Inspection on 04/08/05 for Park Lodge

This inspection was carried out on 4th August 2005.

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 10/08/07

Park Lodge 10/05/06

Park Lodge 09/02/06

Park Lodge 28/08/04

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 42 Monks Park Wembley Middlesex HA9 6JE Lead Inspector Andreas Schwarz Unannounced 4 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park Lodge Address 42 Monks Park Wembley Middlesex HA9 6JE 020 8903 5370 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs A Kelly Mrs A Kelly Care Home Three Category(ies) of Older People - Three registration, with number of places Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/03/05 Brief Description of the Service: Park Lodge is a residential care home registered for three service users. It is situated in a quiet street close to a park and about five minutes walk from shops. The Inspector was advised, that the proprietor/care manager lives on the premises and is fully involved in the care of service users. There are three members of staff employed.The ground floor used to consist of a service user’s bedroom, a lounge/diner, a kitchen, laundry and toilet. The first floor accommodation consists of two service users’ bedrooms and a bathroom and separate toilet.The lounge/diner opens on to a concreted patio area and garden. There is also a large garden to the front of the building.The house had undergone a major refurbishment and there are now two bedrooms on the ground floor and a new kitchen put in along with an additional shower room and toilet and utility room. The living room has also been extended at the back.The refurbishment was in the final stages of completion. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours in August 2005. The Lead Inspector was accompanied by Virginia Allen to shadow this inspection. Ms Winsome Chambers (Care Assistant) assisted the inspector throughout this inspection. The registered manager was available to answer questions during this inspection. The inspectors viewed all care plans and a number of other records and documents relating to residents and the home. The inspector spoke to residents and was shown around the property by Ms Chambers. The inspectors would like to thank residents, Ms Chambers and the registered manager for being so welcoming and supportive throughout this visit. What the service does well: What has improved since the last inspection? The redecoration and refurbishment of the lounge, kitchen, etc. is almost completed. The registered manager addressed a number of requirements made during the previous inspection. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3; 6 Residents are involved within the assessment process and needs are assessed appropriately. The home does not provide intermediate care, therefore this standard was not assessed. EVIDENCE: The inspector viewed the homes’ assessment records, which were done by the care manager. The registered manager informed the inspector of visiting new prospective residents and does a verbal assessment. The inspector explained that the home must have written documented evidence of the assessment. However it was evident that information gathered at the assessment forms part of service users care plans. The inspectors noted that one resident is diagnosed with Alzheimer/Dementia and one resident is diagnosed with a mental illness. The inspector informed the responsible individual that the home must apply for a minor variation to meet registration requirements. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7; 8; 9 Care plans are of good standard, however it was not fully clear how residents are involved in review processes. The home supports and meets residents’ health care needs. The inspector was not fully satisfied with the new medication procedure recently implemented. EVIDENCE: The inspector viewed all three care plans, care plans are assessed by the key worker monthly, however care plans were not signed or dated by residents. Therefore it was not clear if residents are involved in the assessment process. The key worker explained to the inspector, that some residents refuse to sign; this must be documented in care plan reviews. Care plans were viewed as appropriate, but the inspector explained that more detailed information should be provided during review processes. The inspector assessed a number of risk assessments in the care plan files, these were of good standards, but the was no evidence of regular reviews; this is required. Funeral arrangements are discussed with residents, all residents have appropriate funeral arrangements. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 10 The home provides adequate health care support to residents. All residents have their own GP and the chiropodist and optician visit the home at regular intervals. None of the residents had any pressure sores on the day of inspection. The home has one resident with Dementia and one resident with Mental Health problems. The inspector judged the care provided for these individuals as appropriate, however the home has no registration status for Dementia or Mental Health. The inspector informed the manager of applying for this. The home has changed the supplying pharmacist and medication procedure since the last inspection. The home previously used Boots MDSystem. Currently medication is packed in their original boxes and the home redispenses medication in doset boxes; this practice must cease. The inspector advised the inspector that the dispensing pharmacist must pack doset boxes for the home. Loose medication was found in medi cups locked in the medication cupboard and the inspector explained that this is not good practice and must not be done. Medication records assessed were of acceptable standard, however the following is required. Dosage of medication and residents allergies must be recorded on the MAR sheet. The home currently does not record medication received and returned to the pharmacist; this is required. The home does not have a list of staff able to administer medication; this is required. The inspector was not able to assess the homes’ medication policy, the home is required providing a medication policy for the next inspection. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12; 15 Residents are offered a range of appropriate activities to choose from. The home provides a wholesome and varied diet to residents. EVIDENCE: The inspector viewed the homes’ activity plans. Residents can attend the weekly luncheon club if they choose to, but the carer informed the inspector that residents recently chose not to take the home up on the offer. The home provides a variety from activities, ranging from exercises, outings on the bus or taxi, listening to music, etc. Participation of activities is recorded in residents’ daily records. There was a bowl of fresh fruit available on the day of the inspection. The manager informed the inspector of having a two weekly menu, which was discussed with the residents. Previously the manager asked residents the day before of their meal choice and recorded this on a menu. The inspector feels considering the size of the home that this would be better practice and advised the home of restarting this practice. The viewed menu was judged of being varied and wholesome and the fridge was stocked well. The home provides drinks and snacks throughout the day. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff have understanding of protecting residents from abuse, but more work needs to be done to comply with National Minimum Standards. EVIDENCE: The home has not received or dealt with any POVA related issues since the last inspection. The inspector viewed the homes’ abuse policy, but found that there is more work required. The policy was judged as very basic and does not give any information to staff, residents and visitors of what to do when reporting allegations of abuse. Staff the inspector has spoken to demonstrated good understanding of what to do when witnessing abuse, but did not receive any training. The inspector advised the home of acquiring Brent’s’ POVA guidelines. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19; 26 The home has recently been redecorated and residents live in a safe and wellmaintained environment. The home is clean, hygienic and was free of any offensive odours. EVIDENCE: The home has recently undergone a redecoration program. This includes repainting of the walls and new flooring in the bedrooms. It had a homely feel and the communal sitting area was decorated with family photos. The residents had comfortable chairs in their own rooms and in the lounge. Hand basins in rooms were clean. The kitchen is undergoing a refit and this area was clean and hygienic. All residents spoke warmly of their experience in the home. The home was clean and free of any offensive odours during this unannounced inspection. The home does not have sluice facilities, but none of the residents has any major continence problems. Laundry facilities are appropriate and adequate for the needs of the residents living at the home. The washing machine and dryer are of domestic character and has a program to wash above 65 Degrees Celsius. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 14 Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27; 30 There is an adequate number of staff supporting the residents. Staff are experienced and appropriately trained. EVIDENCE: During this inspection two members of staff were on duty. The home employs three staff and the registered manager is fully involved within the care of residents. Staff did not seem rushed of their feet. Staff confirmed that the number of staff is sufficient and appropriate in providing adequate care. Two staff have successfully completed their NVQ Level 2 in Care. The home provides Fire, Health and Safety, Food hygiene and Manual Handling training for new and existing staff. However training records were not clearly available and the inspector recommends that all staff have a training and development plan. Staff informed the inspector that the manager started to provide supervisions, but records were not available. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33; 34; 38 There was no clear documented and recorded evidence if the home is run in the best interest of residents. It was not clear if residents are protected by financial and accounting procedures due to records being unavailable. Residents live in a safe and well-maintained home and are protected through appropriate procedures. EVIDENCE: The home has a quality assurance policy in place, however the home does not have an annual development plan in place. The manager informed the inspector of having send out questionnaires to families and outside professionals, but has not received any comments back. According to the quality assurance policy residents should have regular meetings, but records were not available. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 17 The inspector was not able to assess financial records for the home. The manager was not willing providing these for inspection. This was required in previous inspections. The inspector viewed a number of certificates relating to fire safety, gas safety and electrical safety. All certificates were judged to be in order, with the exception of the portable appliances test, which expired in October 2003 and must be renewed. Fire records were judged of adequate standards, however the records of fire drills must capture who was in the home during the drill. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 2 1 x x x 2 Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 19 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. 3. Standard OP3 OP3 OP7 Regulation 14(1)(a) 23(1)(a) 15(2)(c)& 12(3) Requirement The registered manager must provide a written assessment of prospective residents. The registered manager must apply for a minor variation to meet registration requirements. Service users contribution / choices regarding their care plans must be clearly stated and where possible also signed by the resident or their representative who should be invited.(Expired 31/05/05) Risk assessments must be reviewed regularly. Secondary dispensation of medication is not allowed. The home must record medication received and returned to the chemist. The home must record residents allergies and medication dosage on MARsheet. A medication policy must be provided for inspection. A list of signatures and initials must be provided. All staff must receive POVA training. (Expired 30/06/04) The home must review the abuse policy. Timescale for action 15/09/05 30/08/05 15/09/05 4. 5. 6. 7. 8. 9. 10. 11. OP7 OP9 OP9 OP9 OP9 OP9 OP18 OP18 13(4)(b) 13(2) 13(2) 13(2) 13(2) 13(2) 13(6) 13(6) 30/09/05 31/08/05 31/08/05 31/08/05 31/08/05 31/08/05 30/09/05 15/09/05 Page 20 Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 12. OP30 18(2) 13. OP33 24 14. OP34 25(3)(a)( b)(c) 25 15. OP34 16. 17. OP38 OP38 13(4)(c) 23(4)(e) Staff must receive six supervisons per year and records must be made available (Expired 31/05/05). The quality assurance system must be put into effect and residents, carers and outside proffesionals views must be captured.(Expired 31/07/05) The accounting and financial procedures must be made available for inspection.(Expired 30/06/05) The registered person must provide a financial and business plan for the home.(Expired 31/07/05) The portable appliances test (PAT) must be renewed. The registered manager must record who was available for the fire drill. 31/08/05 30/09/05 30/09/05 30/09/05 31/08/05 31/08/05 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 OP7 OP18 OP30 Good Practice Recommendations Care plans should have more detail when assessed monthly. The home should obtain Brents POVA guidelines. All staff should have a training and development plan. Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 Park Lodge G62 G11 S17472 Park Lodge V233497 290605 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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