Archived: Pembroke Lodge

Updated 12 April 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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.

The inspection was prompted by whistleblowing concerns. These involved staff not having appropriate checks before starting employment, language barriers of staff, poor working and living conditions for staff working as agency staff, competency of staff undertaking maintenance checks and lack of equipment across the Glenside Manor site.

The information was shared and consultations were held with CQC colleagues in the hospital directorate, Wiltshire Council Safeguarding and Commissioners and Clinical Commissioning Group (CCG). Associated agencies that have regulatory powers for the safety of the premises and staff were made aware of concerns.

This inspection was carried out by two inspectors and took place on 7 and 15 of November 2018 and was unannounced.

Before the inspection, we reviewed all the information we hold about the service, including previous inspection reports and notifications sent to us by the provider. Notifications are information about specific important events the service is legally required to send to us.

One person agreed to give us feedback. The other person we asked refused to give feedback about their experiences of living at Pembroke Lodge. We contacted two relatives and one responded to our request for feedback. We spoke with the unit manager, registered managers from other locations, registered nurses and rehabilitation assistants including senior rehabilitations assistants. We also spoke with the office manager, quality and safety lead, HR assistant, maintenance staff, night manager, catering staff and chef.

We looked at documents that related to people's care and support and the management of the service. We reviewed a range of records which included two care plans in detail. We reviewed the staff duty rosters, policies and procedures and quality monitoring documents.

Updated 12 April 2019

Glenside Manor Healthcare consists of six adult social care services and a hospital all situated on the same complex. Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

This inspection took place on 7 and 15 November 2018 and was unannounced. Pembroke Lodge is one of the six adult social care locations. Up to sixteen people can be accommodated at the home. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain.

At the time of the inspection, there were three people living at Pembroke Lodge. It 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.

A registered manager was in post. 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. Staff said the unit manager “often pops in” to the home. The staff were not aware who was the registered manager. The staff on duty told us this registered manager rarely visited the home.

In December 2016 the provider told us that the service was not accommodating people and was “dormant”. The provider failed to inform the CQC that the regulated activity of accommodation for people who require nursing or personal care at Pembroke Lodge was reinstated in July 2018. Although we asked the provider to resubmit a notification to lift dormancy, we have not received this.

Following the inspection CQC formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We requested further information from the unit manager to be provided by 30 November 2018. We received some of the information requested but not all.

Quality assurance systems were not effective. Audits were not robust and did not provide an accurate assessment of the quality of care delivered. Action plans were not developed to drive improvements. The CQC was not kept informed of accidents and incidents reportable under the Care Quality Commission (Registration) Regulations 2009: Regulation 18.

People were not safe from the risk of potential harm. Risk assessments were not clear on the actions to minimise the risk. There were people who expressed their frustration and anxieties using behaviours that staff found difficult to manage. Documentation about these incidents did not show behaviour management plans were always followed. Records of incidents were not detailed and did not include the actions taken to manage difficult behaviours. Staff told us they were not confident to use MAPA holds. MAPA (Management of Actual or Potential Aggression) programme teaches management and intervention techniques to help staff manage escalating behaviour in a safe manner.

Recruitment procedures did not ensure the staff employed at the home were suitable to work with vulnerable adults. The CQC received whistleblowing concerns about staff not being able to speak basic English and that agency staff were working without appropriate checks. These agency staff were working at Pembroke Lodge to maintain staffing levels. There were some agency staff that were working across locations including Pembroke Lodge that did not have the appropriate disclosure and barring checks or references in place. Relatives also expressed concerns about staff not able to speak or understand basic English. These relatives said their family members were at risk of harm because these staff were not able to understand instructions.

The CQC received whistleblowing concerns about the competency of the staff undertaking maintenance checks of systems and equipment. These findings apply to all Glenside Manor locations including Pembroke Lodge as systems checks and repairs were carried out by the same maintenance staff. The CQC requested proof of the competency of these staff from the provider. The documentation provided did not give CQC reassurances that staff undertaking maintenance checks were skilled or competent.

There were insufficient staff employed to deliver continuity of care. Five staff were employed to work at the home. However, five staff were not sufficient to maintain staffing levels. The staffing rota included a registered nurse on duty during the day and at night. On both days of the inspection a registered nurse and three rehabilitation assistants were on duty. One person had one to one support from staff during the day and another had one to one support throughout the day and night. The staff on duty told us agency staff and staff from other locations were deployed to the home to maintain staffing levels. The registered nurse on duty on 15 November was from an external agency. This registered nurse had worked at the service three times before but not consecutively. This meant the registered nurse leading the shift was not well known to people.

Medicine systems were not managed safely and people were not having their medicines as prescribed. The stock of medicines held did not demonstrate people were having their medicines as prescribed. Guidance to staff was not in place for all medicines prescribed to be taken “as required”.

One of the two staff we spoke with knew the types of abuse and to report their concerns. The other member of staff had not attended safeguarding training and was unaware of the actions to take for skilled are made to the local authority, who have the lead in investigating safeguarding concerns, where there are significant concerns about people’s health or wellbeing.

Care records were not up to date and guidance was inconsistent for some people. This included people at risk of choking. Mental capacity assessments were undertaken for some complex decisions. However, there was no documented rationale for withholding people’s cigarettes and lighter. CQC hospital inspectors had identified one person at the home was detained under the MHA since July 2018. However, all appropriate documentation for this person was not in place. We noted section 3 was discharged the day following the hospital inspection. There were no reports on how this decision was reached. DoLS applications were to be made to the supervisory authority.

People’s needs were not assessed before they moved between the Glenside locations and hospital. Personal information was brief where it was documented. Some care plans gave staff guidance on how to care for the person. However, most lacked detail and were not always person centred. People were not involved in the planning of their care. The staff told us they had read the care plans but found them inconsistent. Structured activities did not take place and there were little opportunities for people to develop their daily living skills. One person told us it was “boring” living at the home.

The information received from relatives about raising concerns was not consistent with the complaints log. This did not enable a clear audit of complaints to take place so that improvements could be made or lessons learnt. A relative told us they would approach the staff or the Clinical Commissioning Group (CCG) with concerns.

The CQC received whistleblowing concerns that the boiler was faulty and hot water was not always available to people. During the inspection we saw maintenance staff visiting the home to switch the boiler back on as it was switching itself off. Staff confirmed this and on both days of the inspection, they told us there were times, when there was no hot water or heating in parts of the building.

There was insufficient equipment across sites. During the inspection the staff from another location contacted the home to borrow aids. The staff appropriately refused for equipment belonging to one person to be given.

People had access to healthcare services as required. A relative told us they were kept informed about GP visits and important events.

We saw some good interactions between people and staff.

We found breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.