Archived: Pembroke Lodge

Updated 7 September 2018

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 unannounced comprehensive inspection took place on 5 and 6 July 2018. This meant that neither the provider nor the staff knew we would be visiting the home on the first day of our visit. This inspection was carried out by one inspector.

Prior to our inspection we reviewed the information we held about the service including statutory notifications. Statutory notifications are submitted to the Commission by registered persons in line with their obligations under the Care Quality Commission (Registration) Regulations 2009. They are reports of deaths and other incidents that have occurred within the service. We used this information to inform the planning of this inspection.

We contacted the local Healthwatch service, and spoke with the local authority commissioning and safeguarding teams to gather views of professionals who come into regular contact with the service. Healthwatch are an independent organisation who listen to people’s views about local service to help them to improve.

Not everyone who used the service was able to communicate verbally with us. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with five people who used the service and chatted with them about their views on the service. After the inspection we spoke with one relative over the telephone.

We spoke with the provider’s regional manager, the registered manager, and three care workers. We reviewed a range of documents and records including; three people's care records in detail, four records of staff employed at the home, complaints records, accidents and incident records, minutes of staff meetings, minutes of meetings with people who used the service and a range of other quality audits and management records.

Updated 7 September 2018

Pembroke Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Pembroke Lodge accommodates up to 15 people with physical and mental health needs, in one purpose built building. Nursing care is not provided at the home. At the time of our inspection there were 13 people using the service, including three people on respite.

This unannounced comprehensive inspection took place on 5 and 6 July 2018. This meant that neither the provider nor the staff knew we would be visiting the home on the first day of our visit.

This was the first time we inspected the service, which was registered with CQC in May 2017.

A registered manager was in place. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People we spoke with were relaxed in the home, and at ease with staff. People told us they felt safe at Pembroke Lodge. Staff had all undertaken training in spotting any signs of safeguarding concerns, and were able to describe to us the provider’s process that they would follow if any arose. Prompt referrals had been made to the local authority safeguarding team when necessary.

Risks were well managed. Accidents and incidents were monitored by the registered manager for any trends, and to ensure staff had taken appropriate action. People received their medicines as prescribed. The home was clean and the risk of infection was kept to a minimum.

There were enough staff to meet people's needs. Staff were had time to sit and talk with people as well as carrying out their tasks. Robust recruitment procedures had been followed and evidence was available to show prospective staff employment references had been sought and Disclosure and Barring Service (DBS) checks undertaken to highlight any known reasons why staff should not work with vulnerable people.

Staff received appropriate training so they had the skills and knowledge to meet the needs of the people they supported. Training was monitored to ensure it stayed up to date. Staff met regularly with their supervisors to discuss their role and personal development.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People spoke positively about the food on offer. People had access to their own kitchen where they could make meals, drinks and snacks.

People were supported to access health professionals and to have their healthcare needs met. People told us that staff monitored their health and wellbeing and made appointments with healthcare professionals whenever needed.

Staff were warm, friendly and knew people and their needs well. People enjoyed friendly relationships with staff and we observed them sharing lots of laughs and jokes. People told us staff were caring and treated them with dignity and respect.

People's care records evidenced that the service sought to promote people's independence, and we observed that people were supported to do as much as they could or themselves. Staff we spoke with talked knowledgably about how they supported people, and these conversations reflected the information we had read in people's care records.

Care was person-centred. Assessments had been used to determine what support people required. People and relatives had been included in planning people’s care. Records included photographs and information about what was important to the person being supported.

People’s needs and their plans of care were evaluated on a regular basis. However, we saw limited evidence that people were involved in this process. We have set a recommendation about this.

There was a program of activities on offer in the home. People were included in planning events, activities and trips out of the home. People's feedback was sought and acted on. There were regular residents’ meetings and the results of the annual satisfaction survey had been very positive. People were provided with information about how to make a complaint, but none had been received in the year prior to our visit.

People and staff told us the home was well run. All of the feedback we received about the registered manager was positive.

The provider and registered manager gathered information about the quality of the service and sought to make improvements. Surveys had been sent to people, relatives, staff and visiting professionals. Most responses had been positive and changes had been implemented where responses indicated that improvements could be made.

A range of audits were carried out to assess and monitor the quality of the service. The quality monitoring system included regular checks by both the registered manager and the provider. It was evident that areas for improvement had been highlighted and improvement actions taken.