Archived: Pembroke Rest Home

Updated 25 March 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 25 and 27 January 2017 and was unannounced. This inspection was undertaken by one adult social care inspector.

Before the inspection we reviewed information we held about the home, including the notifications we had received from the provider. Notifications are changes, events or incidents the provider is legally obliged to send us within required timescales. Information from health and social care commissioners of care was also reviewed.

During the inspection we spoke with seven staff including the registered manager, four people who used the service and one relative. Observations were carried out and medicines were reviewed. We also spoke with an external professional who regularly visited the service.

Three care records were reviewed as were three medicines records and the staff training matrix. Other records reviewed included safeguarding adults records and deprivation of liberty safeguards applications. We also reviewed complaints records, three staff recruitment/induction and training files and staff meeting minutes. We also looked at records relating to the governance and management of the service.

The internal and external communal areas were viewed as were the kitchen and dining areas, storage and laundry areas and, when invited, some people’s bedrooms.

Updated 25 March 2017

This inspection took place on 25 and 27 January 2017 and the first day was unannounced. This means the provider did not know we were coming.

Pembroke Rest Home is a care home which provides personal care. Care is mainly provided to people who have acquired brain injuries or mental health support needs. It is registered to support 14 people.

At the last inspection, the service was rated good. At this inspection we found the service remained good.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Systems were in place to protect people from avoidable harm or risk. Staff received safeguarding training and were knowledgeable about their roles and responsibilities for ensuring people’s safety. Risks to people, staff and visitors were assessed and regularly reviewed. The service took action to minimise risks where appropriate in order to keep people safe from harm.

Robust recruitment processes were in place to ensure staff members were suitable to work with vulnerable people. Staffing levels were based on the dependency levels of people living at the home and were reviewed on a regular basis. Our observations during the inspection and from feedback we received were that staffing levels continued to be appropriate to safely meet people’s needs.

Appropriate systems were in place for the management of people’s medicines. People were encouraged to maintain their independence, for example through retaining responsibility for managing their own medicines or self-care. Peoples medicines were stored in peoples bedrooms

Staff were supported through the provision of role specific training, formal supervision and annual appraisals. Staff confirmed they felt well supported in their roles and spoke positively about the recently appointed registered manager and their leadership and management of the home.

The service worked within the principles of the Mental Capacity Act 2005. People’s capacity to make decisions about their care and treatment was assessed and where appropriate, “best interest” decisions were made on people’s behalf. These involved relevant healthcare professionals as well as people’s friends and family members as appropriate.

People were very complimentary about the kind and caring nature of the staff team. Staff had developed strong, caring relationships with the people they supported and were very knowledgeable about their individual needs, likes and dislikes.

People’s needs were assessed prior to them joining the service. Detailed, person-centred care plans were produced which guided staff on how to care for people. These included details of any preferences people may have. People and their representatives were actively involved in their care planning and were also encouraged to voice their opinions about the service in general.

People’s needs were reviewed on an on-going basis and action taken to obtain the input of external professionals where appropriate. Systems were in place to ensure people had sufficient to eat and drink and to access other healthcare professionals in order to maintain good health.

A range of systems were in place to monitor and review the quality and effectiveness of the service. Action was taken to address areas for improvement identified. Complaints were taken seriously and records maintained of the action taken by the service in response to any form of dissatisfaction. The service was about to undertake major improvements to the environment and furnishings as part of a planned refurbishment.