Inspection on 09/01/06 for Kings Lodge

This inspection was carried out on 9th January 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 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 19/04/06

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 Announced Inspection 3rd January 2006 09:30 Kings Lodge DS0000017459.V266353.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 Kings Lodge DS0000017459.V266353.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. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 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.V266353.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 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 three 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 with 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 are 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.V266353.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place in January 2006 and lasted 8hrs and 30mins. The registered manager Mr Balendran was available throughout this inspection. The home did send pre–inspection documents back to the local Commission for Social Care Inspection office. The inspector spoke to Mr Balendran, two residents, one member of staff and the two registered individuals Mr Rawley and Mr Sinha. In addition to this the inspector assessed the majority of records and documents during this inspection. The inspector assessed almost all National Minimum Standards and requirements made during the previous inspection. The inspector would like to thank residents, staff, registered manager and registered individual for being helpful and welcoming during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The inspector assessed 75 of the National Minimum Standards and it is therefore expected of having a large number of requirements during this announced inspection. The inspector noted a lack of structured annual development and regular quality assurance visits. Staff training needs must be assessed annually and the Commission for Social Care Inspection must be informed of this. The home must ensure that all staff receive appropriate training around Protection of Vulnerable Adults and ageing. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 6 The complaints policy must be up dated to receive full compliance with National Minimum Standards. 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.V266353.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 Kings Lodge DS0000017459.V266353.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; 3; 4; 5 Prospective residents receive the appropriate records and documents enabling them to decide if they want to move to Kings Lodge. Prospective residents needs are assessed to establish if the home can meet service users needs. Prospective residents can visit the home before they decide to move in. Contracts clearly describe rights and responsibilities residents have once they move into Kings Lodge. EVIDENCE: The inspector viewed the homes Service users guide and statement of purpose, both documents were judged of good standard and compliant with National Minimum Standards. The above documents are available in all residents’ rooms. The registered manager informed the inspector that he sends SUG and SoP to care managers on their request. Residents confirmed of having seen both documents. The inspector sampled the needs assessment of the most recent admission to the home. The assessment was judged as being detailed addressing needs such as personal care, communication, health, etc. Resident and advocate have been involved in this process. In addition to this the home applied to the Commission for Social Care Inspection for a variation of the registration enabling the home to provide care for one residents over the of 65. The inspector informed the registered manager that he must provide training in Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 9 ageing to meet the need of this individual fully. The home is currently not providing any respite placements, but has done so in the past. Residents confirmed of having had an introductory visit prior moving into Kings Lodge, this was clearly recorded and confirmed by the advocate the inspector has spoken to. Records sampled by the inspector provided evidence of residents spending a minimum of two separate days in the home. During these visits prospective residents are offered meals and are encouraged taking part in activities. All residents have contracts, which are compliant with National Minimum Standards. Two of the three contracts have been signed by the service users. The registered manager explained that the third contract is not signed due to the fact that the resident is unable to sign. The inspector informed the registered manager that the resident or their representative, such as next of kin or advocate, must sign all contracts. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 10 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): 7; 8; 9; 10 Residents are encouraged and supported in making choices and decisions about there live. The home consults with residents and offers opportunities to fully participate in aspects about the home. Service users are supported in taking risks and the home is encouraging residents to be as independent as possible. Confidential records are stored and handled appropriately. EVIDENCE: Residents are involved within the care planning processes and are encouraged and supported to sign and take owner ship of their care plans. During this visit the inspector observed staff on numerous occasions given residents choices in regards to food, what they want to do and where they want to go. One of the residents living at the home has an independent advocate, who unfortunately will discontinue his services. The registered manager informed the inspector that he contacted Brent Advocacy Services, who informed him that they would provide advocates if there is a crisis. The home is managing finances of one resident and the manager is currently in the process of applying to become an appointee. Finance records viewed by the inspector have been correct and of good standard. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 11 Residents are supported to attend regular residents meetings and the inspector has viewed minutes of these meetings. Issues regarding the home are discussed in these meetings and actioned by the registered manager if possible. The home has a range of policies in place, which are written in a simple understandable language. Policies like the complaints policy has been made available in user-friendly format. The home has a number of basic risk assessments in place, which are in need of being reviewed. The registered manager informed the inspector that the home is assessing risks if needs change and health deteriorates. The inspector informed the registered manager that he should review this practice and assess any eventualities where residents could be at risk. The home has a confidentiality policy in place and records are stored safely in the homes office. Daily records are available to staff at all times. Daily records may include care plans, guidelines and or risk assessments. Residents told the inspector that they are shown their personal file if they request to do so. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 12 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; 14; 15; 16 Residents are supported in learning new skills. Residents access the community independent or with staff support. The home is providing appropriate leisure activities and residents are occupied. The home supports residents to maintain and make relationships. Residents are treated with respect and responsibilities are clearly recorded. EVIDENCE: The registered manager informed the inspector that none of the residents living at Kings Lodge want to go to church, this was confirmed by one service users and is recorded in care plans. Staff informed the inspector that one resident is currently taught to write his signature. Residents informed the inspector that they are involved in laying the table and basic house hold tasks. The registered manager informed the inspector that one resident who smoked a lot before moving into Kings Lodge almost stopped, which is a great achievement by the home. Residents are not restricted in accessing the community, the inspector observed residents going to Harrow, Wembley during this inspection. Residents informed the inspector that they go shopping, to the pub, cinema, etc. The registered manager informed the inspector that the electoral register has been informed and the home is currently waiting for a response. Residents use Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 13 public transport or dial a ride to access the community. The home does not provide transport. The home is providing in-house activities such board games and a small video library is available to residents. Residents informed the inspector that they watch TV, listen to music, etc. One resident informed the inspector that staff practices his signature with him. The registered manager said that none of the residents went on holidays last year, but he is currently exploring places and outings for residents in the coming year. The home has a relationship policy in place. One resident informed the inspector that he goes once a month to Brentford Age Concern to visit old friends. Another resident told the inspector that he has a number of friends in Wembley, which he does visit regularly. The inspector observed residents interacting very well with each other during this announced visit. Two residents have family involvement and are visited regularly. The inspector observed residents accessing all areas within the home. Residents informed the inspector that they have a key, but do not wish to use it. The inspector observed mail given to the resident was unopened. Residents informed the inspector that they help and are involved in household tasks such as clearing and setting the table, etc. It was observed during this inspection that residents could stay in their own room if they wish to do so. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 14 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 The inspector assessed requirements made in regards to medication and personal support, which have all been met and complied with. The home supports residents healthcare and emotional needs. Procedures are in place to support residents around illness, ageing and dying, but more work must be done to reach full compliance. EVIDENCE: All residents are registered with their own local GP. Care plans provide evidence of residents visiting the dentist and optician for check ups. Residents informed the inspector that they go to the GP independent or with staff support. The home is monitoring service users health by doing regular weight checks, blood sugar monitoring, etc. The home currently records blood sugar readings in daily records. The inspector recommends purchasing a separate book for these records to make it easier when they need to be accessed. The home has a detailed policy on death and dying in place. There was however no evidence that death and funeral arrangements are addressed and discussed with the residents. The inspector informed the registered manager that this must be addressed and discussed with residents. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 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 Residents are encouraged and supported in expressing their dissatisfaction regarding the services received from the home. Residents are protected from abuse, neglect and self-harm. EVIDENCE: The inspector viewed the homes’ complaints policy, which is available in the service users guide. The inspector informed the manager that the policy must be reviewed and the Commission for Social Care Inspection address as well as the right of contacting the Commission for Social Care Inspection at any stage of the complaint must be included in the policy. The manager informed the inspector that the home did not receive any complaint since the last inspection. Residents informed the inspector that they do not have any complaints at the moment. The home has a Protection of Vulnerable Adults policy in place and some staff has received Protection of Vulnerable Adults training. Staff interviewed by the inspector demonstrated knowledge of appropriate Protection of Vulnerable Adults procedures. Ealing funds one of the residents and the inspector informed the manager that he must obtain Ealing’s Protection of Vulnerable Adults guidelines. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 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 The home is overall judged as comfortable and homely, but a number of requirements must be addressed to reach full compliance. The home is clean; there is however strong urine smell on the downstairs lavatories, which must be addressed. EVIDENCE: The home did some improvement since the last inspection and the manager begun to hang pictures in the lounge and purchased a TV stand to make the lounge more homely. The registered manager showed the inspector around the home and a number of requirements have been made; please see schedule. The inspector found some gaps in the paintwork in room A, which must be addressed. The home received a visit by the environmental health officer and the two requirements made have been addressed. The home purchased separate cutting boards and is now monitoring and recording cooking temperatures. The inspector noted that the kitchen was dirty above the fridge and above the cooker, which must be cleaned. The home has eight bedrooms one of the bedrooms is a double room, the rooms are judged spacious and compliant with National Minimum Standards. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 17 The ground floor toilet is judged as being very small and has a step, which could lead for residents to trip or fall. Previous inspections did require reconsidering the layout of the toilet, which remains still to be outstanding. The home has purchased an electrical hoist, which must be serviced every six months. The home was clean during this inspection; the inspector noted however strong urine smell on the ground floor toilet and bathroom, which must be resolved. In addition to this paper towel dispensers were out of paper, this was raised with the manager. The home has detailed Hygiene and Health and Safety policies in place. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 18 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; 32; 33; 34; 35; 36 Residents understand staff roles and responsibilities. A skilled and effective staff team supports residents. Appropriate recruitment practices protect residents from unsuitable staff. Staff receive support and supervision from the manager, there is however a need to improve this practice. EVIDENCE: The inspector viewed individual job descriptions made available to him, the job descriptions were judged of being appropriate and define clearly roles and responsibilities of each post. The home is providing the General Social Care Councils Code of Conduct as part of the induction. Residents informed the inspector of having good relationships with staff and demonstrated knowledge of their roles and responsibilities. The majority of staff employed by the home are qualified nurses who are currently in the adaptation process to receive their UKCC registration. The manager informed the inspector that two staff would start their NVQ Level 2 in Care this year. The inspector judges the skill mix appropriately. The majority of staff employed originates from the Indian sub continent, this does not fully represent the ethnic background of the residents and the registered manager should consider this when recruiting staff in the future. All staff employed by the home is older than 18. The inspector assessed the homes rota and current staffing levels are appropriate to meet service users needs. The inspector noted however that the registered manager must record the hours he is actually available on the Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 19 homes rota. Previous inspection raised the concerns of lack in recruitment checks, this has been addressed and all staffing files viewed by the inspector are compliant with National Minimum Standards. Staff informed the inspector of having received compulsory training such as food hygiene, manual handling, first aid, etc. This was clearly recorded in the homes training files and certificates were available for inspection. The inspector however informed the manager that there is a lack of forward planning regarding staff training and an annual training development is required for all staff. All staff has received a detailed induction and records of these are available in individual staffing files. Records confirmed that staff has received formal one to one supervisions, the inspector however noted that these records are very recent and there was no clear evidence if staff are supervised regularly. Staff the inspector has spoken to told the inspector having received one supervision recently confirmed this. The inspector informed the manager that he must ensure that all staff receives regular supervisions. The staff team employed by the home is very new and therefore did not receive any annual appraisals. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 20 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; 40; 41; 42 Resident’s benefit from an experienced manager. Residents are consulted about the home and care they receive, but more work is needed to achieve full compliance. Policies and procedures safeguard service users rights. Resident’s confidentiality is protected by appropriate storage of records. Residents’ safety and welfare is not compromised and service users are protected appropriately. EVIDENCE: The registered manager Mr Balendran has RMA qualifications and is currently attending a care manager course at the Open University. In addition to this the manager has over 15 years of practical experience in care. The registered manager informed the inspector that he is receiving regular supervisions and feels supported by his Line Manger. Staff told the inspector that they receive appropriate help and support from Mr Balendran. Residents have the opportunity to attend regular residents meetings and informed the inspector that the registered manager and staff do listen to their Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 21 opinion. The home has however now structured processes to capture residents, staffs and outside professionals’ opinion about the home and care in place. The home equally does not have an annual development plan in place; this is required. In addition to this the home must be visited by the proprietor monthly and records of this report must be send to the Commission for Social Care Inspection. The home recently purchased a set of policies, which are written in plain English making them more accessible to residents. In addition to this the old policy and procedure file is still available and used. The inspector informed the manager that he must amalgamate both folders and create one clear set of policies and procedures. The home has a record keeping policy in place and records are securely stored in the homes lockable office. Previous requirements regarding Health and Safety and fire safety have been addressed, with the exception that the inspector still found fire doors wedged open. The inspector informed the registered manager that this must be addressed and alternative options explored. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 22 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 X 2 3 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kings Lodge Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 X 1 2 3 2 X DS0000017459.V266353.R01.S.doc Version 5.0 Page 23 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. 2. Standard YA3 YA5 Regulation 18(1)(c)(i) 5(1)(c) Requirement The registered manager must ensure that all staff receives training on age related issues. The registered manager must encourage residents or their representative to sign the contracts. The registered manager must ensure that risk assessments are reviewed in regular intervals The registered manager must discuss funeral arrangements with residents The registered manager must discuss issues regarding terminal illness, ageing and dying with residents. The home must include the Commission for Social Care Inspection address in the complaints procedure. The right to approach the Commission for Social Care Inspection at any stage of the complaint must be included in the policy. All staff must receive formal Protection of Vulnerable Adults training. (Expired 15/09/05) DS0000017459.V266353.R01.S.doc Timescale for action 28/02/06 15/02/06 3. 4. 5. YA9 YA21 YA21 14(2)(a) 12(3) 12(3) 28/02/06 31/03/06 31/03/06 6. YA22 22(7)(a) 15/02/06 7. YA22 22(7)(b) 15/02/06 8. YA23 13(6) 31/03/06 Kings Lodge Version 5.0 Page 24 9. 10. YA23 YA24 13(6) 23(2)(a) The home must obtain Ealing’s Protection of Vulnerable Adults guidelines. The manager must reconsider the layout of the downstairs toilet. (Expired 31/05/05 & 30/09/05) The paintwork in room A must be remedied. The kitchen must be cleaned. 28/02/06 31/03/06 11. 12. 13. 14. 15. 16. 17. 18. 19. YA24 YA24 YA24 YA24 YA30 YA33 YA35 YA36 YA39 23(2)(d) 23(2)(d) 13(3) 31/01/06 31/01/06 31/01/06 15/02/06 31/01/06 31/01/06 28/02/06 31/01/06 31/01/06 20. YA39 21. 22. YA40 YA42 The registered manager must ensure that the paper towel dispensers are filled with paper. LOLER The electrical hoist must be Regulations serviced every six month. 16(2)(k) The strong smell of urine in the ground floor toilet and bathroom must be addressed. 17 The registered manager must Schedule3 record the actual hours worked in the home on the rota. 18(1)(c)(i) All staff must have an annual training and development plan. 18(2) All staff must receive at least six supervisions per calendar year. 26 The registered individual must visit the home monthly and a written record of this must be provided to the Commission for Social Care Inspection. 24(2) The home must have an annual development plan and a copy of this must be send to the Commission for Social Care Inspection. Appendix 2 The home must amalgamate the NMS two policy files and create one set of policies. 23(4) Fire doors must not be wedged open. (Expired 31/07/05) 31/03/06 28/02/06 31/01/06 Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 25 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. 3. Refer to Standard YA9 YA19 YA33 Good Practice Recommendations The registered manager should assess a wider range of risks. The home should record residents’ blood sugar separately. The registered manager should try to recruit staff to represent service users ethnic and cultural background. Kings Lodge DS0000017459.V266353.R01.S.doc Version 5.0 Page 26 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. 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