Inspection on 03/08/06 for Edwin Lodge, 6 Victoria Court

This inspection was carried out on 3rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Edwin Lodge, 6 Victoria Court 30/04/07

Edwin Lodge, 6 Victoria Court 16/12/05

Edwin Lodge, 6 Victoria Court 13/07/05

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 6 Victoria Court Wembley Middlesex HA9 6QJ Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 3rd August 2006 10:00 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.V306760.R01.S.doc Version 5.2 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.V306760.R01.S.doc Version 5.2 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.V306760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 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 and by car. Parking is available on Victoria Court. The home has been opened for about seven 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 living area for themselves, which consists of the second floor (the loft conversion). The providers offer the bulk of the care, and are assisted by three carers and a domestic assistant. 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 three service users at the time of the inspection. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is key unannounced inspection. It started at about 09:30 on a Thursday and lasted for about 4 hours. The inspector was able to tour some of the premises, talk to two service users and looked at a sample of records in the home. He was also able to talk to Mr and Mrs Yasaratna and to observe interactions between staff and service users. The inspector would like to thank the service users, Mr and Mrs Yasaratna for their support and assistance during the course of the inspection. What the service does well: What has improved since the last inspection? Service users now have a continence assessment detailing how continence will be promoted and how incontinence will be managed. Staff have training to ensure that they are competent to care for the service users. Satisfaction questionnaires have been sent to stakeholders and the home was waiting for them to be returned. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 6 A few issues were identified with regard to medicines management during the last inspection. These have been addressed. 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, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 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.V306760.R01.S.doc Version 5.2 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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a pre-admission assessment to determine if the home is able to meet their needs. Service users can be reassured that once admitted in the home, their needs will be met. EVIDENCE: At the time of the inspection, there was an empty bed in the home. The manager stated that there has been a number of referrals and that he has carried out the preadmission assessment of a prospective service user. He has noted, following his assessment, that the home would not be able to meet the needs of that service user. He was clear that the home would only take service users whose needs can be met in the home. Following on from the above it is clear that service users who are admitted in the home can be confident that there needs would be met. The home has staff who are sufficiently skilled and there are appropriate numbers of staff on duty to care for the service users. On one occasion the care of one service user from an ethnic minority was described in great details demonstrating that the needs of service users from ethnic and other cultural backgrounds are being Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 9 met in the home, although the records were not always clear about this aspect of care. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 10 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): 7-12 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans of service users were not always updated when needs of service users changed. There seemed to be little involvement of service users and/or relatives in the care plans. The healthcare needs of service users are being met in the home. Medicines management in the home is carried out in a manner to ensure the safety of service users. Although the home is a care home providing personal care, the end of life care of service users can be managed appropriately by staff in the home with the support of community healthcare professionals. EVIDENCE: Two care plans were inspected. These were in good order and kept in the office most of the time. A range of risk assessments was in place and care plans were formulated to meet the needs of the service users. It was noted that the plans of care on some occasions were not specific enough to identify all the actions that need to be taken to meet the needs of the service users. One service user who was diabetic had a care plan but the care plan did not describe the signs to watch for hypo and hyperglycaemia and the actions to take in each case. The care plan and risk assessment in the case of a service user whose mobility had changed had not been updated to reflect the changes. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 11 There was some evidence of the involvement of relatives in the care plans of the service users and the manager confirmed that this happens where possible. However a record was not always available to demonstrate that the care plans have been formulated and reviewed with the service user or with their relatives. The manager mentioned that there are regular reviews of the care of the service users by the funding authorities. Service users are registered with a GP and there was evidence that they were seen by other healthcare professionals when required. Records were kept about the other healthcare professionals visiting service users. The health of service users is monitored by care staff. In one case the blood sugar testing of one service user was being carried out by the manager and his wife who is a trained nurse. While they may both be competent to do this task, it was not clear who ultimately was responsible and accountable for this task. It is recommended that the registered manager review the additional task which staff carry out in the care home, such as blood sugar testing in line with responsibility and accountability. All service users presented as appropriately dressed and groomed. Some were sitting in the lounge and one service user preferred to sit in her room. Personal care was mostly provided in circumstances to promote the privacy and dignity of service users. Medicines management in the home was good. There were records of all medicines received into the home and of all medicines which were being disposed of. Medicines charts were signed when medicines have been administered. There were codes identified on medicines charts which could be used to describe the reasons for medicines not being administered when that happened. There has recently been a death in the home. Reports from the manager and the care records showed that the death of the service user was appropriately and sensitively managed by the home. There was evidence that a number of healthcare professionals were involved in providing end of life care and that the wishes and instructions of the service user with regard to that aspect of care were respected. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 12 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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are activities in the home to meet the needs of the service users. Meals provided is nutritious and suitable for the service users. EVIDENCE: Service users on the day of the inspection were observed sitting in the lounge talking to each other and with Mr and Mrs Yasaratna. There was a religious programme on the TV which some of them were enjoying. The service users were also having their nails done while watching TV and chatting. The other service user who preferred to stay in her room was reading a book and was quite contented to do that. There was some information about the social and recreational needs of service users and a care plan was also in place. However there was little information about the background of the service users. It is recommended that the home develop a life history on service users to provide additional information on the background of the service users. The home has open visiting and although no visitors were observed during the inspection, records showed that visitors do come to see service users. Service users are also able to go out with their relatives. One service user regularly goes to church with her relatives. The manager stated that service users are Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 13 given the opportunity to go out at times and that few of them take this opportunity. The inspector was informed that the local priest also visits service users in the home. It was noted that the home supports the service users in practising their faith. The inspector observed a meal of pasta and tuna being served for lunch to service users. They were all enjoying the meals. The home has a menu which is used as a guideline to prepare the meals, however at times the home is flexible in providing the meals. The likes and dislikes of service users were recorded and conversation with staff showed that these are taken into consideration when the meals are prepared. Records of the food cooked in the home showed that service users were offered appropriate meals. Service users were happy with their meals and records showed that their weights were stable. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an assurance that it will deal with complaints and incidences of abuse seriously to ensure that service users are safe. EVIDENCE: The complaints’ register showed that the home has had a verbal complaint. This was dealt with at the time in an appropriate manner and the complainant was happy with the response from the home. It was positive to note that the manager had taken the verbal complaint seriously enough to record it as well as the action that has been taken to address the complaint. The complaint procedure mentioned that a complaint records form should be completed for each complaint. However in this case there was none. There was evidence that staff have had training in abuse and protection of vulnerable adults. It was also covered as part of the induction. The manager was clear of what needs to be done in cases of allegations and suspicions of abuse. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and pleasant environment for service users. EVIDENCE: The outside of the home was in good order. It was clean and pleasant. There is a small garden at the back of the home full of shrubs and flowers. There is also a paved area where service users can sit and enjoy the garden. The area at the back of the home is wheelchair accessible. The inside of the home was in good redecoration order and the bedrooms were also homely and personalised. Furniture, fixtures and fittings were in good condition and were appropriate to meet the needs of the service users. The empty bedroom has been totally repainted and refurbished. Bathrooms and toilets were also appropriately decorated and accessible to service users. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 16 There was no smell in the home and it was clean. The home employs am ancillary support worker for domestic tasks. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 17 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and they are appropriately trained to care for service users. EVIDENCE: Mr and Mrs Yasaratna were on duty to care for the service users and there was an ancillary support worker also on duty. The duty roster showed that there are three additional carers employed by the home who are on duty as required. The manager stated that checks as per schedule 2 of the Care Homes Regulations 2001 have been completed for all care staff. He however stated that a CRB check has not been obtained for the ancillary support worker, and that the latter is always supervised. The ancillary worker must have at least a standard CRB check as per regulations. There has not been any new care staff since the last inspection. There was evidence that a range of training was provided for staff. Individual records were available for inspection. The home has also acquired a number of training videos which could be used to train staff while formal training is being arranged for them. Most staff were up to date with regard to statutory training. The home uses the common induction package produced by Skills for Care for new members of staff. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 18 There are five members of staff who care for service users, two are trained nurses and one member of staff has completed NVQ level 2 in care. The home therefore has more than 50 of its staff qualified to NVQ level 2 in care. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 19 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, 33 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be reassured that the home is run appropriately and in line with good practice. The home has a quality assurance procedure, but does not have a quality management system. Health and safety issues in the home are appropriately addressed. An emergency fire plan was not available for inspection. EVIDENCE: The manager has completed the Registered Managers Award. He has run the home since it was registered. There was evidence of staff meetings where staff have the opportunity to share their views about the service. The manager is approachable and is aware of the issues in running the home. He is supported closely by his wife in managing the home. The manager stated that he would Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 20 be promoting one of the carers to the position of deputy manager to increase the involvement of staff in managing the home. The home has a quality assurance policy. It mentions that audit will be carried out six monthly in the various sections such as in catering, housekeeping, care and administration. It is however not clear how the audit is going to be carried out. There is no quality management system and there are no standards, which have been set, against which the home is to audit itself. There has however been a satisfaction survey. Satisfaction questionnaires have been sent in July to gauge stakeholders’ views about the service. The manager stated that once the questionnaires are received a report would be published. The home does not manage the social benefits or keep the personal money of service users. This standard has therefore not been assessed. The home has a gas safety, an electrical wiring and a portable appliances test certificates. There was evidence that the fire system and the call bell system in the home were being monitored and service. Records showed that all fire checks were taking place. The home normally has a six-monthly health and safety check, but this was being carried out monthly. A fire risk assessment was available for inspection but an emergency fire plan was not in place. Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 21 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 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 3 13 3 14 3 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X x 2 Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 15(1,2) Requirement The manager must ensure that care plans clearly describe the actions that need to be taken to meet the needs of the service users. Risk assessments and the care plans must be updated as and when the needs of service users change Care plans must be agreed and reviewed with the service users or with their representatives. A record must be made when this is not possible. The registered person must ensure that all new employees have the necessary information as detailed in Schedule 2 of the Care Homes Regulations 2001 before they are offered employment (Previous requirement- timescale 28/02/06 not fully met) The registered person must ensure that the home has an effective quality management system with clear standards against which the service can be measured. The home must have a fire DS0000017496.V306760.R01.S.doc Timescale for action 15/10/06 2 OP7 15(1) 15/10/06 3 OP29 19(1)(b) 15/10/06 4 OP33 24(1) 31/10/06 5 OP38 23(4) 15/10/06 Page 23 Edwin Lodge, 6 Victoria Court Version 5.2 emergency plan. 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 2 Refer to Standard OP4 OP8 Good Practice Recommendations The manager should include the ethnic and cultural aspects of the needs of service users in the care plans. It is recommended that the registered manager review the additional tasks which staff carry out in the care home, such as blood sugar testing in line with responsibility and accountability. It is recommended that the manager develop a section of the care plan on the life history of service users to provide additional information on the background of the service users. 3 OP12 Edwin Lodge, 6 Victoria Court DS0000017496.V306760.R01.S.doc Version 5.2 Page 24 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.V306760.R01.S.doc Version 5.2 Page 25 - 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!