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Inspection on 16/12/05 for Edwin Lodge, 6 Victoria Court

Also see our care home review for Edwin Lodge, 6 Victoria Court for more information

This inspection was carried out on 16th December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service continues to provide a clean and pleasant environment for service users. The home is well decorated and free from odours. At the time of the inspection service users were appropriately dressed and were well cared for.

What has improved since the last inspection?

There is evidence to suggest that the home has made attempts at involving service users and their relatives in the care and the care planning process of service users. The home has made attempts at improving the assessments of the social and recreational needs of service users and plans were in place to meet these needs. The manager has also made attempts to address the end of life care of service users in the home.

What the care home could do better:

The continence needs of service users could be assessed more comprehensively by the use of a continence assessment. The recruitment procedures in the home must be more thorough to ensure compliance with Schedule 2 of the Care Homes Regulations 2001. Although there was evidence that some training has been arranged, the manager must consider developing a training plan which would give details of the proposed training and the time scale/dates for these training.

CARE HOMES FOR OLDER PEOPLE Edwin Lodge, 6 Victoria Court 6 Victoria Court Wembley Middlesex HA9 6QJ Lead Inspector Mr Ram Sooriah Unannounced Inspection 16th December 2005 12:30 X10015.doc Version 1.40 Page 1 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 Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 2 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, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edwin Lodge, 6 Victoria Court Address 6 Victoria Court Wembley Middlesex HA9 6QJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8795 2007 020 8902 0303 yohana@lineone.net Mrs Tiina Yasaratna Mr Sabaragamu Yasaratna Mr Sabaragamu Yasaratna Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 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 six years and belongs to Mr and Mrs Yasaratna. They have both 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, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second statutory inspection for the period 2005-2006. The inspection was unannounced and lasted from 1230 to about 1530. It concentrated mostly on the standards, which have not been assessed this year, and on compliance with previous requirements and recommendations. During the course of the inspection, the inspector had the opportunity to speak to two service users, the manager and one of his staff. He also toured some of the premises and looked at a sample of records including health and safety, training and personnel records. The inspector would like to thank the service users, the manager and her staff for a kind welcome to the home and for their cooperation and support during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The continence needs of service users could be assessed more comprehensively by the use of a continence assessment. The recruitment procedures in the home must be more thorough to ensure compliance with Schedule 2 of the Care Homes Regulations 2001. Although there was evidence that some training has been arranged, the manager must consider developing a training plan which would give details of the proposed training and the time scale/dates for these training. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 6 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, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 3 Service users in the home have a clear assessment of their needs. EVIDENCE: No new service users have been admitted in the home since the last inspection. The needs’ assessments of service users were in the main comprehensive and the format used for the description of service users was generally well completed. There was evidence that review meetings had been arranged and that discussions had taken place with the relevant people in cases where the needs of service users needed to be reviewed. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7,8 9 and 10. Care plans in the main address the personal and social needs of service users. The health care needs of service users are in the main addressed appropriately, but service users did not always have a continence assessment. Medicines management in the home was generally safe. The amounts of medicines received and in stock in the home were however not compiled together to facilitate audits. Where possible, the end of life care of service users were addressed in care records. EVIDENCE: The care plans of service users were in good order and tidy. Plans of care were in place in cases where needs have been identified and these were generally thorough. All service users had a number of risk assessments including a fall risk assessment, which has recently been introduced. Service users who faced other risks had care plans or risk assessment regarding these. The risk assessments and the care plans were reviewed on a monthly basis. There was also evidence that the care plans and risk assessments have been discussed with the service users/representatives and that they have agreed to these. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 10 The inspector was informed that service users are seen by the GP when this is required as well as by a number of other healthcare professionals including the optician and dentist. The Waterlow risk assessment was used to assess service users at risk of pressure sores. In cases where service users were at risk, equipment was in place to provide pressure relief. Service users had care plans to address continence issues. The inspector however noted that there was not always a continence assessment in place. The plans of care addressing continence issues were also not always very clear with regard to how the continence was being promoted and the aids that were used to manage incontinence. The inspector looked at the management of medicines in the home. There were records of medicines received in the home and of administration. Medicines are normally provided on a three monthly basis and the medicines chart is for 28 days. The amount of medicines, which remains after medicine charts have been completed, should be brought over to the new charts to ensure that the appropriate audit can be undertaken. Similarly if a new supply of medicines has been received into the home, the amount should be added to the amount, which is already in the home. The inspector noted that a code was used when service users did not receive medicines. The reasons were however not described as to why the service users did not receive the medicines. It is therefore recommended that a number of codes be used to describe the various reasons for service users not taking their medicines. The manager showed the inspector records to support the fact that he had made attempts with regard to approaching relatives/service users to discuss the future of service users in the home and the arrangements in place to care for them when approach end of life or after death. He added that service users would be able to stay in the home as long as the home is able to care for them. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 11 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 the following standard(s): The home has made some progress with regard to providing recreational and social activities for service users. The home provides appropriate meals for service users. EVIDENCE: Since the last inspection, the manager stated that he has been looking at improving the provision of activities in the home. There is now a carer who spends some time with the service users particularly for activities. The assessment of the recreational and social needs of service users have been completed to an extent and there were plans in place to address these needs. The inspector observed lunch being served to service users. Since it was Friday, there were fish, chips and peas for service users. The manager stated that staff are familiar with the likes and dislikes of service users as the home is little and the home is therefore able to cater to these. The inspector noted that all service users enjoyed their meals and that assistance was provided to service users as required. The kitchen was clean and relevant records were kept, including a record of food cooked in the home. Although the kitchen was also used by the providers for their private use, there were a separate fridge and freezer for the service users. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The home has systems in place to ensure that complaints and allegations of abuse are dealt with in an appropriate manner. EVIDENCE: The complaint book showed that the home has not received any complaints since the last inspection. The home has a complaint procedure which is available to service users. Training records showed that the manager has attended training on abuse. The home also has a training video on abuse that new members of staff are able to see as part of an introduction to understand abuse of vulnerable people and its prevention. The manager stated that he or his wife are on the premises most of the time and are able to directly supervise the care given to service users. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The home provides a safe and pleasant environment for service users. The bedrooms of service users are in a good state of decoration and are personalised according to the tastes of service users. EVIDENCE: The outside areas of the home were clean and the exterior of the building remains in good condition. The home is in keeping with other houses in this quiet residential area. The interior of the home was in a good state of decoration. Communal areas were also appropriately decorated. Items of furniture were in good condition and appropriate to meet the needs of service users in the home. All the bedrooms are single and have a wash hand basin. They are all appropriately personalised and decorated to a very good standard. There are two bedrooms on the first floor and two on the ground floor. The home has had some minor adaptations to ensure that the environment continues to be suitable to meet the needs of service users, for example grab rails in the bathrooms and handrails up the stairs. Service users also had bed Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 14 tables in their rooms from which they could eat their meals if they did not want to go to the dining areas. The inspector was informed that service users who were accommodated on the first floor were able to negotiate the stairs with the help of staff. However as the needs of service users increase, the manager may have to consider adaptations/aids, which might be needed to ensure that the needs of service users continue to be met in the home. The home continues to benefit from a high standard of cleanliness. It was free from odours. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The needs of service users are met appropriately by staff in the home. Recruitment procedures could have been more thorough to ensure that all members of staff have the necessary personnel information on file. The manager has made attempts to provide appropriate training for his staff, but not all staff’s members were up to date with statutory training at the time of the inspection. EVIDENCE: The manager stated that there are two members of staff during busy periods of time. Two more carers have been recruited since the last inspection to support the owners in caring for the service users. In addition a domestic has also been recruited to help with non-care duties. The owners continue to live on the premises and are therefore easily accessible if help is required. The personnel files of two new members of staff were inspected. One had all the required information as per schedule 2 of the Care Homes Regulations 2001 and the other one was missing a proof of identity and a reference. They both had a CRB check with regard to employment in the home. Training records showed that staff generally received an induction in the home. There were copies of certificates in the personnel files of staff. They showed that some members of staff have had training in statutory areas such as manual handling, fire training and food hygiene. While some members of staff were not fully up to date with statutory training, there was some evidence that some training has been arranged. The manager must now confirm this by preparing a training and development plan with details of the training that has Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 16 been arranged, members of staff to attend and the time scales for this to happen. A copy must be sent to the Commission. The manager is currently studying for the Registered Manager’s Award and his wife is a trained nurse. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 17 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 The home is appropriately managed and run by the current manager. Safety requirements in the home were in the main being met. EVIDENCE: The manager is approachable and knowledgeable with regard to issues relating to running the care home. He showed evidence that he was in the process of completing the Registered Manager’s Award. The inspector concluded that he was aware of his legal responsibilities with regard to ensuring that service users are safe and comfortable in the home and that he is discharging with these appropriately. A number of safety certificates were available for inspection in he home. They were all up to date and demonstrated that maintenance was being carried out and that safety procedures were in place to ensure the welfare of the service users. There were health and safety checks available for inspection. While there was a fire risk assessment in place, it could have been a little more thorough. An Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 18 emergency fire plan was not available in the home. The inspector recommends that the manager review the fire risk assessment in line with advice from the Fire Brigade and that he also draw up a fire emergency plan for the service. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 19 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X x 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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. 2. Standard OP8 OP29 Regulation 14(1,2) 19(1)(b) Requirement The registered person must ensure that all service users have a continence assessment. The registered person must ensure that all new employees have the necessary information as detailed in Schedule 2 of the Care Homes Regulations 2001 The manager must prepare a training and development plan confirming details of the arrangements that are being made to provide statutory training to members of staff. A copy must be sent to the Commission. Timescale for action 28/02/06 28/02/06 3. OP30 18(1)(c) 28/02/06 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 OP9 Good Practice Recommendations It is recommended that the amount of medicines which remains after a medicines chart has been filled, be brought DS0000017496.V273812.R01.S.doc Version 5.0 Page 21 Edwin Lodge, 6 Victoria Court 2 3 OP9 OP38 over to a new chart and that when a new supply of medicines is received into the home, that the amount be added to the amount which is already in the home to ensure that appropriate audit can be carried out. It is recommended that a number of codes is used to describe the various reasons for service users not taking their medicines. The inspector recommends that the manager review the fire risk assessment in line with advice from the Fire Brigade and that he also draw up a fire emergency plan for the service. Edwin Lodge, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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, 6 Victoria Court DS0000017496.V273812.R01.S.doc Version 5.0 Page 23 - 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. 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