Inspection on 19/04/06 for Kings Lodge

This inspection was carried out on 19th April 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kings Lodge 18/04/08

Kings Lodge 09/01/06

Kings Lodge 11/01/05

Kings Lodge 09/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Kings Lodge 47 Kingsway Wembley Middlesex HA9 7QP Lead Inspector Andreas Schwarz Key Unannounced Inspection 19th April 2006 09:30 Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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 Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kings Lodge Address 47 Kingsway Wembley Middlesex HA9 7QP 020 8903 0952 020 8902 9611 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 Anil Rawlley Mr Brijendra Sinha Mr Kathirgamu Balendran Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one service user, AA, over the age of 65 years for the duration of his stay. 9th January 2006 Date of last inspection Brief Description of the Service: Kings Lodge is a care home providing care and accommodation for up to 9 adults 18-65 with learning disability. The home is owned by Ablegrange Ltd and is managed by Dr K Balendran. The home has been through a process of transition and used to provide personal care and accommodation for nine older people who have moved to other residential homes. Currently there are five residents at Kings Lodge. The home is located in a residential area near Wembley and within reasonable walking distance of two underground stations. A number of bus-routes and Wembley High Street is close by. The home is a converted semi-detached house and was first registered under the Registered Homes Act 1984 in April 1990. Accommodation for the service users is provided on the ground and first floors; all but one of the bedrooms is single occupancy. There is parking at the front of the house and on the street; at the rear there is a good-sized garden and a building, which is the head office of Ablegrange Ltd, and the Registered Manager’s office. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during a day in April 2006. The inspector spoke to all service users, three members of staff, the registered manager and the registered individual during this key inspection. The inspector case tracked three residents and viewed files and other documents during this visit. The registered manager showed the inspector around the building. The home has send Regulation 26 reports to the Commission for Social Care Inspection. The inspector would like to thank everybody for their help and support during this key inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must improve the way residents are consulted about the care and service received at Kings Lodge. Appropriate day service activities must be found for one resident in particular. The home must do additional work to fully Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 6 comply with fire safety regulations and electrical installation must be serviced. Staff must receive training in age related issues and manual handling training meeting fully the need of one resident recently moved into the home. 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. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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 Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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): 2 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users’ individual aspirations and needs are assessed. Prospective residents are involved within the assessment process and have an opportunity to test drive the home. EVIDENCE: The inspector viewed a number of detailed assessment documents during this visit. All assessed documents were found to be of similar standard and the registered manager has done all assessments. Residents informed the inspector of being involved in the process and having had an opportunity of visiting the home before moving in. The home has a detailed referral policy in place. Previous inspections required for all contracts to be signed. All viewed contracts were found to be signed by the service users or their representative. It was also evident that information obtained during the assessment process has been included within the care plan and care planning process. Previous inspection addressed the need for training on ageing and age related issues to ensure the service meets all service users needs equally, this was found to be still outstanding. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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; 9 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users assessed and changing needs and personal goals are reflected in their individual Plan. Residents are encouraged making choices about the care and supports received by the home and are involved within the care planning process by attending meetings and being listened to. EVIDENCE: The inspector assessed three care plans during this inspection visit. The home has two care plan folders one with current information such as daily records, monitoring sheets and basic information on the residents. A more detailed folder, which is kept in the managers office contains service user information and a care plan, which has been signed by the service users and or their representative. The inspector found the care plans of good standard, but informed the registered manager that the care plan should be filled out in more detail to provide the necessary information to service users and staff. Care plans have been reviewed regularly and up dated where necessary. All assessed care plans had detailed achievable goals for residents in place. Residents informed the inspector that they take part in meetings and meet Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 10 with their key worker. Residents however seemed not to be clear who their allocated key worker is, this can be due to the fact that staff and service users are new at the home. The registered manager informed the inspector that some residents have family involved and one resident has an independent advocate. The inspector informed the registered manager to provide the opportunity for independent advocacy to all service users living at the home. Individual daily choices like where to go and what to do is clearly recorded and documented within service users’ daily records. The registered manager is supporting service users around their finances and the inspector observed the manager assisting a resident with problems he had with one of his personal accounts. The inspector assessed two service users’ financial records, which have found to be in order. The home had three residents meetings since the last inspection and records of these have been forwarded to the inspector. The inspector viewed risk assessments during this inspection. Not all risk assessments were found to be of the same standard. Some were very detailed with a variety of risks assessed and others lacked this detail. The registered manager must ensure that all risk assessments are of the same standard. Risk assessments have been reviewed as required previously. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 11 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): 12; 13; 15; 16; 17 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity for personal development. Service users are encouraged to access the community on their own if they wish to do so, or with staff if they require support, residents have a healthy varied diet and can make choices of what they want to eat. EVIDENCE: Two residents access day centres full time and one resident informed the inspector that he is very happy about going to the centre and likes his activities. There was a timetable available in the service user’s file outlining in detail what activities are provided by the day centre. One resident informed the inspector that he wants to go to the day centre, which was discussed in detail with the registered manager; social services have been informed about this and look currently for a suitable place. The registered manager informed the inspector that one resident has the incontinence pad only changed once per day, while in the day centre. This is not considered appropriate; the resident leaves the home at 7:45am and returns home around 16:30 pm. The service user’s care manager and a representative of the day centre agreed that Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 12 it is sufficient changing the continence pad once a day. The registered manger is required to address and discuss this further with social services and day centre. On the day of the inspection one resident went for a walk and shopping trip with staff to Wembley. He told the inspector that he is happy with this and does not want to have a structured day service. The resident informed the inspector that he is listening to music, is offered in-house art sessions, can watch television, play games or just relax. Two residents go independently to-do their shopping and or visit friends and families. The home must continue offering different day service opportunities for residents. The registered manager informed the inspector that the home is planning an annual holiday for resident this year and informed the inspector that this would be discussed in the next residents meeting. Residents informed the inspector of having friends and visiting them at their home. One resident left the home to see a family member during this inspection. Service users records demonstrated that families are involved in the care and residents are visited by family and friends. The home has a relationship policy in place. The inspector observed staff knocking before entering service users rooms and staff has been seen interacting with residents. The inspector observed residents moving around the home unrestricted and one resident told the inspector that he could go wherever he wants to within the home. The home has clear rules about smoking in place and service users follow these rules. The inspector viewed the homes menu, which was judged as being wholesome and varied. The inspector however noted that no fresh vegetable were available and staff confirmed using mostly frozen vegetable; it is required to provide fresh vegetable for residents on a regular basis. The home records food choices on resident’s daily records. The kitchen has been cleaned since the last inspection, but some cupboards were again found to be dusty and dirty. The home must ensure to maintain the same level of cleanliness at all times. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 13 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; 21 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. The home is providing support for residents attending health care appointments and guidelines are in place supporting residents appropriately around their personal care needs, however there is a need to expand them. EVIDENCE: The inspector viewed service users care plans during this inspection, the sampled files provided evidence of personal care guidelines, these guidelines however were very basic and must be expanded to contain information such as continence, toileting, feeding, how residents prefer being assisted around their personal care needs and how they prefer to be moved and transferred. Personal care can be provided in a lockable bathroom, the home has a shower room on the ground floor, one service user on the ground floor has mobility problems and is fully wheelchair bound and therefore not able having a bath due the location on the first floor. The inspector recommends reviewing this and finding ways how service users living on the ground floor can have a regular bath. Residents were observed wearing appropriate clothes and informed the inspector that they choose what to wear independently. Staff informed the inspector of being trained in manual handling, the course was a Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 14 half-day training course, which may have been sufficient prior to the admission of residents with mobility problems, but considering the high use of manual handling techniques and technical aids such as hoist. The home must provide appropriate manual handling training. The inspector viewed a very detailed health action plan in one of the resident’s files, this plan contained excellent information about the residents health needs, the inspector informed the registered manager that all residents must have the same high standard of records on file. The inspector viewed clear health records in service users’ files and a range of outside professionals such as psychiatrist, chiropodist, GP, etc. are involved in service users care. One resident receives support from the bereavement councillor, who also provided training to two members of staff in how to support service users around loss and bereavement. The registered manager informed the inspector that one newly referred service user has a history of Epilepsy; the epilepsy nurse is involved in the service users care. Records however provided no evidence of detailed Epilepsy risk assessments and Epilepsy guidelines, which is required. The homes medication policy is compliant with National Minimum Standards. Medication Administration Records had no gaps and administered medication was found to be clearly recorded. The home has separate records of medication disposal and medicines received. The home has a list of signatures of staff trained to administer medication. The home does record blood sugar levels in a separate book as recommended during a previous inspection. The inspector found evidence that the home has addressed service users wishes of death and dying; records were found in service users files. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 15 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 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and acted on. Residents and visitors are encouraged voicing their satisfaction and dissatisfaction about the service received and are protected from abuse, harm and neglect. EVIDENCE: The home has updated their complaints procedure and is now meeting National Minimum Standards. The home has not received any complaints since the last inspection and residents demonstrated knowledge of whom to complain to. The home has Brent’s and Ealing’s Protection of Vulnerable Adults guidelines in place. Staff have attended in house Protection of Vulnerable Adults training, but certificates where not available for inspection. The registered manager however send certificates at a later date during the writing of this report. Staff spoken to demonstrated clear understanding of whom to report to in case of witnessing any Protection of Vulnerable Adults related issues. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 16 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; 30 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. The home is decorated to good standard and service users have brought their own belongings to the home when moving in. EVIDENCE: The home has addressed the majority of requirements made during the previous inspection. The newly purchased hoist has been serviced and is now safe to use. The home has currently one vacancy. The home put a lot of effort into making the home as homely as possible. A new TV stand has been purchased, pictures are hung on the walls, and one resident brought a fish and bird with him, when moving into the home. The home was clean and overall free of odour; the downstairs toilet however had a very strong smell of urine, which must be addressed. The downstairs toilet is still judged as not appropriate and the home must consider a different lay out as required previously. The home has purchased a new washing machine and electric dryer, the sluice room is currently not in use and clinical waste is safely disposed off. The home has an infection control policy in place. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 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): 32; 33; 34; 35 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff supports service users. Residents are well supported by a new but experienced staff team. EVIDENCE: The majority of staff employed by the home are adaptation nurses, waiting for their UKCC registration and pin number. Staff who do not have nursing qualification are in the process of completing their National Vocational in Care Level 3. The home does not employ staff under the age of 18. Staff has some experience of how to deal with GP’s, Social workers and other outside professionals, Staff however informed the inspector that the registered manager does the majority of this work. The inspector observed staff supporting residents appropriately and found staff listening and asking questions when not understood by the service users. The home has currently adequate staffing levels, however consideration should be given to additional residents moving in and day service support to the residents currently living at the home. The inspector suggested creating a middle shift, which would enable staff to support residents better around outings and day service activities. The inspector viewed the homes rota and found the managers hours not being recorded, which is required. Staff Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 18 informed the inspector that the registered manager is always available and is working hands on with the residents. The home has a recruitment policy in place and Staff files assessed by the inspector included all necessary documents such as two references, Enhanced CRB check, work history, right to work in the United Kingdom, etc. All staff have an annual training and development plan, which has been updated regularly. The home is providing a number of in house training sessions, with the help of videos and is providing certificates to staff after successful completing the sessions. Staff is provided with induction training and records of this was found in staff files assessed by the inspector. The inspector raised the lack of training in some areas, e.g. Age related issues (Dementia) and Manual Handling Training. Staff informed the inspector of having received regular supervisions and records have been viewed and assessed. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 19 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; 39; 42 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Resident’s benefit from an experienced and qualified manager and are consulted about the care they receive, more work is required to reach full compliance. EVIDENCE: The manager Mr Balendran has achieved his Registered Managers Award and is currently undertaking a Management in Care course to enhance his training portfolio. The manager is experienced and staff informed the inspector of felling supported and spoke very positive about the manager. The appropriate registration and insurance certificates have been displayed during this inspection. The registered provider started sending regular monthly reports to the inspector as required in National Minimum Standards. The home has provided Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 20 a service development plan, but the registered manager informed the inspector that service users questionnaires are still outstanding. Residents however have the opportunity to voice their satisfaction or dissatisfaction in regular residents meetings, which are clearly recorded. The home has now one policy file in place as required in previous inspections. The home has a Health and Safety policy in place and the following certificates have been assessed and are up to date Portable Appliances Test Certificate, Landlords Gas Safety Certificate, the inspector noted that the Electrical Installation Certificate has expired and a copy of a valid certificate must be send to the inspector once completed. The home is having regular fire drills and fire points tests. The Fire risk assessment has recently been reviewed and the fire equipment has been checked. A number of fire doors were found wedged open, the inspector however acknowledges that the home has installed four mechanical door stoppers and the registered manager informed the inspector that due to cost implications this will be done in three stages. The inspector informed the registered manager that the home must fit the outstanding doorstoppers to comply with Fire Safety Regulations. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 21 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 3 3 X 3 X X 2 X Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 22 YES 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 YA3 Regulation 18(1)(c)(i) Requirement The registered manager must ensure that all staff receive training on age related issues. (Expired 28/02/06) The registered manager must ensure that care plans are more in detail. The registered manager must ensure offering independent advocacy to all residents living at the home. The registered manager must ensure that all risk assessments are of the same standard. The registered manager must discuss day service practices around continence care and a more suitable solution must be found. The home must ensure maintaining the same level of cleanliness in the kitchen at all times. The home must update and expand residents personal support guidelines. The home must provide adequate manual handling training to meet service users changing needs. DS0000017459.V288285.R01.S.doc Timescale for action 31/05/06 2. 3. YA6 YA7 15(1) 15(2)(c) 31/05/06 31/05/06 4. 5. YA9 YA12 14(2)(a) 12(1)(a) 31/05/06 15/06/06 6. YA17 23(2)(d) 30/05/06 7. 8. YA18 YA18 12(1)(b) 13(5) 15/06/06 15/06/06 Kings Lodge Version 5.1 Page 23 9. 10. 11. YA19 YA19 YA24 17(1)(a) 12(1)(a) 23(2)(a) 12. YA30 16(2)(k) 13. YA33 17 Schedule3 18(1)(c)(i) 14. YA35 15. 16. YA42 YA42 23(4)(a) 23(4) All residents must have the same standard of records, i.e. health action plan. The home must provide detailed Epilepsy risk assessments and Epilepsy guidelines. The manager must reconsider the layout of the downstairs toilet. (Expired 31/05/05, 30/09/05 & 31/03/06) The strong smell of urine in the ground floor toilet and bathroom must be addressed. (Expired 31/01/06) The registered manager must record the actual hours worked in the home on the rota. (Expired 31/01/06) The registered manager must ensure providing training such as age related issues and in Manual Training as required in YA3 and YA19. The home must continue and complete the fitting of mechanical door stoppers Fire doors must not be wedged open. (Expired 31/07/05 & 31/01/06) The home must complete and forward a copy of the Electrical Safety Certificate to the Commission for Social Care Inspection. 31/05/06 31/05/06 31/07/06 30/05/06 31/05/06 31/05/06 30/06/06 30/06/06 17. YA42 23(2)(c) 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 24 1. 2. 3. YA9 YA18 YA33 The registered manager should assess a wider range of risks. The manager should consider ways in how residents with mobility problems can have regular assisted baths. The registered manager should review the current staffing levels and consider a middle shift. Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 25 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 Kings Lodge DS0000017459.V288285.R01.S.doc Version 5.1 Page 26 - 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!