Care Home: Pembroke Lodge

Annual service review Name of Service: Pembroke Lodge The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Susie Stratton Date of this annual service review: 1 1 0 2 2 0 1 0 Annual Service Review Page 1 of 5 Information about the service Address of service: Pembroke Lodge South Newton Salisbury Wiltshire SP2 0QD 01722742066 Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : physical disability Conditions of registration: Glenside Manor Healthcare Services Ltd Number of places (if applicable): Under 65 Over 65 14 0 The staffing levels set out in the Notice of Decision dated 18 November 2002 must be met at all times Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Pembroke Lodge is a long-stay nursing unit for younger adults with acquired brain injury. The building was purpose built for the client group. All bedrooms and living facilities are on the ground floor, with wide corridors. The bedrooms are single all with an en-suite facility providing a good standard of accommodation. The registered manager is Sarah Weston; she leads a team of nursing staff and care assistants. Pembroke Lodge is one of seven registered care homes and a private hospital on one campus which are owned by Glenside Manor Health Services Ltd. Mr Andrew Norman is the nominated responsible individual. Glenside Manor Health Services are situated in the village of South Newton, on the A36, five miles north west of Salisbury. Annual Service Review Page 2 of 5 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: - The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. - Surveys returned to us by people using the service and from other people with an interest in the service. - Information we have about how the service has managed any complaints. - What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. - The previous key inspection. - Relevant information from other organisations. - What other people have told us about the service. What has this told us about the service? Pembroke Lodge submitted an AQAA when we asked for it. It was clear and gave us information which we asked for. They report that they provide a homely, professional, caring placement for people users with complex, diverse needs, looking after their welfare and safety. They comment on their comprehensive, individualised care plans reflecting dignity, privacy and the rights of their residents. They report on the continued good liaison between therapists, medical staff and external specialists. Staff are supported by an effective training department, which is readily accessible by all staff and that staff have been extensively trained in care of high dependency people. They report that during the past year, they have improved supervision of staff on the unit to support them in meeting the needs of residents with highly complex dependency needs. Interdisciplinary training opportunities for all staff had been increased, particularly between nursing staff and physiotherapists. Communication systems have been improved by starting to use interdisciplinary notes system, which means all information about a persons treatment is in one place. A day centre is now accessible by all residents, hydrotherapy now being well used following extensive training in hydrotherapy, and many of their residents visit the physiotherapy gym, which is reported to be well equipped. Recruitment has been made more specific to the home, with managers being more involved in the interviewing process alongside human resources in order to make recruitment more efficient and to improve retention of staff. They report that during the next year, they plan to nominate link nurses who will be responsible for sourcing the latest research and organising training sessions in specific areas relating to nursing and care. They will seek to work more closely with residents and their families before admission to make the move from hospital less traumatic. Four members of staff are to train in Sensory Modality and Assessment Rehabilitation Technique (SMART) used for assessing Coma, Vegetative State and Minimally Conscious State at Putney Royal Hospital for Neuro-disability. It is reported that this Annual Service Review Page 3 of 5 will benefit their their more severely disabled residents as they will have more idea of what level the person is functioning at and ensure their care is appropriate. We received responses in surveys from eight people. Generally all surveys were positive about care provided and some were highly positive. One person described the good care and friendly staff, another it cares for the people as well as looking after all needs, another that Pembroke Lodge treats people with respect, another Pembroke Lodge really do well to look after XX and bring the best out of XX and another we are pleased with all the care XX receives, XX is so relaxed and chilled, its nice to see XX pain-free . One person commented particularly on the good and cheep cafe provided in the new hospital, describing it as a big point, which is MUCH appreciated. One person did comment that more activities could be provided but also reported that this is improving month by month, another that some shelving in the persons en-suite would help to clear some floor space and another person described the lovely grounds, but stated that more seating would be a great benefit. One person reported that staff should spend more time talking to the clients and getting them out for walks etc. A member of staff commented that the Pembroke Lodge does personal care and communication well. Another member of staff reported that the home keeps us all up to date with our training. However one member of staff reported that the home needed more staff. The home continues to let us know about things that have happened since our last key inspection, including the matters detailed in the AQAA. The home works well with us and in an open manner. The home have reported two medication errors to us during the past year, so our pharmacist inspector performed a random inspection on 8th December 2009. As a result of this inspection, four requirements and seven good practice recommendations were identified. Requirements related to accuracy of recording of drugs, including Controlled Drugs, storage systems for Controlled Drugs and safety in management of oxygen cylinders. Good practice recommendations related to clarity of record-keeping, management of limited life medicines, storage systems for medicines for external use and regular audits of medicines arrangements. The provider responded to this random inspection in full and we are aware from visits to other homes on the campus that progress is being made to address matters identified. All other notifications from the home are of the type that would be anticipated for a home of this size and speciality. We have not received any complaints about Pembroke Lodge during the past year. No safeguarding referrals have been made about the home or by the home in support of a resident. Our judgement is that the home is continuing to provide a good service. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and Pembroke Lodges next key inspection will be by 4th November 2010. Annual Service Review Page 4 of 5 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: 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 copy of the findings 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. 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