Inspection on 29/06/07 for Park Lodge

This inspection was carried out on 29th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Park Lodge 03/05/06

Park Lodge 12/12/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Park Lodge 11-15 Park Road Berrylands Surbiton Surrey KT5 8QA Lead Inspector Adrian Gordon Key Unannounced Inspection 29th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Lodge Address 11-15 Park Road Berrylands Surbiton Surrey KT5 8QA 020 8390 7712 020 8547 1580 parklodge@supanet.com 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) CHD (Care Homes) Ltd ** Post Vacant *** Care Home 35 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (35) of places Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two (2) places for service users over the age of 65, with dementia, can be accommodated. 3rd May 2006 Date of last inspection Brief Description of the Service: Park Lodge provides nursing care for up to thirty five older people, some of whom have dementia care needs. The home is owned and managed by Care Homes of Distinction Ltd. It is situated in a quiet residential street close to local bus routes and the rail station in Surbiton. Information about the service is available in the Statement of Purpose and Service User Guide. The current weekly fees range from £528 to £700 per week. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. It consisted of a tour of the premises, examination of records and observation of care practice. The inspector met with a number of residents and visitors, four members of staff and the Operations and Quality Manager. Feedback questionnaires were received from nine residents and one relative. What the service does well: What has improved since the last inspection? What they could do better: Care plans must continue to be improved so that they are more person centred, and include details of personal history and meaningful relationships. The programme for refurbishment must completed so that residents live in a comfortable and well maintained environment. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 6 To protect residents financial interests the system for monitoring their finances must leave a clear audit trail and residents must be made aware of what this is used for. To ensure there is effective management, an application to register the manager of the home must be submitted to the CSCI. 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. The summary of this inspection report can be made available in other formats on request. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives get they information they need to make an informed decision about moving in. EVIDENCE: Park Lodge does not provide intermediate care. Detailed needs assessments are in place for residents and these provide good information on different areas of need such as personal care, communication and emotional well-being. An information pack and Statement of Purpose give good, up to date guidance about the service. One resident who recently moved in said staff have been very supportive and that they are settling in very well. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 9 Another resident confirmed on a questionnaire that they visited twice with a relative before moving in. On feedback questionnaires most residents were unsure if they had a contract but felt it is probably kept by a relative. More must be done to explain to residents what their contract says and where it is held. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans in place allow staff to meet the needs of residents but there is a lack of information about each individuals personal history and identity. EVIDENCE: Care plans hold good guidance about how to meet the needs of residents and are reviewed every month. Information includes personal hygiene, mobility, nutrition and social activities. There was little relevant information about relationships and sexuality. Two residents who are married have separate rooms in the home. The Quality Manager said that this was their choice but there was not any information about this in their files. More must be done to make sure information is person centred and specific to each resident, including a detailed personal history to give a picture of who the person is. The Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 11 activity co-ordinator said she will be working with residents to create biography files in the future. There is good information about how to meet the health needs of residents. Evidence was seen that there is access to outside specialists such as an optician, chiropodist, dentist or doctor as required. Risk assessments are in place for moving and handling, falls and pressure sores. A new system has been introduced to monitor wound care. This ensures that wounds are properly assessed and reviewed and the correct treatment given. The system in place for the administration of medication helps to protect residents. Medication Administration Record (MAR) sheets which were examined showed no gaps and were accurate. Medication is stored appropriately and a record is kept of medication received or returned to the pharmacy. Each resident has a medication profile which includes a photograph. Staff were seen to treat residents with respect and to talk to them in an appropriate way. If residents were in their bedrooms, staff knocked before entering. Staff offered drinks throughout the day but some are served in plastic beakers. It would be more dignified if residents are offered proper drinking glasses. One resident who shared a room said they were not given a choice about the room and that they had a lack of privacy when making phone calls. The Quality Manager agreed to make sure calls can be made in private. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a good range of activities. To promote the health of residents a greater range of fresh fruit and vegetable must be offered. EVIDENCE: An activity coordinator is employed to offer a range of suitable recreation for residents. This includes exercise, newspaper reviews, reminiscence, arts and crafts, one to one sessions and visiting entertainers. A newsletter gives a list of future events. Day trips are sometimes arranged and, if required, a minibus is hired to take people out. During the day of inspection some residents chose to spend time in the lounge with friends. Staff were observed to explain to residents before offering any support. The activity coordinator was going round the room chatting to residents and offering things to do. The atmosphere was relaxed and pleasant. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 13 Other residents preferred to stay in their rooms and spend time on their own. Two residents confirmed that this is what they had chosen to do. One resident said however that she is left alone too much. This person also said that although they have a mobile phone to contact relatives, they are unable to use it because of the buttons. The Quality Manager said this would be looked into. Visitors are made welcome and were seen to come and go throughout the day. Comments received from relatives were generally positive. One said that it is ‘a lovely home – very clean’, another said the home is ‘marvellous’. At lunchtime some residents ate in the dining area while some had a meal in the lounge or in their bedroom. The dining room is not large enough to hold all the residents if they chose to eat there. This area was a little sparse and plastic flowers on the tables felt institutional. Residents were being assisted properly by staff but the use of bibs did not promote their dignity. Menus showed a good range of food however there is a lack of fresh fruit and vegetables. The cook was keen to develop the range of food and wanted training in this area. It would benefit residents if fresh fruit was available in bowls throughout the home in the day. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel safe and are aware of how to make a complaint. EVIDENCE: The record of complaints shows that any complaint is taken seriously and properly investigated. However records did not include information about whether the person who complained was satisfied with the outcome of an investigation. Compliments from relatives about the care given were also seen. Residents said that they knew how to make a complaint if they needed to. There have been no recent incidents relating to the protection of vulnerable adults (POVA). Not all staff have been on POVA training over the past year. However, a new system is being introduced to make sure this happens. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents who are not able to lock their rooms do not have suitable privacy. The environment must be improved to the benefit of people who live there. EVIDENCE: Park Lodge is laid out over three floors. All parts of the home were seen to be clean, tidy and free from hazards. Some areas needed redecoration and carpets on stairs and corridors were old. On the ground floor a reception area has been refurbished and the lounge is comfortably furnished with a homely feel. The lounge leads out to an accessible rear garden area. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 16 There are bedrooms on all three floors, some of which are double shared rooms. Some of the bedrooms were nicely decorated and had personal possessions and pictures on the walls. Others were very sparse and contained nothing of the residents. Bedroom doors were not lockable from the inside and did not promote privacy. Old hospital style nursing beds were used in many of the rooms. The Quality Manager said that major refurbishment is planned for the next two years and that many of these issues would be addressed. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide good support and ensure residents get the care they need. EVIDENCE: On the day of inspection the staffing levels were appropriate for the number of residents. This was confirmed by the rota. Staff were observed to relate well with residents and to offer support sensitively. Comments received from residents and relatives include ‘I’m very happy with the care’ and ‘staff are friendly and welcoming’. In surveys sent out by the manager, all residents who replied said they felt safe and well cared for. Recruitment records showed that all the necessary checks take place. One record did not contain a photograph of the member of staff but the Quality Manager made arrangements to do this. Criminal Records Bureau Disclosures are in place. Some were carried out over three years ago, but they are currently being redone. Application forms include the question ‘Have you been convicted of an offence?’ but do not leave any space for a response. This must be amended. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 18 Induction training is in line with Skills for Care guidance. All staff have recently been re-inducted to ensure consistency of practice and awareness of new procedures. Some staff are completing NVQ 2 or 3 in care. Recent training includes confusion and dementia, pressure area care, eating and drinking and catheter care. A new system is being put in place to make sure all staff receive mandatory training every year. This will include health and safety, manual handling, and first aid. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been management improvements to the service which has helped residents lead better lives. The system for recording residents finance does not fully protect their interests. EVIDENCE: There home remains without a registered manager. The provider must make sure that in order to comply with Regulations, an application is submitted to the Commission. The current acting manager was not present during this inspection however the Operations and Quality Manager was on site to assist. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 20 This manager said that there is a greater focus on quality assurance and monitoring of practices. There are a plans to make further improvements to working systems and the environment. Residents and their relatives are sent questionnaires as part of the quality assurance process. The most recent survey was at the beginning of June 2007. These gave a mostly satisfactory response about living at the home. An action plan must be put in place to summarise the survey and show how the service will respond to the comments made. The system for monitoring the finances of individual residents was confusing. A stock of toiletries are kept by the home which residents can purchase. When money is taken for these items it is recorded but there is no receipt or petty cash voucher. There is also not always a receipt for hairdressing payments. One receipt was not dated. This does not fully protect residents financial interests. One resident and their relative said they did not know how much money was held or what it was used for. Health and safety responsibilities are closely monitored. All the necessary checks such as Gas Safety and Portable Appliance Testing are up to date. Call bells and hot water temperatures are checked weekly. A fire risk assessment is in place and fire training fro staff took place in November 2006. Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5(c), 5A Requirement So that residents are clear about rights and responsibilities, a contract must be provided which sets out clear information in an understandable format. If this is given to a representative the resident must be informed. So that the needs of residents can be fully met, care plans must be person centred and include a life history. Information on sexuality must be more detailed. To ensure residents are treated with respect there must be telephone facilities which can be used in private and which are suitable for their needs. To improve mealtimes more freshly cooked vegetables must be offered. Fruit must be available at all times. Dignity must be promoted by replacing bibs with napkins. To further protect residents all staff must receive yearly training on the Protection of Vulnerable Adults. Timescale for action 01/09/07 2 OP7 12(1), 15 01/09/07 3 OP10 OP14 16(2)(b) 01/09/07 4 OP15 16(2)(i) 12(4)(a) 15/08/07 5 OP18 13(6) 01/10/07 Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 23 6 7 OP19 OP24 23(2)(b) 12(4)(a) 16(2)(c) 8 OP29 19, Schedule 2 9 OP31 8 10 OP33 24 11 OP35 16(2)(l), Schedule 4(9) To improve the environment for residents, old and worn carpets must be replaced. To respect the privacy of residents all bedrooms must be lockable from inside and they should be given a key to their room unless there is a risk to their wellbeing. Old hospital style beds must be replaced. To ensure that recruitment protects residents, records must contain all the requirements of Schedule 2 and application forms must be amended to allow details of any previous offences. To meet Regulations and ensure there is effective management an application for registration must be submitted to the CSCI by the manager. To show that residents are involved in the running of the home, a development plan must be put in place to show how the service will respond to a quality assurance survey. To make sure there are no financial errors in the handling of resident money receipts must give clear details and be numbered and dated. Residents must be kept up to date about finances kept on their behalf. 01/10/07 01/10/07 01/09/07 01/10/07 01/10/07 15/08/07 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 OP10 Good Practice Recommendations To promote the dignity of residents, drinks should be offered in suitable glasses rather than plastic beakers. DS0000065224.V344617.R01.S.doc Version 5.2 Page 24 Park Lodge Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Park Lodge DS0000065224.V344617.R01.S.doc Version 5.2 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. 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