Inspection on 28/07/05 for Elm Park Lodge

This inspection was carried out on 28th 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

Elm Park Lodge 25/09/06

Elm Park Lodge 07/12/05

Elm Park Lodge 11/01/05

Elm Park Lodge 09/09/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 ELM PARK LODGE 2-4 Elm Park Road Finchley London N3 1EB Lead Inspector Tom McKervey Announced 28 July 2005 @ 09.30 am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elm Park Lodge Address 2-4 Elm Park Road, Finchley, LondonN3 1EB 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) 020 8349 2388 020 8346 3288 Mr Kam Choy Lim Mr Kam Choy Lim PC Care Home only 27 beds Category(ies) of MD Mental Disorder registration, with number of places ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 specific service users who are currently resident in the home and are over 65 years of age can reside in the home. This condition will need to be reviewed when any of the service users vacate the home. Date of last inspection 11 January 2005 Brief Description of the Service: Elm Park Lodge is a privately run care home which is registered to provide care and support for a maximum of twenty seven younger adults who have a mental disorder. The home is authorised, as a condition of its registration, to accommodate four service users who are over the age of sixty five. Prior to November 2003, the service consisted of Elm Park Lodge and The Lindens next door, which accommodates four service users in two flats. Both parts of the service are now registered as one home, i.e. Elm Park Lodge. The stated aim of the home is to maintain the quality of life for service users by promoting their independence, dignity, rights, privacy, choice and welfare. The home is a large three-storey house with two flats next door. There is a space at the front of the home for car parking, and there is a large, very attractive garden and patio at the rear of the premises. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out in a period of seven hours and thirty minutes. The proprietor/manager was present throughout the inspection and fully cooperated in the process. A tour of the main home and adjoining “Lindens” was carried out as part of the inspection, and ten residents, five staff and two relatives were spoken to. The inspector examined residents’ case files and other documents relating to the management of the home. Prior to the inspection, comments about the service were sent to the inspector from residents, relatives and professionals who have input into the home. All the comments were very complimentary about the service. What the service does well: What has improved since the last inspection? Three requirements from the last inspection regarding medication errors and implementing regular supervision for staff have been complied with. Bathrooms and toilets have been refurbished, and new curtains have been provided in some of the bedrooms. New mattresses have also been purchased for ten residents. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 6 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. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 4 Service users have comprehensive assessments about their needs and they are able to visit the home, before deciding to take up residence. EVIDENCE: Three case files were examined. They contained comprehensive assessments by referring care managers and the manager and deputy of the home. Risk assessments were also carried out. There was evidence of ongoing assessments by a multi-disciplinary, mental health team at regular care programme approach meetings. Service users’ individual cultural and religious needs were also identified. Two relatives who were visiting the home, told the inspector; “Our son has stayed out of hospital for over a year. He had been a “revolving door” patient before coming here”. Residents who were spoken to, stated that they had visited the home on day and overnight visits before deciding to move in. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 & 10 Not all service users are provided with care plans on admission to the home, which could result in care staff being unaware of a service user’s needs and care objectives. Information about the residents is held securely. EVIDENCE: Three case files were examined. In one instance, a care plan had not been made for a resident, who the manager said was on a four-week trial in the home. A requirement is made for a care plan, including a risk assessment, to be provided for all service users within twenty-four hours of admission. The other two samples of care plans met the standard. The inspector saw minutes of residents’ meetings, which indicated the support given to enable service users to make decisions about their lives in the home. Service users told the inspector that they were subject to very few restrictions and were encouraged to be as independent as possible. In discussion with staff, the inspector was satisfied that they were aware of their responsibilities in relation to confidentiality. Records were seen to be securely stored. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, & 17 The opportunities and support provided for service users’ personal development is excellent, and the residents are fully integrated with the local community. EVIDENCE: The inspector was impressed with the progress of a resident who described their attendance at “Wellbeing” sessions run by the Mind charity. This person was also training to undertake a sponsored walk for charity soon. Two residents work in the local Oxfam charity shop. The home also employs an occupational therapist, whose sessions were well attended by the residents. The inspector saw an exhibition of their work, which was very impressive. There were records of other residents attending day centres, and further education colleges. Some of the residents help with shopping and cooking, and there was evidence of attendance at religious services. The inspector spoke to ten residents, all of whom were very complimentary about the service, and said that they were encouraged to make decisions about a wide range of issues pertaining to living in the home. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 11 An inspection of the kitchen found that it was very clean and there were adequate supplies of food. The temperatures of the fridge and freezers were monitored and food was stored safely. The residents stated that they are asked the day before about their choice of menu. Special diets were catered for and the menus showed a good variety of nutritious meals. Service users can avail themselves of hot and cold drinks at any time, and fresh fruit was available. The home employs a cook for five days and staff and residents do the cooking at weekends ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 & 21 Service users receive care and support in accordance with their needs and in the manner they prefer. However, service users’ health and welfare is potentially at risk due to unsafe practices in the administration of medicines. EVIDENCE: Residents who were spoken to, stated that they did not require help with personal care, but they were very happy with the way staff supported them in all other aspects of their care. They said that they were always treated with dignity and respect. Accidents were appropriately recorded, and the case files contained evidence of healthcare appointments; for example, Clorazil clinics, G.P’s, and psychiatric outpatients. There were records of Community Psychiatric Nurses, (CPNs), visiting residents in the home. The medication standard was inspected. One resident injects their own insulin, but otherwise, no residents were self-medicating. A mistake in a date was noted in the administration of medicines record, and one dose of Olanzapine was missing from the blister pack. A requirement and a recommendation is made regarding this issue. The case files contained service users’ wishes in relation to their funerals. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 There are good systems in place to address complaints and to safeguard service users from abuse. EVIDENCE: There is good recording of complaints. The records indicated that six complaints had been received in the past twelve months, all of which had been resolved satisfactorily. Staff who were interviewed were aware of their responsibilities regarding potential abuse of residents and had attended training in this subject. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26 & 30 Service users benefit from living in a well-maintained and comfortable environment. However, consideration must be given to an alternative means of access to bedrooms in emergencies, to ensure that residents’ health and safety is not compromised. EVIDENCE: A tour of the main home and The Lindens was carried out. There had been many improvements to the décor of the home, particularly the toilets, bath and shower rooms, which had all been retiled. Generally the home was well maintained and was comfortably furnished. However, the covering on the floor of the laundry, which had bubbled, needs to be replaced. Four bedrooms were visited with the resident’s permission. They were comfortable and there was evidence of personal possessions. Each bedroom is protected by a coded entry system, the code being known only to the individual and the staff. However, a recent visit by the fire safety officer raised concern about this system in an emergency. As a consequence of this, the manager stated that he is considering an alternative means of access to bedrooms. A requirement is made to address this issue. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 15 At the time of the inspection, the home was very clean and tidy and free from offensive odours. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 Service users’ needs are being met by a committed group of competent staff who are well trained and supervised. However, the amount of time spent with residents by the care staff is reduced by the inappropriate amount of time spent on cleaning duties. EVIDENCE: ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 17 The inspector attended the staff handover, at which residents’ health and other issues were discussed. It was evident that the staff had a good knowledge of the range of residents’ needs. The interactions between staff and service users, which were observed by the inspector, demonstrated that the staff were competent and confident in their roles. The registered manager is supported by a deputy and an administrator In addition to the care staff, there is a maintenance person and a part-time cook and cleaner. The manager and deputy are on call one week in rotation. The staff rotas showed that there is normally two staff on duty during the day, one waking member of staff at night, and one sleeping-in. At a meeting with the care staff, they expressed dissatisfaction about the increasing amount of cleaning they were having to do, which was said to be detracting from one-to-one time with residents. A requirement is made for the manager to review staffing levels, particularly in relation to the cleaner’s hours. The records of six most recently recruited staff were sampled. The files contained all the information required under this standard, including references and proof of identity. Satisfactory checks had also been made with the Criminal Records Bureau-(CRB). Staff records showed that they had an induction when starting work in the home and mandatory training had been provided. Two staff had attained NVQ level 2 and the manager stated that further NV Q training was planned this year. There were records to show that the staff now receive regular supervision. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 & 42 Service users benefit from living in a home that is well managed and safe, and where their views about the service are listened to. EVIDENCE: ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 19 The registered manager is a qualified nurse and is very experienced in caring for people who have mental health problems. The manager stated that he has applied to undertake NVQ level 4 in September 2005. The inspector observed the interactions between the manager and service users and staff. The residents and the relatives who were interviewed, spoke highly of the manager. The concerns expressed by the staff, were fed back by the inspector. The comments were appropriately received by the manager. The inspector saw a report of a quality audit of the service that had been carried out, which indicated a high level of satisfaction by service users. There were also minutes of residents’ meetings which showed that their views were sought and responded to. There were records of weekly fire alarms tests and regular fire drills. The temperatures of fridges and freezers were being monitored. COSHH substances were kept securely, and there were current certificates of safety for fire, gas and electrical installations. The water supply had also been tested for the presence of Legionella. A workplace assessment had been conducted by an occupational therapist. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 x x x 3 Standard No 11 12 13 14 15 16 17 4 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 ELM PARK LODGE Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 21 No 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 6 Regulation 15(1) Requirement The registered person must ensure that a care plan is provided for new service users within 24 hours of admission. The registered person must ensure that the correct date is entered when medication is given and missing medication is properly accounted for. The registered person must replace the floor cover in the laundry room to ensure that it is impermeable. The registered person must review the system for access to residents bedrooms in the event of emergencies and replace it with a system which meets fire regulations. The registered person must review the staffing levels, particularly cleaning hours, and increase these as necessary. Timescale for action 31/8/05 2. 20 13(2) 31/8/05 3. 24 23(2)(b) 30/9/05 4. 26 13(4)(c) 31/12/05 5. 33 18(1)(a) 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 22 No. 1. Refer to Standard 20 Good Practice Recommendations The registered person should set up a system to check the administration of medicines records after each shift as part of the handover between staff. ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 ELM PARK LODGE G59 S10435 Elm Park Lodge V231110 28.07.05 Stage 4.doc Version 1.30 Page 24 - 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!