Care Home: Pembroke Lodge

Similar services:

• The Shelley
• Springfield House
• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House

What the care home does well The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident in the home. Residents spoke positively about their experiences at the home.Pembroke LodgeDS0000014224.V376291.R02.S.docVersion 5.2The staff was observed to deliver care with dignity and respect. Four residents spoken with felt the care provided respected their privacy and dignity. Residents live in a clean and homely environment, with their private accommodation personalised to suit their taste. What has improved since the last inspection? Staff recruitment files contain the required information. A robust recruitment procedure has been put in place. The pre-admission procedure has been developed to request and record more information about a prospective resident. Residents are protected by a risk assessment in place in relation to falls Storage and recording of controlled drugs has been put in place to meet current requirements. An administrator post has been created to assist the manager and liaise with the residents. The laundry room has been upgraded and a storage room provided for mobility equipment in the home. The induction for new care workers has been checked to ensure it meets the Skills for Care Induction Standards. Regular fire drills have been maintained. The outcome of the quality assurance undertaken in the home has been collated and residents informed of the outcome. Further guidance has been sought from Environmental Health as to the controls in place in relation to the unguarded radiators. What the care home could do better: No Requirements and Recommendations have been made following this inspection. Where shortfalls have been identified the proprietor was able to demonstrate or stated work would be completed to address the issues. The Statement of Purpose and Service Users Guide would benefit from further development to ensure residents and their representatives have all the information to make a choice as to becoming a resident in the home. Residents would benefit from further development of the social activities provided in the home, to ensure all their social care needs are met in the home.Pembroke LodgeDS0000014224.V376291.R02.S.doc Version 5.2 A system should be in place to ensure that the CQC is informed of incidents in the home, to protect the residents. Care workers supervision should be re-started and maintained to support care workers and ensure they continue to have the skills to meet the care needs of the residents. Staff training records should continue to be developed to clearly detail the training that staff has completed and when any updates are required. To ensure all staff have received the required training and updates. Key inspection report CARE HOMES FOR OLDER PEOPLE Pembroke Lodge 8/10 Aymer Road Hove East Sussex BN3 4GA Lead Inspector Judy Gossedge Key Unannounced Inspection 13th August 2009 11:10 DS0000014224.V376291.R02.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pembroke Lodge Address 8/10 Aymer Road Hove East Sussex BN3 4GA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 777286 01273 779069 admin@pembrokelodgeresthome.co.uk Mr L Brand Mrs Susan Brand Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number to be accommodated is nineteen (19) Date of last inspection 14th August 2008 Brief Description of the Service: Pembroke Lodge is a privately run care home registered for up to 19 older people. It offers hotel style accommodation to people aged over 65 who are independent and mobile. It does not provide nursing care. The detached building is situated close to the seafront and town centre of Hove, with all local amenities and transport routes conveniently nearby. Accommodation is on three floors with access via a passenger lift: all bedrooms are en-suite. There are two lounges, the larger one located on the ground floor and another, smaller one on the first floor. Paid parking is available in the streets around the home. The service is aimed at retired people who wish to maintain an independent lifestyle and continue to live their lives to their maximum potential. The home has achieved various awards, including ‘5 stars on the doors’ awarded by Brighton & Hove Environmental Health Department; Investors in People and Residential Domiciliary Benchmark star rating. The current fees are from £425.00 to £525.00 per week. Chiropody, hairdressing and complimentary therapies are additional extras. At the time of the inspection a copy of the homes Statement of Purpose and Service User Guide was available for reference. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations`2001 uses the term ‘service users’ to describe those living in care home settings. For the purpose of this report, those living at Pembroke Lodge will be referred to as ’residents.’ This unannounced key inspection took place over five hours between 11:10 and 16:10 on 13 August 2009. The last key inspection was undertaken on 14 August 2008. The Manager had been asked to complete an Annual Quality Assurance Assessment (AQAA), which was detailed and information from which is quoted in this report. Communal areas and a selection of resident’s bedrooms were viewed during the inspection. A sample of care records were viewed and are detailed in the report. Twelve people were resident and five were spoken with individually in their bedroom or in the garden. The care that three of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. Eight residents surveys were sent out and five came back completed. Information was sought on the day from two care workers; the cook, the domestic support, the proprietor and the deputy manager. Three care workers surveys were sent out and one completed survey was returned. Four relatives and visitors were spoken with during the inspection. The Registered Manager has left working in the home. The proprietor is currently working in the home whilst new management arrangements are put in place. The proprietor has acknowledged during the transition period some of the recording has lapsed, but that she and the deputy manager are working to address the shortfalls. What the service does well: The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident in the home. Residents spoke positively about their experiences at the home. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 6 The staff was observed to deliver care with dignity and respect. Four residents spoken with felt the care provided respected their privacy and dignity. Residents live in a clean and homely environment, with their private accommodation personalised to suit their taste. What has improved since the last inspection? What they could do better: No Requirements and Recommendations have been made following this inspection. Where shortfalls have been identified the proprietor was able to demonstrate or stated work would be completed to address the issues. The Statement of Purpose and Service Users Guide would benefit from further development to ensure residents and their representatives have all the information to make a choice as to becoming a resident in the home. Residents would benefit from further development of the social activities provided in the home, to ensure all their social care needs are met in the home. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 7 A system should be in place to ensure that the CQC is informed of incidents in the home, to protect the residents. Care workers supervision should be re-started and maintained to support care workers and ensure they continue to have the skills to meet the care needs of the residents. Staff training records should continue to be developed to clearly detail the training that staff has completed and when any updates are required. To ensure all staff have received the required training and updates. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is information about the home available for residents and their representatives to view. Potential new residents are individually assessed prior to an admission to ensure that their care needs can be met in the home. Intermediate care is not provided in the home. EVIDENCE: The joint Statement of Purpose and Service User’s Guide was read during the inspection. This recorded it had been reviewed and further detail as required has been included in the documents. This should continue to be developed to ensure all the required information is contained in the document. The AQAA details a copy of the Statement of Purpose and Service Users Guide has been given to the existing residents and a copy is given to prospective residents or their representatives as part of the admission process. A copy of the last Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 10 inspection report is available to read in the home. Three residents surveys stated they had received enough information prior to moving in, one did not know and one did not answer the question. One new resident spoken with had not received any information prior to moving, but stated this was due to limited time between discharge from hospital and admission in to the home The AQAA details that the pre-admission procedure has been reviewed to request and record more information about a potential resident. The deputy manager stated that she visits new residents prior to any admission. This is to ensure individual resident’s care needs can be met in the home and to provide staff with information on the care to be provided. A detailed pre-admissions format has been put in place, and for three new residents admitted to the home since the last inspection there was detailed pre-admission information viewed, which had been completed. Intermediate care is not provided in the home. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected by a detailed individual plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care, which needs to be provided. Supporting risk assessments are also in place. Medication policies and procedures are in place to protect residents. EVIDENCE: Four of the residents individual care plans were viewed and are kept in wellstructured folders. These were detailed and gave clear guidance to staff of the care to be provided, resident’s health care requirements, dietary needs, and social and leisure interests. Supporting risk assessments were also viewed and where there are any identified risks the recording detailed how these will be Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 12 managed. Risk assessments have been further developed to fully demonstrate all residents have a falls risk assessment completed. One resident who went out independently from the home did not have a supporting risk assessment in place. This was discussed with the deputy manager who stated this would be addressed immediately, and the proprietor has subsequently confirmed this had been addressed. So a further Requirement has not been made. The AQAA details that these documents are reviewed monthly. The records viewed detailed these reviews had not been maintained over the last two months. This was discussed with the deputy manager who stated that the reviews would be reinstated and maintained. So a Requirement has not been made on this occasion. The outcome of a resident’s questionnaire sent out by the home in June 2009 was that of the eleven residents who responded, ten stated very good when asked, ’are you satisfied with the standard of care that you receive’ and one stated good. The AQAA details that the home maintains and promotes residents health and help them access health care services to meet their needs. Records viewed evidenced residents are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, those appointments with or visits by health care professionals are recorded. Residents spoken with confirmed good access to their GP. The AQAA details the home has a policy for the handling of medication which includes receiving, recording, storage, handling, administration and disposal of medicine. The storage and recording of administration of control drugs has been reviewed and changes have been made to ensure that current storage and recording requirements have been met. Residents are free to self medicate under the management risk assessment framework. None of the residents self medicated at the time of the inspection. Medication is stored in lockable facilities in the home and a sample of the recording of medication administered was viewed. Information and advice is sought from a pharmacist who visits the home three monthly and a copy of the last visit to the home was viewed. The deputy manager and the care worker spoken with confirmed they had received medication training. Four resident’s surveys stated that they felt that their medical care needs were met in the home and one did not answer the question. The staff was observed to deliver care with dignity and respect. The residents spoken with felt the care provided respected their privacy and dignity. Four resident’s surveys stated they always received the care and support they needed and one stated usually. Pembroke Lodge DS0000014224.V376291.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Where possible residents are enabled to exercise choice in their lives whist resident in the home, there are some opportunities to participate in social and recreational activities provided and would benefit from further development, residents are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: Resident’s social interests are recorded on their individual care plans. The AQAA details that this is an area which would benefit from further improvement and that over the next twelve months it is planned to develop a social activity programme to meet residents social care needs. On the day of the inspection there were no activities arranged in the home. Some residents go out with their relatives and friends and this was observed on the day. Records viewed detailed that there is an activities programme and activities Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 14 which have been facilitated include quizzes, board games, music hours, videos, and reminiscence sessions. The resident’s surveys were varied and stated that activities were always, usually or sometimes arranged. The outcome of a resident’s questionnaire sent out by the home in June 2009 was that of the eleven residents who responded six stated very good when asked,’ are you satisfied with the activities and events organised,’ and one stated good, one fair and three poor. This was discussed with the proprietor and the deputy manager who both stated that this was an area which was being developed and so a Requirement has not been made on this occasion. The deputy manager confirmed that there is a monthly religious service in the home provided by a local church, but that staff will discuss and help facilitate any other requirements to meet individual resident’s spiritual needs. The AQAA details that residents are free to have visitors at any reasonable time. Residents and visitors spoken with confirmed there was flexible visiting that staff is very welcoming and they could see their relatives and friends in private if they wished. The care and support provided was observed to enable residents where possible to exercise choice whilst at Pembroke Lodge. The four residents files viewed, staff, visitors and the residents spoken with confirmed this. The cook was spoken with, who works two days a week and also works a four evenings a week to the residents suppers. She stated she holds a basic food hygiene certificate. A further cook works five days a week and there is a supper cook working each evening. A rotating menu is place. It does not identify that choices available at all meals, but staff and residents all confirmed if they do not like what is on the menu there are always a range of alternatives. Lunch on the day was chicken supreme with spinach, carrots and potatoes and stewed apples and custard. Special diets are catered for. Fresh fruit was available in the dining room. On the day some residents were observed eating their lunch in the dining room and others had their lunch in their bedroom. It was a relaxed environment taking into account the different length of time that individual residents would need to finish their meal. All the residents spoken with stated they had enjoyed their meal. Records are kept of food consumed individually by each resident to ensure they are receiving an adequate diet. Three resident’s surveys stated they always liked the meals, one usually and one did not answer the question. Pembroke Lodge DS0000014224.V376291.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures are in place to enable residents or their representatives to raise any concerns about the care being provided and to ensure that residents are protected from abuse. EVIDENCE: The AQAA details that there is a clear and accessible complaints policy and procedure in place, and that a copy of the procedure is given to new residents. Three complaints have been received at the home during the last year. The CQC have not been made aware of any concerns in relation to the care provided at Pembroke Lodge. Four residents surveys stated they were aware who to talk to if they were not happy and one did not answer, and three residents knew how to make a complaint and two did not answer the question. The AQAA detailed that there are policies and procedures in place in relation to the safeguarding of vulnerable adults and it has previously been evidenced that a copy of the East and West Sussex County Council, Brighton and Hove safeguarding adults’ procedures is available to reference in the home. One complaint received was investigated under safeguarding adults’ procedures. The CQC was not informed of this investigation. This was discussed with the Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 16 proprietor who stated it would be ensured that the CQC are informed as required. So a Requirement has not been made on this occasion. The deputy manager and the one care worker spoken with confirmed they had attended this training and demonstrated an awareness of the policies and procedures. Pembroke Lodge DS0000014224.V376291.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides residents with a pleasant and well-maintained environment. The home is clean and tidy. EVIDENCE: The AQAA detailed there is an ongoing external and internal maintenance programme serviced by the homes maintenance person or external contractors. That over the last twelve months the laundry room has been upgraded and redecorated, an equipment room has been added for the storage of mobility aids and it is planned over the next twelve months to install Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 18 handrails from the front door of the house to the pavement and continue the upgrading of resident’s bedrooms when they become available. A selection of communal areas and residents bedrooms were viewed during the inspection. The home is decorated and furnished in a homely style. There are sixteen bedrooms on all floors in the home; all were being used as single bedrooms at the time of the inspection. A number of bedrooms were viewed and displayed resident’s individual styles and interests. All bedrooms have an emergency call bell system. All of the bedrooms have en-suite facilities of a toilet and wash-hand-basin. The outcome of a resident’s questionnaire sent out by the home in June 2009 was that of the eleven residents who responded ten stated very good when asked, ’are you satisfied with the facilities provided in your room,’ and one stated good. Bathroom facilities are provided throughout the home. Residents are able to control the temperature in their own bedrooms. Four of the residents spoken with confirmed there is adequate heating and hot water in the home. A passenger lift is available from the ground floor to the second floor. There is one lounge and a dining room on the ground floor and a smaller lounge on the first floor. Residents have access to a private and well-stocked garden at the rear of the home. Two residents were in the garden and spoke of their enjoyment at be able to sit outside. The AQAA details that there is a policy in place for managing infection control and it has previously been confirmed that the Department of Health Guidance has been used to assess current infection control management and an action plan is in place to deliver best practice in the prevention and control of infection. The home was clean and free from offensive odours at the time of the inspection. Feedback from the resident’s surveys was that the home was always or usually fresh and clean. The outcome of a resident’s questionnaire sent out by the home in June 2009 was that of the eleven residents who responded five stated very good when asked, ’is your room cleaned to your satisfaction,’ and three stated good and two stated fair.’ A domestic assistant was spoken with who stated she had recently started working in the home and was currently on an induction when guidance on the procedures in the home had been given. The deputy manager confirmed that both the new domestic assistants would receive training and guidance in infection control and the control of substances hazardous to health regulations (COSHH). The AQAA detailed that infection control training has been facilitated for three members of staff and it is planned more staff will be able to attend this training. The deputy manager has become a ‘champion of infection control’. Staff confirmed that there was good access to protective clothing, liquid soap and paper towels. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 19 Recording was viewed of routine fire checks that had been carried out in the home. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are recruitment policies and procedures in place, care workers receive an induction and are provided with opportunities for training to develop their skills and ensure the individual care needs of residents can be met. EVIDENCE: Staff spoken with and rotas viewed confirmed that one member of care staff is deployed to work in the home during the morning and one during the afternoon. Two domestic staff was on duty during the morning of the inspection. The proprietor stated that the domestic staff as well as undertaking domestic duties, provides general support not including personal care to the residents. A morning and supper cook is also employed seven days a week. Catering staff undertake care duties where required during the afternoon after the catering duties have been completed. The deputy manager was also working in the home at the time of the inspection. The proprietor stated she is currently working in the home, whilst new management arrangements are put in place. The proprietors hours worked in the home should be detailed on the staff rota and the deputy manager agreed to address this. A part-time administrator was also on duty during the morning. At night the home deploys one ‘sleeping in’ member of staff. Staffing levels were Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 21 discussed with the proprietor and the deputy manager, who both stated that staffing levels in the home is kept under review to ensure that the resident’s care needs to be met and will be adjusted and increased where required. Three of the residents surveys stated staff always listen and act on what residents say and two usually. Four resident’s surveys stated they always receive the care and support needed and one usually. All stated staff are available when you need them. The AQAA detailed that of the three care workers, two hold an NVQ Level 2 in care. One care worker spoken with stated she was in the process of completing NVQ Level 3. The AQAA detailed that new staff working in the home had satisfactory preemployment checks. The documentation was viewed for the three new members of staff, who had been recruited since the last inspection. All demonstrated the completion of an application form, two had two written references in place, for one member of staff one of the references was a verbal reference which had been sought, all had completed a Criminal Records Bureau check (CRB)/and a Pova First check, which recorded had been received prior to staff commencing work in the home. The proprietor subsequently confirmed that a second written reference had been received, but not filed for the member of staff. A sample of staff documentation was viewed and all had had a check completed. The deputy manager evidenced that the induction training for new members of staff in place meets the requirements of the General Skills for Care induction standards. The proprietor stated that not all the new care worker have commenced the induction as required due to the staffing changes in the home, but that this would be addressed. So a Requirement has not been made on this occasion. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team have strived to create an atmosphere within the home, which is open, relaxed, homely and caring. Quality assurance systems are being developed to enable ongoing feedback about the care provided in the home and systems are in place to ensure a safe environment for staff and residents. EVIDENCE: There is not a Registered Manager in place in the home. The proprietor is currently working in the home whilst new management arrangements are put in place. There is a deputy manager, who is currently attending a course to Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 23 complete the Registered Managers Award and NVQ Level 4 in care. The proprietor stated she has attended training on the Mental Capacity Act and the Deprivation of Liberty, and that no applications have been made under the Deprivation of Liberty. That when a new Registered Manager is in place she will ensure this training is also provided for the new Manager. A quality assurance system is in place. It was evidenced that feedback about the service provided has recently been sought from residents through resident’s surveys. The AQAA details that over the next twelve months it is planned to introduce regular residents meetings. The deputy manager stated that a one resident’s meeting had recently been held and the next was due to be held the following week and a topic on the agenda will be infection control in the home. Feedback from the outcome of the recent resident’s surveys undertaken in the home has been collated and the proprietor has written to the residents with the overall outcome. The AQAA detailed that policies and procedures are in place and that these had been reviewed. The deputy manager stated that there are records of a monthly visit being carried out by the proprietor of the home to meet Regulation 26 have been carried out, but these were not viewed on this occasion. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible person external to the home. The proprietor reported that they do sometimes hold small amounts of money for a few residents, but there was none being held at the time of the inspection. There was no evidence to view of supervision for care staff, which the AQAA detailed was in place to meet the requirements of Standard 36. This was discussed with the proprietor and the deputy manager who stated that the care workers supervisions had fallen behind, but the deputy manager evidenced she had a plan to re-start the supervision of care workers. It was not possible to evidence that staff have received the required training/updates in moving and handling, basic food hygiene, first aid and infection control within the required timescales. That there has been some delay in staff accessing this training due to a period of staff in the home. The proprietor and the deputy manager both stated that an audit of staff training needs had been completed and training was being accessed as required to ensure all staff have received the training and updates, and that records would be updated to detail training completed. The deputy manager and care worker spoken with stated they had attended all the required training/updates A detailed check of the environment had been completed and the AQAA detailed that the maintenance of equipment and services has been carried out. Risk assessments are in place for the building, but detailed these had not been reviewed since 2007. This was discussed with the proprietor who stated these would be reviewed where required. So a Requirement has not been made on Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 24 this occasion.There were records of regular testing of the hot water temperatures at outlets accessed by residents to ensure these are being maintained at close to 43 º C. None of the radiators within the home are guarded. This matter has been discussed before at previous inspections and the proprietor has stated that they have installed a specific valve, which does not allow the radiator temperatures to go above 43°C. It was also stated that radiator temperatures were checked on a weekly basis by staff. A sample of records viewed during the inspection evidenced these checks had been maintained prior to the heating being switched off in the home during the warmer weather. The proprietor also stated that further guidance has sought from Environmental Health and acted upon to ensure current controls in place are adequate to protect residents. A fire risk assessment in place undertaken by an external agency in 2006. This was discussed with the proprietor who stated this had been subsequently reviewed and had been recently viewed during an inspection by the East Sussex Fire and Rescue Service. Records evidenced that fire drills had been maintained in the home and the proprietor stated that fire training was also provided with the fire drill. A sample of recording was viewed of incidents and accidents. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 27 Care Quality Commission SouthEast Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Pembroke Lodge DS0000014224.V376291.R02.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!