Inspection on 13/07/05 for Edwin Lodge, 6 Victoria Court

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Edwin Lodge, 6 Victoria Court 30/04/07

Edwin Lodge, 6 Victoria Court 03/08/06

Edwin Lodge, 6 Victoria Court 16/12/05

Edwin Lodge, 6 Victoria Court 23/03/05

Edwin Lodge, 6 Victoria Court 28/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Edwin Lodge 6 Victoria Court Wembley Middlesex HA9 6QJ Lead Inspector Ram Sooriah Unannounced 13 July 2005,at 14:00h00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Edwin Lodge Address 6 Victoria Court Wembley Middlesex HA9 6QJ 020 8795 2007 020 8902 0303 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Tiina Yasaratna Mr Sabaragamu Yasaratna CRH PC Care Home only 4 Category(ies) of OP Old Age 4 registration, with number of places Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23rd March 2005 Brief Description of the Service: The home is an extended semi-detached house which is registered for four elderly service users of mixed gender requiring personal care. It is found in a residential road off the main Harrow Road in Wembley. As such it is close to local shops and amenities and is also easily accessible by public transport. The home has been opened for about five years and belongs to Mr and Mrs Yasaratna. They both have worked for a number of years in the area of health and personal care. They live on the premises and have a separate area for themselves, which consists of the second floor (the loft conversion). The providers offer the bulk of the care. The main aim of the home is to provide personal care in a homely and family setting. The home is indeed homely and pleasant. Accommodation for service users is provided in single rooms on the ground and first floors. There is a bedroom on the ground floor and three on the first floor. The home, including the internal and the external areas, is pleasantly decorated and looked pleasing and inviting. There were four service users at the time of the inspection. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at about 1400 on a Wednesday and lasted for about two hours. The inspector had the opportunity to speak to the service users and Mr and Mrs Yasaratna. He also inspected the premises; check for compliance with past requirements; and looked at a sample of records in the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Service users’ needs are assessed to ensure that the home provides accommodation to service users whose needs it can meet. EVIDENCE: The home has had a new admission. The inspector noted that the manager visited the service user and completed the pre-admission assessment. The manager has also obtained the needs assessment of the placement authority. Once admitted to the home, the needs of the service user were further assessed to identify the needs of the service user for care plans to be drawn. The inspector was informed that the service user was in the home for a trial period depending on the outcome of a review meeting. The care plan of the service user was generally comprehensive. The needs of the service user were identified and care plans were in place to meet these needs. The manager and his wife are both experienced in looking after elderly service users and they are supported by two carers. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 Care plans are mostly comprehensive to ensure that the healthcare needs of service users are being met in the home. Areas for improvement include the production of comprehensive risk assessments for service users and the consultation of service users or relatives in the care planning process. The home benefits from a good medicines management system. EVIDENCE: The care records contained a number of action plans to meet identified needs of service users. The inspector noted that the home uses a number of risk assessments, but noted that one service user did not have a falls risk assessment. Other general risk assessments were also missing. For example one service user would engage in domestic tasks. While this is encouraged, at the same time there is a need to manage the situation within a risk assessment context. Risk assessments are necessary to deal with likely risks such as with regard to the possibility of service users leaving the home without supervision. The inspector noted that care plans and risk assessments for service users were not always agreed with the service users or with their relatives. Care plans showed that service users were seen by the GP when that is required. The home also monitors the nutritional status of service users and Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 9 the risk of developing pressure sores and makes referrals to the district nurses as required. There was also evidence that where service users had behaviour problems, staff had set out a plan to monitor and to record the behaviour of the service users for future interventions. The inspector was informed that the owners are mainly responsible for the management of medicines in the home. There were records of receipts, administration and disposal of medicines. All medicines were locked safely in a cupboard. The inspector concluded that the management of medicines in the home continues to be good. All service users appeared clean, well groomed and looked well cared for. Some were sitting in their rooms and others were in the lounge. The inspector observed that they were able to move to different areas of the home. The home has a portable phone to enable service users make and receive calls from the privacy of their bedrooms. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The lifestyle of service users could be improved by the provision of more social and recreational activities to provide stimulation and interest. Meals offered to service users are healthy and varied. EVIDENCE: The inspector noted that care plans did not always identify the social and recreational needs of service users. This continues to be a weak area for the home, but there was evidence that the owners were trying to address this area of care. They had for example attempted to find out and to provide what one particular service user enjoyed doing. It was positive that they agreed that this was an area where they could improve, as they can then put an action plan in place to address the issues. The home has an open visiting policy and visitors can stay with service users in the bedrooms of the service users or in the lounge. Service users could also go with their relatives for home visits. The inspector was informed that the priest from the local church sometimes visits a service user in the home. At the time of the inspection one of the service users was not in the home as he had gone out. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 11 There was evidence that service users who could manage their finance were offered this opportunity. In other circumstances the relatives of the service users handle their money. The bedrooms of service users were pleasantly personalised and the manager stated that service users are offered the opportunity to bring personal belongings in the home. The kitchen was clean and tidy. There were records of the fridge’s and freezer’s temperature and of all the meals cooked in the home. Records showed that the provision of meals was flexible and generally appropriate for the needs of the service users. The meals are prepared by staff and according to the likes and dislikes of the service users. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home takes the concerns of service users and relatives seriously and would deal with them appropriately if these were expressed. The manager and his staff are aware of the procedure to follow in cases of allegations or suspicions of abuse. EVIDENCE: The complaint procedure was in the foyer of the home and offered to service users in the service users’ guide. The owners stated that if service users or relatives have concerns they would take these seriously and would deal with them as appropriate. There has however not been any complaint since the last inspection. The home has a training video on abuse, which is used to update staff on abuse issues. The abuse policy in the home has also been reviewed and a copy of the Brent policy and procedures for the protection of vulnerable adults was available in the home. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 The home provides a clean, homely, safe and well-maintained environment for service users. EVIDENCE: The outside of the home gives a good impression on the home and showed that it is maintained to a good standard. The garden at the back is also very well maintained with a wide range of shrubs and flowers. This area is also accessible to service users who sit there sometimes, when the weather is nice. The inside of the home continues to be pleasant and in a good state of decoration. The bedrooms of service users were pleasantly personalised and were well furnished. There was evidence that the owners were in the process of redecorating one of the bedrooms and that they were placing locks on the doors of the bedrooms. The home also has a call bell system, which is maintained. Communal areas were found of the ground floor and service users from the first floor sometimes come to the ground floor to meet other service users. The home does not have a lift and the inspector was informed that service users on the first floor are able to manage the stairs. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 14 All areas of the home were clean, pleasant and hygienic. The home has a separate laundry area. During the last inspection, the manager was asked to check if the washing machine provided a sluice cycle. He has contacted the manufacturer who has informed him that the pre-wash cycle on the machine was the sluice cycle. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The numbers and skills of staff are appropriate to meet the needs of service users. Staff were not always up to date with statutory training. EVIDENCE: The owners of the home continue to provide the main bulk of the care. There are now two carers who assist them in looking after the service users. The inspector was informed that at least one of the owners is in the home at most times or easily contactable on the phone in cases of emergency. The inspector looked at the training records of staff in the home. They showed that not all staff have had updates of statutory training. For example a number of them have not had recent training on manual handling, fire training and food hygiene. The manager stated that he has booked training on food hygiene and this was confirmed by the booking letter. There are videos that the home uses for training. While these are good for introduction and updates to the above subjects, the registered person must ensure that all staff are up to date with regard to statutory training and that the training offered is in a more formal manner. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 38 The home is run in an open and inclusive manner with service users at the centre of what the home does. The health, safety and welfare of service users are promoted and protected most of the times, but more should be done to ensure that an appointed person in first aid is on duty at all times. EVIDENCE: The registered manager of the home is one of the owners. He has worked in care homes for a number of years and was in the process of completing the Registered Managers Award Course. He was familiar with the category of service users in the home and with their needs. The manager stated that he runs the home in a manner to ensure that service users are given choices and that they are treated as if they are in their own homes. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 17 The home has reviewed all its policies and procedures. The manager stated that the home does surveys to assess the level of users’ satisfaction with the service, but that as a result of a poor response he has not been able to compile a report about the responses from the satisfaction surveys. The inspector noted that the owners asked service users about their choices and took these into consideration. The inspector observed that the owners work in a constructive manner and that they take comments and suggestions by stakeholders in a positive manner to ensure improvement of their service. The home does not keep money for any service users and the manager or staff do not act as the agent for any service user. They only monitor that a service user receive his spending allowance as necessary. Health and safety issues in the home were attended to, to ensure a safe environment for service users. The home only had one person with a First Aid certificate. This could pose a problem when that person is away from the home. It is required that there is at least one person trained to deliver first aid on each shift. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 2 Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? 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. 1. Standard OP7 Regulation 14(1,2) Requirement Timescale for action 30/9/5 2. OP7 15(1,2) 3. OP12 16(2) (m,n) 4. OP30 18(1)(c) The registered person must ensure that service users have comprehensive risk assessments including a falls risk assessment as per standard 6 of the national Service Framework for Older People. The registered person must 30/9/5 ensure the involvement of service users or that of their relatives in drawing and reviewing the care plans. The registered person must 30/9/5 ensure that the social and recreational needs of service users are assessed and recorded comprehensively and that a range of activities are provided suited to the needs of the service users. The registered person must 30/9/5 ensure that all staff are up to date with regard to statutory training and that more formal training is provided for statutory training. Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlsex HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Edwin Lodge G62-G11 S17496 Edwin Lodge V239544 130705 Stage 4.doc Version 1.40 Page 22 - 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!