Inspection on 07/11/05 for Pembroke Rest Home

This inspection was carried out on 7th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pembroke Rest Home 12/07/07

Pembroke Rest Home 17/07/06

Pembroke Rest Home 07/07/05

Pembroke Rest Home 07/02/05

Pembroke Rest Home 08/07/04

Pembroke Rest Home 06/02/04

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

CARE HOMES FOR OLDER PEOPLE Pembroke Rest Home 2 Pembroke Avenue Walkergate Newcastle Upon Tyne Tyne & Wear NE6 4QU Lead Inspector Deborah Haugh Unannounced Inspection 7th November 2005 09:30 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 Rest Home DS0000000451.V255781.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 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 Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pembroke Rest Home Address 2 Pembroke Avenue Walkergate Newcastle Upon Tyne Tyne & Wear NE6 4QU 0191 224 0862 0191 224 5803 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) Mrs Jennifer Houghton Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (15) of places Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Pembroke House provides care and support for 21 older people who require residential care. Six of the 21 places available are specialist beds for older people with dementia care needs. The Home is situated in a residential area of Walkergate. The accommodation is spread over two floors and offers the following facilities – nineteen single bedrooms, including two with en-suite, and a double bedroom; a central kitchen and laundry; a large lounge and a dining area; a conservatory. A pleasant garden area is available to the side of the building and there is a yard to the rear of the Home.The Home has good access to local facilities and transport systems. On-road parking is available to the front of the building. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The un-announced inspection took place on 7/11/05 from 9.30am until 3.10pm. There were 16 service users living at the home. The home does not have a Registered Manager but the proposed manager Wendy Wood was on duty during the visit. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Time was also spent observing the contact between the service users and staff. Visitors were seen to freely come and go. Two Care Plans were examined. Arrangements for the administration and management of medication were checked. Health and safety arrangements were examined as well as the catering, recruitment, service users finances, fire instruction, training and complaints. What the service does well: What has improved since the last inspection? A number of improvements have been made sine the last inspection regarding the nutritional needs of service users. Care plans and assessments on nutrition are consistently completed and reviewed. Vacuuming the lounge dining room has ceased during meal times and the communication book is now confidential. Service users medication has been reviewed by their GP’s. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 6 A full training programme is underway as well as NVQ training for care staff. 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 Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 & 3 (6 Not applicable) Service users and their representatives are unable to read the Service User Guide. The home ensures that it can meet the needs of the service users as their needs are assessed prior to admission. EVIDENCE: The Service User Guide has been photocopied and placed in bedrooms. The quality of some of the copies seen was illegible. Two service user care plans were examined and assessments are completed which look at a range of the needs of the service users. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 -10 Service users have care plans and risk assessments, which enable them to have their needs met but personal preferences and activities, must be developed more. Service users good health is promoted. Service users receive the medication they require but some areas must improve. Service users feel their privacy is respected and they are treated well. EVIDENCE: Care plans identify a range of needs and assessments. These include mobility, nutrition, skin care, personal hygiene and social care. Improvements have been made regarding nutrition. Personal preferences were not included in the two care plans examined regarding personal care and activities/occupation. The home completes a Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 10 social history and activity assessment but care plans are generalised and do not reflect the assessed information. One service user did not have a care plan for activities/occupation. Meaningful occupation for people is seen as good practice. Two risk assessments are required for a service user who administers their own medication and another for someone who spends some if the day in bed. A moving and handling risk assessment does not include how to transfer a service user only by whom i.e. 1 carer. Service users have access to a range of health professionals such as GP’s, District Nurses, Community Psychiatric Nurses, Chiropodists, Opticians and Dentists. Service users said that they felt that staff respected them and treated them well. Service users are called by their preferred name and this is recorded in their care plans. A full audit of the medication arrangements was completed and some areas require improvement. (See Requirements). Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 -15 It is not clear if service users expectations, choice and preferences are provided by the home (activities). Service users maintain contact with family and friends. On the day of the inspection service users were provided with an adequate nutritious diet. New menus are being developed by the Registered Provider, which will provide more detail of the nutritional value. EVIDENCE: As mentioned in NMS 7 the two care plans examined do not identify the preferences of service users and develop their social interests. Visitors are welcome and staff contact with relatives is positive. The lunchtime meal was corned beef pie or bacon with vegetables and chipped potatoes. The sweet was fruit sponge, custard or fruit and ice cream. Service users said that they enjoyed the meal. The presentation was good. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 12 During lunch two care staff left the dining room and helped the cook wash and dry dishes, leaving the floor unsupervised at times. When asked the manager said this was to help the assistant cook, as she was new. However service users require support and supervision throughout the mealtime. At the last visit to the home in October the lunchtime meal was relaxed and staff were present, sat with service users and encouraging them to eat. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 The Registered Provider takes complaints seriously and visitors feel they can share concerns and make complaints to the home. EVIDENCE: The Registered Provider has a complaints policy and procedure. In the last 12 months there has been 1 anonymous complaint (with 3 elements) to CSCI, which was jointly investigated by the Registered Provider and CSCI. The outcome was unresolved, unresolved and not upheld. Visitors said they would feel able to go to staff and make their concerns known. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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 & 26 Service users do not live in a home which is adequately clean or has adequate housekeeping. EVIDENCE: The manager accompanied the inspector around the home to check the cleanliness, maintenance and decoration. The cleanliness of the home and housekeeping are not acceptable. - A number of emergency pull cords were tied up, or not long enough to reach the floor. Several had ladies hosiery tied on to lengthen the cords. - A shower chair attached to the wall was rusty and as a consequence has sharp edges, which a service user may be injured from. - A freestanding shower chair was not clean and marked underneath the seat. - Identified bedroom en-suite has a strong offensive smell. The floor was sticky. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 15 - A number of bedroom metal lockable cabinets are rusty and not clean. - A large number of towels and flannels in bedrooms were frayed, ripped, stained and threadbare. The manager said all were the service users own towels. This was later found not to be so when the linen supply was checked and no Pembroke Care Home towels were found. A duvet was torn and frayed in the linen cupboard. - A sheet on a bed was ripped and the valance was marked. The sink and surrounding area was dirty and stained. - The clinical waste bin lid in the ground floor bathroom was marked with faeces. The used continence pads were not placed in bags before being put in the bin (double bagging) so there was an offensive odour. - The nearest and most used toilet near the lounge does not have a clinical waste bin and staff use the ground floor bathroom bin. It is strongly recommended that the bin be placed in this toilet. - Bathrooms and shower rooms do not have thermometers for staff to test the water before service users are immersed in hot water. Thermostatic values are fitted to hot water supplies to maintain safe temperatures but temperatures can alter as valves become ‘furred’. The handyman checks the water temperatures weekly. - A shower room extractor requires cleaning. - A vertical blind in room 7 requires repair. - Unlabelled sprays of disinfectant were found in the sluice (written identification had rubbed off). The domestic and laundry hours have been decreased by the Registered Provider due to occupancy rates. The manager must ensure that adequate hours are dedicated to ensuring the cleanliness of the home. Paper towels, disposable gloves and liquid soap are used in the home. The kitchen was well organised and the cook was in the process of cleaning during the inspection. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 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): 27,29 & 30 Staffing numbers are not appropriate to the assessed needs of the service users, size and layout and purpose of the home at all times. Staff must receive fire instruction so that service users are protected. People who have been vetted care for Service users. EVIDENCE: The home does not maintain the level of staffing in accordance with previous agreements with the local authority and this reflects the size and layout of the building and the needs of the service users currently living in the home. The current levels of staffing required are Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 17 Staffing Levels 19 residents 21 residents Domestic Laundry 15 residents 21 residents Cook 15 20 AM 3 4 PM 3 3 EV. 3 3 WAKING NIGHTS 2 2 55.5hours/week 74 hours/week 43.5 47 The Registered Provider has decreased the domestic and laundry hours due to occupancy rates. Reductions in staffing must not occur without prior agreement with CSCI. According to staff rotas for October/November the following hours are allocated Cook Laundry Domestic 49 (35 14) 20 30 (15 15) Using the calculations there must be 55.5 hours a week domestic and laundry in place. The manager and Registered Provider must ensure that adequate hours are dedicated to ensuring the cleanliness of the home. All staff providing personal care to service users are aged at least 18 but on one occasion staff left in charge of the Home have been under 21 years. According to the manager she is currently working 28 hours a week as care and has 12 hours supernumery to complete management tasks. Staff have not received fire instruction at 3 (night staff) and 6 (day staff) monthly intervals. New staff are receiving Induction training. Safe handling of medication training is being provided. Further training is planned for care practices, nutritional awareness, risk assessment, supervisions and decontamination/disinfection. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 18 A training plan was forwarded to CSCI by the Operations Manager which indicated that staff will receive further training in Protection of Vulnerable Adults, Manual Handling, Fire Safety, Food Hygiene, Infection Control and First Aid. Six care staff have NVQ Level 2 and seven are to commence. One staff member has NVQ Level 3 and three are to start. Recruitment of staff was checked and service users are protected through robust systems. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 19 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): 31,33,35 & 38 The home does not have a Registered Manager who is legally responsible for the care of the service users. The Registered Provider works with CSCI and has measures to ensure that service users are provided with a quality service. The home ensures that service users finances, which are looked after by them, are protected but one area requires improvement. Routine servicing and maintenance checks are completed apart from 2 items. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 20 EVIDENCE: The proposed manager is not registered under the Care Standards Act 2000. But is to commence the Registered Managers Qualification. However management systems must ensure that the home is clean and house keeping maintained. The Registered Provider has a Quality Assurance System where audits are undertaken periodically. Regulation 26 monthly visits and the Operations Manager completes reports. However the standards of cleanliness and attention to detail must be maintained. A check of finances looked after on behalf of service users were checked in the presence of the manager. Arrangements were satisfactory but two signatures must be consistently obtained for every transaction. The home employs a handy man and maintenance checks are undertaken such as fire alarms and hot water temperatures. The servicing of equipment is in place such as fire checks, chlorination, lift and hoist servicing. However a carbon dioxide fire extinguisher is required to be fitted next to the electrical cupboard next by the office. The Portable Appliance Test was last completed 6/8/04 and must be completed annually. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 21 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X X X X 1 STAFFING Standard No Score 27 1 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X 2 Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23(4) Requirement Portable Appliance Tests must be completed annually. Timescale for action 30/11/05 2 3 OP35 OP30 Schedule 4 23(4) 4 OP27 18(1) Confirmation must be provided in writing that a carbon dioxide fire extinguisher is provided next to electrical cupboard near the office as per Fire Maintenance Report 7/9/05 Two signatures must be obtained 07/11/05 for records in relation to service users finances. Staff must receive fire 07/11/05 instruction at agreed timescales 3 monthly for night staff and 6 monthly for day staff. The Registered person shall 07/11/05 ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health ands welfare of service users.(Domestic/laundry and care staff). Reductions in staffing must not occur without prior agreement with CSCI. Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 23 5 OP26OP19 23(2) The following environmental 30/11/05 requiremenst must be addressed; - Emergency pull cords must not be tied up and must reach the floor. (Immediate Requirement by 8/11/05) - Repair or replace rusty shower chair. - Clean free standing shower chair. - Take measures to control odour in identified bedroom ensuite - Clean, repair or replace metal bedroom cabinets. - Audit and replace worn linen (towels, duvets, sheets) Immediate Requirement by 8/11/05 - Remove marked valance from identified bedroom (Immediate requirement 7/11/05) - Clean clinical waste bin which has faeces on lid. (Immediate Requirement 7/11/05) - Provide theromemters in each bathroom/shower room. (Immediate Requirement 8/11/05) - Clean extractor fans in bathrooms/shower rooms - Repair vertical blind in rm 7. - Label disinfectant spray on container. (Immediate Requirement 8/11/05) Service users must be provided with appropriate support and supervised during meal times The following medication requirements must be addressed; - Handwritten Medication Administration Records (MAR) must be signed and counter signed. - MAR must record the strength of the prescribed medication DS0000000451.V255781.R01.S.doc 6 7 OP15 OP9 12 13(2) 07/11/05 30/11/05 Pembroke Rest Home Version 5.0 Page 24 8 OP12OP7 15 & 16(1) - Creams when opened must be dated. Care plans must identify service users preferences regarding personal care. Activity care plans must be identified and reflect personal preferences regarding activities/occupation. Risk assessments must be identified for people who wish to self administer their medication and if service users choose to spend long periods in bed through the day. Moving and handling assessments must be in sufficient detail to guide the practice of staff 30/11/05 13(4) 9 10 OP1 OP7 13(5) 5(2) 15 (2) 11 OP36 18(2) 12 OP15 16(2) & Schedule 4 The service user guide must be legible for service users and/or their representatives to read Reviews must be held regarding the care which service users receive and involve the service user and/or their representatives. Staff must receive 1:1 supervision in line with NMS agreed timescales (6 times a year) Records of food provided to service users must be in sufficient detail to determine whether the diet is satisfactory and service users must receive adequate quantities of nutritious food. (offer 2 portions of fruit a day, provide 2 dairy items, use butter to build calorific value, provide detail of snacks and drinks, provide 2 vegetables and DS0000000451.V255781.R01.S.doc 30/11/05 31/12/05 31/12/05 31/12/05 Pembroke Rest Home Version 5.0 Page 25 detail fillings of sandwiches and flavour of soup.) OUTSTANDING 31/7/05 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 OP26 OP9 Good Practice Recommendations Provide clinical waste bin in toilet near lounge/diner Insert allergies on front sheet of MAR Pembroke Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Rest Home DS0000000451.V255781.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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