04/07 for Pembroke Residential Home

This inspection was carried out on 17th April 2007.

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 Residential Home 01/09/05

Pembroke Residential Home 18/04/05

Pembroke Residential Home 04/10/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Pembroke Residential Home 81 Marine Parade Saltburn TS12 1EL Lead Inspector Katherine Acheson Key Unannounced Inspection 17th April 2007 09:40 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 Residential Home DS0000061528.V335093.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 Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pembroke Residential Home Address 81 Marine Parade Saltburn TS12 1EL 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) 01287 625334 F/P 01287 625334 Mr Robert Andrew Finney Mrs Judith Ann Weedall Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Pembroke Residential Home is located on Marine Parade, Saltburn in a pleasant location overlooking the sea. The home is situated within a row of large houses and is a short walk from the local shopping centre and public transport facilities. It offers long-term care for up to twelve elderly people. There are eight single and two double bedrooms located on the ground and first floor with a stair lift to provide access to the upper storey. All bedrooms 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. The cost of care at the time of the inspection visit was £405.71 per week. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection lasted for seven and a half hours. Two residents, one relative and one care assistant were spoken to during the visit. A lengthy discussion also took place with the Manager. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Numerous records including care plans, menus, quality assurance, complaints and staff recruitment and training records were examined. The Inspector walked around the home with the Manager. Requirements identified at the last inspection in September 2005 were revisited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: The home is well run and a good standard of care is provided to residents. Residents are happy and their needs are catered for. Food provided is appetizing and enjoyable, activities and outings are stimulating and fulfilling. Staff working at the home are well trained and knowledgeable. Residents and relative comments made during the inspection included, “I can’t fault anything they do, the staff are wonderful and the meals are excellent” “You couldn’t find a better home in the world, it is wonderfully placed with views right across the sea front” “The staff are a friendly lot” Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 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 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 Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 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 Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: The Manager said that before going into the home residents are assessed by a Social Worker. The home then carries out their own assessment of the person to ensure that their needs can be met at Pembroke. Any emergency admission to the home would have had a basic assessment carried out by a Social Worker with further assessment taking place soon after admission. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 9 Care plans looked at during the inspection highlighted that both the Social Workers and homes assessment were used, along with discussion with the resident and their family to form a detailed plan of care. The Manager said that where possible prospective residents and their families are encouraged to visit the home and spend some time with other residents residing at Pembroke. Pembroke does not provide intermediate care so standard 6 is not applicable to this home. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 10 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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care. Care plans are detailed, which will help to ensure that resident’s needs are met. Some improvements are needed in respect of medication practice to reduce/prevent errors. EVIDENCE: Two plans of care were looked at during this visit both of which contained detailed information about the resident and the help they needed. Care plans gave a very informative life history of the person going back to childhood and including relevant and important parts of their life. Likes, dislikes and personal preferences were recorded. Care plans showed clear evidence of choice. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 11 Care records and information in respect of residents was stored in lots of separate files and although very informative was difficult to follow. The Manager said that she is to develop an individual file for each resident so that all information can be stored in one place. Care plans were evaluated on a monthly basis. Evaluations included deteriorations and improvements made. Two residents and one relative were spoken to during the visit comments made included, You couldn’t find a better home in the world, the staff are wonderful” “I’m very happy I couldn’t be happier” “They are pretty good I have no complaints” “The staff are a friendly lot” “The girls are very caring” “They really do think these carers. They put fitted sheets on my bed because I was restless as the others kept coming off” Residents spoken to say that their privacy and dignity was respected. During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication were observed and examined. The home has a medication policy. The Manager said that staff who administer medication to residents have all received appropriate training, however this did not include a competency check. In recognition of this the Manager showed the Inspector a new checklist that had been devised to carry out the task of observation and competency checks for staff giving out medication. During the visit a medication audit on one residents medication was carried out. Medicines prescribed by the GP were written up on a Medication Administration Chart (MAR chart). The home use the MAR chart to record the amount of medication coming into the home and check that it matches with the amount prescribed and dispensed. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 12 MAR charts contain a code to use if medicines are not administered, an example being if a resident was in hospital or refused their medication, however staff are not always using the codes. If medicines are not administered for any particular reason then a full and clear explanation should be given. The majority of medication prescribed is dispensed by the Pharmacist in blister packs, however some medication in particular tablets to control pain are dispensed in a bottle or packet. It was noticed that if more than one resident was on the same pain control then staff would not use dispensed medication for each individual resident but use one packet/bottle for all and when that ran out use another residents. The Manager was informed that this practice must stop and that each resident must get their own medication. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate and enjoyable activities do take place at the home. Residents are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is varied, appetizing and appealing and provides residents with a wholesome balanced diet EVIDENCE: The Manager said that the home has a weekly plan of activities for residents, however this more often than not changes on a daily basis to reflect resident choice. Activities mentioned included crosswords sing songs, dominoes, walks along the sea front and fairly regular trips out. Residents spoken to during the inspection said, “Yesterday they took two of us to the sea front for ice cream” Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 14 “We have someone who plays the electronic piano to us once a month” “Two guitarists come and sing songs, they came the other night” “I join in the quiz, bingo and sing songs” The home supports residents to practice their religion. Care plans examined during this inspection gave detailed information in respect of supporting individuals spiritually, socially and through prayer. One resident spoken to during the inspection said, “I used to go to church when I lived at home, I say my prayers every night. I would like to have occasional communion if it can be arranged”. The Manager advised that although the home have visiting clergy the home at present do not have anyone from the Roman Catholic church visiting, however she would try to arrange. Residents spoken to during the inspection said that contact with family and friends is encouraged and that visitors are made to feel welcome at any time. Residents interviewed spoke of flexibility in routine and freedom of choice. The lunchtime of residents was observed. Mealtime was relaxing with residents enjoying the food provided. The lunchtime menu on the day was braising steak or sausage with carrots, cabbage and potato. Pudding was apple crumble with custard or yoghurt. Residents spoken to said, “The meals are excellent, they always put the menu on the board” “I absolutely clear my plate every time” “The food is alright, the braising steak was nice and tender and I like the fish and chips on a Friday”. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are encouraged and supported to make any complaints they feel necessary. Adult protection procedures are in place, which helps to protect residents from abuse. EVIDENCE: The home has a complaint procedure. This procedure should be updated to inform residents/relatives of their right to complain to any commissioning authorities such as the Primary Care Trust or Social Services. The complaint procedure within the statement of purpose/service user guide should also to be updated to include such information. Residents spoken to during the inspection said that they would feel comfortable in raising and concern or making a complaint to the staff or management of the home. The home keeps a record of complaints. There have not been any complaints made to the home or the Commission for Social Care Inspection in the last twelve months. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 16 The homes adult protection procedure has been developed in line with the Department of Health guidance No Secrets, however this could be better if it included name and telephone number of who to contact within the Social Services if abuse is suspected. There have not been any adult protection referrals in the last twelve months. The Manager said that staff receive regular updates in adult protection and signs and symptoms of abuse. The one staff member spoken to during the inspection was able to give clear information of what she would do if abuse was suspected. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing the people who live there with an attractive, homely and comfortable place to live. EVIDENCE: The Inspector walked around the home with the Manager. Lounge and dining room areas were homely and generally well maintained. The Manager said that the majority of residents had brought in their favourite lounge chair when they came into the home to create familiarity and promote comfort. Bedrooms looked at during the visit were personalized and contained appropriate furniture. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 18 The Manager said that the home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. Appropriate laundry facilities are in place. On the day of the inspection the home was observed to be clean and odour free. One resident said, “It’s hoovered every day it’s very clean” another said, “It is a wonderfully placed home with views right across the sea front”. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are trained, skilled and in sufficient numbers to meet the needs of people living at the home. EVIDENCE: The homes duty rota showed that there is two care staff on duty from eight in a morning to nine at night. On night duty there is one care staff member on duty with the Manager, who lives on the premises on call. In addition the Manager of the home works from eight in the morning to four in the afternoon Monday to Friday, however advised works many more hours as she lives on the premises. Both residents and staff said that there was enough staff on duty to meet the needs of people living at the home. The Manager said that 100 of the care staff are trained to a minimum of NVQ level 2 in care. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 20 The file of the last staff member employed to work at the home was examined during the inspection. This file contained the required documents including, a photograph, proof of identity, two references one being from the last employer. A Criminal Record Bureau disclosure and POVA first (Protection of Vulnerable Adults) check had been carried out on this person, however both were dated after the staff member started working at the home. The Manager said that this staff member had worked supervised until both checks had been received. The Manager was informed that the home must be in receipt of a clear POVA first check prior to commencement of employment of a new staff member and that they must be supervised until a satisfactory Criminal Record Bureau Check is received. The Manager said that she keeps a record of all staff working at the home, the day they started working, qualifications held an a record of the date their employment ceases. Records were available to confirm that new staff receive induction training. Records were available to confirm that regular training is provided to staff working at the home, this included, Moving and handling, fire, abuse training, medication training and first aid. The Manager is clearly committed to ensuring that staff working at the home are trained and competent to do their jobs. Other training undertaken by staff in the last twelve months has included, infection control, dementia care, and caring for someone who is diabetic or has had a stroke. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 21 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, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general the home is well managed, quality assurance systems are in place to ensure that the home is run in the best interest of residents. EVIDENCE: The Manager is both experienced and qualified. The Manager said that she has undertaken lots of training in the last twelve months including, dementia awareness, diabetes and stroke training in addition to required mandatory training. Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 22 It is evident following the inspection that the Manager demonstrates clear leadership. Residents, relatives and staff are involved in the decision making to ensure that the home is run in the best interest of residents. Residents, staff and the one relative spoken to during the inspection spoke highly of the Manager, staff team and care that is provided. Comments made included, “I have a good Manager, I like my job and I like to care” “The Manager is very very nice” “The girls are very caring and residents are reasonably happy”. Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents on a six monthly basis to see if they are happy with the home and care that is provided, however the results are not published and made available. The Manager said that she would take action to address the situation. One comment received from a relative on a survey stated “Only suggestion I would make, when it’s our time please save us a room”. The Manager said that being a small home and living on the premises she is able to speak to residents and relatives on a daily basis to ensure they are satisfied. The home looks after small amounts of money belonging to some residents. Appropriate records of transactions are kept. Records were available to confirm that the Manager does regular checks on the fire alarm system. Water temperatures in the home are also taken and recorded on a regular basis. A gas safety inspection of the home was undertaken in August 2006 this highlighted some concerns, which the Manager says have been addressed. A new fire alarm was fitted to the home in December 2005, however this has not been serviced since. Fire extinguishers were serviced in December 2006. The majority of staff working at the home have received one day first aid training. Appropriate records of accidents in the home environment are kept Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 24 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 Standard OP9 Regulation 13 Requirement The Registered Person must ensure that each resident receives individual medication dispensed for them to avoid any errors The Registered Person must ensure that the competency of staff administering medication is checked in order to ensure safe practice The Registered Person must ensure that appropriate employment checks are carried out and received prior to the commencement of employment to ensure safety of residents The Registered Person must ensure that the results of the residents and relatives surveys are published and made available to all to inform of the findings The Registered Person must ensure that the homes fire alarm system is serviced on a yearly basis Timescale for action 17/04/07 2 OP9 13 17/04/07 3 OP29 13 17/04/07 4 OP33 24 30/07/07 5 OP38 23 17/04/07 Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 25 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 OP9 OP16 Good Practice Recommendations A full and clear explanation should be given if prescribed medication is not administered. The Complaints policy/procedure should be updated to include information of resident’s rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The homes statement of purpose and service user guide should also be updated to reflect such information. The Adult Protection policy/procedure should be developed to include telephone number and who to contact within Social Services if abuse is suspected 3 OP18 Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Residential Home DS0000061528.V335093.R01.S.doc Version 5.2 Page 27 - 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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