Inspection on 07/12/05 for Elm Park Lodge

This inspection was carried out on 7th 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Park Lodge 25/09/06

Elm Park Lodge 28/07/05

Elm Park Lodge 11/01/05

Elm Park Lodge 09/09/04

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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 Unannounced Inspection 7th December 2005 10:00 Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 Elm Park Lodge DS0000010435.V265250.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 Adults 18-65. 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. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elm Park Lodge Address 2-4 Elm Park Road Finchley London N3 1EB 020 8349 2388 020 8346 3288 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) Mr Kam Choy Lim Mr Kam Choy Lim Care Home 27 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (27) of places Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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. 28th July 2005 Date of last inspection 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 residents who are over the age of sixty-five. Prior to November 2003, the service consisted of Elm Park Lodge, a large three-storey detached house, and The Lindens next door, which accommodates four residents in two flats. Both properties are now registered as one home, i.e. Elm Park Lodge. The bedrooms, all of which are single, are located on three floors. There are three communal lounges on the ground floor, one of which is for smokers. A conservatory is used as an arts/crafts room. 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. 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. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in a period of five hours and forty-five 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 eight residents, and four staff were spoken to. There were no visitors during the inspection. The inspection process also included an examination of residents’ case files and other documents relating to the management of the home. What the service does well: What has improved since the last inspection? The staff are happy with the changes to the new cleaning rota. The manager and two staff have commenced National Vocational Qualification training. One bedroom has been redecorated. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 6 A system for checking that medication has been signed for has been introduced, and care plans are provided for new residents within 24 hours of admission. The floor of the laundry room has been recovered. 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 DS0000010435.V265250.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4 & 5 The residents have comprehensive assessments about their needs and they are able to visit the home, before deciding to take up residence. The residents are also provided with full information about the home to enable them to decide on its suitability to meet their needs. EVIDENCE: The case files of two new residents were examined, and the inspector asked them about their experiences of living in the home. They confirmed that they had visited the home before moving in and that the service was meeting their needs. They particularly mentioned the competence shown by the staff and were able to name their key workers. The case files contained comprehensive assessments by 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. The files also contained service contracts, which were signed by the residents. The residents also sign to confirm that they have been given the Service User Guide. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 8 & 9 The residents are supported to live as independently as possible, having considered potential risks. Care plans need to be more comprehensive. EVIDENCE: The care plans of the new residents were examined. Although mental health issues were well covered in the care plans, other areas, eg. physical health. This is important particularly as most of the residents smoke. Other areas such as social, sexual and religious needs were not addressed. A requirement is made about this. The minutes of regular residents’ meetings were seen, which indicated that the residents were able to make decisions about their lives in the home. They also said that they were subject to very few restrictions and were encouraged to be as independent as possible. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 the following standard(s): 11, 13, 17 The opportunities and support provided for the residents’ personal development are excellent, particularly through art and craft sessions, and the residents are fully integrated with the local community. The residents’ diet needs to be supplemented with fresh fruit, which should always be available. EVIDENCE: The home employs an arts-and-crafts facilitator, whose sessions were very appreciated by the residents and were well attended. The inspector spent some time in discussion with the facilitator and the residents in the art room. An exhibition of their work, which was very impressive, was on display. Residents said that they found the sessions very therapeutic in enabling them to express their feelings and also to develop skills. There were records of other residents attending day centres, and further education colleges. There was a rota for residents to help with various tasks eg, shopping and cooking, and there was evidence of attendance at religious services. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 11 The kitchen was very clean. Although there were adequate stocks of food, fresh fruit was not available. At the time of the inspection, food was stored safely, but the temperatures of the fridge and freezers were sometimes not monitored. A requirement is made to address these issues. The residents said that the menus had been changed following their suggestions at a recent meeting. The home employs a cook for five days a week and staff and residents do the cooking at weekends. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 & 20 The home meets residents’ psychological needs, and medication is administered safely. However, the residents and staff’s physical health is at risk from the amount, and lack of safety controls, about smoking in the home. EVIDENCE: The residents who were spoken to, stated that they did not require help with personal care. They also said that there was good communication with staff, which helped to meet their emotional needs. There were good records of healthcare appointments. All residents are given a full check-up by the G.P when admitted to the home. Accidents were appropriately recorded. The medication was checked and there were no errors detected in the administration of medicines records. The inspector was concerned about the issue of smoking in the home. The majority of residents smoke, and the “smoking room” was heavily contaminated with cigarette smoke at the time of the inspection. The inspector was informed that the residents often switch off the extractor fan. This puts the health of residents and staff at risk. People were also observed smoking in another communal room, where smoking is forbidden. The manager should seek specialist advice about helping those residents who wish, to reduce Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 13 and/or stop the habit. Staff should also discuss this matter at residents’ meetings. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22 & 23 There are good systems in place to protect residents from abuse. The complaints procedure has not been followed in one instance. EVIDENCE: The complaints book showed that the last recorded complaint was in October 2005, which was dealt with appropriately. However, in discussion with a resident, it emerged that they had made a complaint that had not been logged. It was not clear how this matter was addressed, as the response to the complainant was not recorded. A requirement is made regarding this. The deputy manager is an accredited trainer on the subject of adult protection and she has implemented a programme to train the staff in this subject. Staff who were interviewed, were aware of their responsibilities regarding potential abuse of residents. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 24, 25, 26 & 30 The home is generally well maintained, and the residents have comfortable rooms that promote their independence. The comfort and well-being of residents and staff is compromised by lack of controls in smoking areas in the home. EVIDENCE: A tour of the main home and The Lindens annexe was carried out. One bedroom had been redecorated since the last inspection, and the floor of the laundry had been retiled. The office had also been redecorated. Generally the home was well maintained and was comfortably furnished. However, the water in the Lindens annexe was not sufficiently hot for residents to have a bath/shower. A requirement is made to address this. The staff need to ensure that the extractor fan in the “smoking lounge” is always operating when residents are smoking. (See comments under Standard 19). Four residents permitted and accompanied the inspector to see their bedrooms. These were comfortable and tastefully decorated. Each bedroom is protected by a coded entry system, the code being known only to the individual and the staff. Each resident is provided with a safe for keeping Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 16 valuables. One resident said that they did not have a key to their safe, and the inspector informed the manager and made a requirement abut this. At the time of the inspection, the home was clean and tidy, but note comments about smoking, which affects hygiene in the home. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 17 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 32, 34 and 35 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, 34 & 36 EVIDENCE: The inspector attended the staff handover, at which residents’ progress, and issues relating to the running of the home were discussed. It was evident that the staff had a good knowledge of residents’ needs. A discussion with a group of staff, confirmed that they were knowledgeable and confident in their roles as carers. The staff said that an issue raised at the last inspection about cleaning tasks, had been resolved by the manager, and there was a good team morale. The records of two recently recruited staff were examined. 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). There were records to show that the staff were receiving regular supervision. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41 & 42 The residents live in a home that is well managed and safe, and their views about the service are listened to. EVIDENCE: The registered manager is a qualified nurse and is very experienced in caring for people who have mental health problems. He commenced training on National Vocational Qualification (NVQ), level 4 in November 2005. Residents said that they were able to make their views about the service known at regular meetings with the staff and management. There has been continuous improvement in the structure of records and documents pertaining to the running of the home. Records of weekly fire alarm tests and regular fire drills were examined, and COSHH materials were safely stored. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 19 Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 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 3 3 3 3 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 X X X 2 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elm Park Lodge Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 3 3 X DS0000010435.V265250.R01.S.doc Version 5.0 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 YA6 Regulation 15(1) Requirement The registered person must ensure that care plans are more comprehensive to cover physical health needs as well as psychological ones. The registered person must ensure that fresh fruit is always available for residents as part of a healthy diet, and fridge and freezer temperatures are monitored daily. The registered person must ensure that specialist advice is provided for residents who wish to, to assist them to give up smoking. The registered person must ensure that all residents’ complaints are logged and responded to within 28 days. The registered person must take action to ensure that the extractor fan in the “smoking lounge” is always operating when residents are smoking. The registered person must ensure that hot water is available in the Lindens. The registered person must provide the resident with a key DS0000010435.V265250.R01.S.doc Timescale for action 28/02/06 2. YA17 12(1) 28/02/06 3. YA19 13(1) 31/03/06 4. YA22 22(4) 28/02/06 5 A24YA30Y 13(4) 28/02/06 6 7 A24 YA26 23(2)(j) 16(1) 28/02/06 28/02/06 Elm Park Lodge Version 5.0 Page 22 to their safe, as discussed at the inspection. 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 YA19 Good Practice Recommendations The registered person should discuss the hazards of smoking with the residents at their meetings. Elm Park Lodge DS0000010435.V265250.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office 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 DS0000010435.V265250.R01.S.doc Version 5.0 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. 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