Inspection on 09/02/06 for Park Lodge

This inspection was carried out on 9th February 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 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 04/08/05

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 Inspection 9th February 2006 08:00 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 DS0000017472.V280705.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 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 DS0000017472.V280705.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Park Lodge Address 42 Monks Park Wembley Middlesex HA9 6JE 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) 020 8903 5370 Ms Avadne Kelly Ms Avadne Kelly Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 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 four members of staff employed. The ground floor consists of a service users 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 is now completed. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in February 2006 and lasted over four hours. The inspector was assisted by Ms Winsome Chambers (Senior Support Worker) and Mrs Kelly the Registered Manager/Provider was available if needed. Ms Chambers was very helpful and demonstrated clear knowledge of the inspection process. The inspector viewed care plans; risk assessments and other records made available to him on request and spoke to all residents during this visit. 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? What they could do better: Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 6 The inspector raised the need for the registered manager to obtain formal qualifications in care and management. There is a lack of service users involvement and consultation, which must be addressed. The home must start forward planning and provide annual business and financial plans. The home must apply for a variation of registration to be able meeting service users changing needs. 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 DS0000017472.V280705.R01.S.doc Version 5.1 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 DS0000017472.V280705.R01.S.doc Version 5.1 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 the following standard(s): 3 Residents are involved in the assessment process and are only admitted if the home can meet their needs. EVIDENCE: The inspector viewed the assessment of the most recent admission to the home, the assessment document was judged as detailed and comprehensive and the prospective service user was involved within the process. The registered manager informed the inspector that the placement broke down due to the resident not wanting to live in a care home and choose to continue living independent. Previous inspections raised the issue of two resident living at the home having Dementia, if this formally diagnosed the home must apply for a minor variation and provide clear evidence that appropriate dementia care is provided. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 the following standard(s): 7; 9; 10 All residents have a detailed care plan, which is reviewed regularly. Residents are appropriately supported from errors, which may occur in the administration of medication. Residents are treated with respect and have the right to choose if they would like to have company or want to be on their own. EVIDENCE: The inspector viewed two care plans, which were judged of being detailed. Care plans have been reviewed monthly and service users are involved within this process. The home encourages residents to sign their care plan after each review meeting and records if residents refuse to sign after the meeting. The inspector could not find any evidence of regular annual reviews, which was discussed in detail with the senior support worker during this inspection. All residents must be offered annual reviews involving families, social workers and clinicians. The inspector viewed a number of detailed risk assessments, which have been reviewed at the end of 2005. The home improved their medication procedures following the previous inspection and complied with all five requirements and is now compliant with National Minimum Standards. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 10 Two residents met with the inspector during this visit, both confirmed that staff treats them with respect and they are happy with the support received from the home. Staff was observed knocking the door before entering a room and mail is given to the residents unopened. The home has a cordless phone, which can be used in the privacy of resident’s rooms if service users choose. Residents informed the inspector that GP visits are done privately. Residents confirmed that the home is responsible for laundering of their clothes and the clothes worn during this unannounced inspection is their own. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 the following standard(s): 13; 14 Residents can maintain relationships with whomever they choose to. Residents are encouraged to life an independent live. EVIDENCE: The home has a visitors policy, which gives residents the right to welcome visitors to their home, the only restriction is that the home asks visitors contacting the home prior to visiting at busy periods such as early in the morning or at lunchtime. Staff informed the inspector that the home respects resident’s decisions not wanting to meet visitors, this was confirmed by one resident the inspector has spoken to. The home supports residents to attend luncheon clubs, local barbers or local church if they wish. The home is managing finances for one service users, records assessed by the inspector were of good standard but did not tally and more money was in the service users bank account than on record, this was discussed with the registered manager. All but one resident have regular family input and contact, the need for independent advocacy was discussed with the senior support worker and it is required to provide access to an independent advocate. Service users records are safely stored in the homes office and a record keeping policy is in place safeguarding service users documents. The inspector viewed two service users room during this inspection and it was evident that residents brought their own possessions when moving in. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 the following standard(s): 16; 18 Residents are supported appropriately to raise their dissatisfaction or complain about any issue important to them. Residents are protected and safeguarded from abuse, harm and neglect. EVIDENCE: The homes complaints policy is compliant with National Minimum Standards and is available in the service users guide, which is given to all new and prospective service users. The senior support worker informed the inspector that the home did not receive complaints since the last inspection. The home has forms to capture complaints, which were difficult to find during this inspection. The inspector recommends having a designated complaints folder to record complaints. The inspector viewed a very basic Protection of Vulnerable Adults policy, which must be reviewed and up dated. The registered manager informed the inspector that she tried to access Protection of Vulnerable Adults training for staff, but without success the inspector recommended contacting Brent Protection of Vulnerable Adults co-ordinator to access and find appropriate training for staff. The home does not have local Protection of Vulnerable Adults guidelines, which must be obtained. The home did not receive any Protection of Vulnerable Adults allegations since the last inspection. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28; 29; 30 An appropriately qualified staff team supports residents. Residents are protected from unsuitable staff. Residents’ benefit from a competent and trained staff team. EVIDENCE: The home has 50 of the current staff team trained to NVQ Level 2. The senior support worker informed the inspector that she has almost completed her Health and Social Care NVQ Level 3 and three support workers have completed their NVQ Level 2 in Care. Once all staff have achieved their qualification 100 of staff have been trained, which would exceed National Minimum Standards. The home does not employ staff below the age of 18 years. The home has a recruitment policy in place, which is compliant with National Minimum Standards. The inspector viewed three staffing files during this inspection and noted that some required checks were missing in individual files; this was discussed with the registered manager. The home is required to obtain all necessary recruitment checks as required in National Minimum Standards. The home provides appropriate training such as medication, manual handling, etc. and certificates have been viewed in staff files. The home however does not capture staff training needs as part of staff development and must provide an annual training and development plan for all care staff. Following the Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 15 previous inspection the home has started providing staff with appropriate supervisions and records have been viewed in files, the inspector informed the home that this practice must continue. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 31, 33, 35 and 38 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; 33; 34; 35; 36 An experienced manager manages the home, but formal qualifications are required to achieve full compliance. There was no clearly 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’ finances are protected and handled safely. Residents live in a safe and well-maintained home and are protected through appropriate procedures. EVIDENCE: The registered manager/provider Mrs Kelly has over thirty years experience caring for people. Mrs Kelly however has no formal management and care qualifications, which is required. Mrs Kelly demonstrated knowledge in caring and staff spoke very positively about the support they have received from Mrs Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 17 Kelly and referred to the registered manager as a very good role model and teacher. The home has a quality assurance policy in place. The senior support worker informed the inspector that the home sent out service users surveys in the past, but did not receive any completed surveys back. The home does not have an annual development plan, which is required. The quality assurance policy sates that residents have regular meetings, but minutes of these meetings were not available and residents confirmed not having had any residents meetings. The inspector was unable to assess financial procedures during this unannounced inspection. The registered manager informed the inspector that she does not want to disclose here earnings to the Commission for Social Care Inspection, which is acceptable. The home however must produce clear evidence if the home is financial viable, the registered manager is therefore required to produce an annual business plan and financial plan. The inspector viewed the homes public liability insurance and adequate insurance cover is provided. The registered manager is acting as an appointee for one resident and monies are paid directly into the service users account. Mrs Kelly withdraws money out of this account and supports the resident in purchasing toiletteries, clothes, etc. The Inspector assessed one service users account and noted that more money was in the service user’s cash tin than was actually recorded and required having the accounts reviewed. The inspector assessed requirements made in previous inspections and a valid Portable Appliances Test has been provided as well as regular fire drills were held and clearly recorded. This standard has now been met. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 1 2 X X 3 Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 23(1(a) Requirement The registered manager must apply for a minor variation to meet registration requirements. (Previous Timescale of 30/08/06 has expired) All residents must have an annual review involving social workers, families and clinicians. All residents must have the opportunity accessing independent advocacy services. All staff must receive POVA training. (Previous Timescales of 31/05/05 & 30/09/05 has expired) The home must review the abuse policy. (Previous Timescale of 15/09/05 has expired) The home must obtain local Protection of Vulnerable Adults guidelines. The home must provide all necessary recruitment checks. All staff must have an annual training and development plan. The registered manager must obtain appropriate qualifications DS0000017472.V280705.R01.S.doc Timescale for action 31/03/06 2. 3. 4. OP7 OP14 OP18 15(2)(c) 12(2) 13(6) 31/03/06 31/03/06 31/03/06 5. OP18 13(6) 31/03/06 6. 7. 9. 10. OP18 OP29 OP30 OP31 13(6) 19(5)(d) 18(1)(c) 9(2)(b)(i) 31/03/06 31/03/06 31/03/06 01/06/06 Park Lodge Version 5.1 Page 20 11. OP33 24 12. 13. 14. OP33 OP33 OP34 24(1) 24(3) 25 15. OP35 17(1)(a) in Care and Management. The quality assurance system must be put into effect and residents, carers and outside professionals views must be captured. (Previous Timescale of 31/07/05 & 30/09/05 has expired) The home must provide an annual development plan Residents must have the opportunity to attend regular residents meetings The registered person must provide a financial and business plan for the home. (Previous Timescale of 31/07/05 & 30/09/05 has expired) Service users financial records must be updated. 31/03/06 31/03/06 31/03/06 31/03/06 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations The inspector recommends having a designated complaints folder to record complaints. Park Lodge DS0000017472.V280705.R01.S.doc Version 5.1 Page 21 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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