Inspection on 22/10/07 for Park Lodge Care Home

This inspection was carried out on 22nd October 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 Care Home 01/07/10

Park Lodge Care Home 14/04/10

Park Lodge Care Home 20/10/08

Park Lodge Care Home 15/05/07

Park Lodge Care Home 04/10/06

Park Lodge Care Home 22/05/06

Park Lodge Care Home 05/10/05

Park Lodge Care Home 11/05/05

Park Lodge Care Home 07/10/04

Park Lodge Care Home 05/05/04

Park Lodge Care Home 16/12/03

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 Care Home 6 Victoria Drive Wimbledon London SW19 6AB Lead Inspector Sharon Newman Unannounced Inspection 22nd October 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 Care Home DS0000019112.V352466.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 Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Lodge Care Home Address 6 Victoria Drive Wimbledon London SW19 6AB 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 8789 5822 020 8785 7449 park.lodge@fshc.co.uk www.fshc.co.uk Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Post vacant Care Home 60 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (60) of places Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th and 16th May 2007 Brief Description of the Service: Park Lodge is a registered home providing nursing care for up to twenty older people and residential care for up to forty older people, ten of whom may have dementia. The home is owned and managed by Four Seasons Health Care, an organisation that has similar services across the country. The home is situated in a residential area on the borders of Wimbledon and Wandsworth, close to local shops, churches of a number of denominations and regular bus services. Accommodation is provided over three floors with the home split into four single units. Each unit has a lounge, dining room, bathrooms and toilets. All bedrooms are single. Service users have access to a large garden around the home and a roof top terrace. The home is serviced by two lifts, one lift for service users and the other being a service lift. Fees range from £455 to £590 per week. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service included an unannounced visit to the home on 22nd October 2007 by two regulation inspectors and a pharmacy inspector. The manager was not on duty however the deputy manager of the home was present throughout this visit and was available for discussions about the service. Three relatives and a number of residents were also spoken to. The deputy manager and staff were welcoming and helpful throughout the inspection. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety documentation. A tour was also taken of the premises. The manager has also completed and returned an Annual Quality Assurance Assessment (AQAA) which is a self assessment survey of the home. Surveys were left at the home for residents, staff, relatives health professionals and social care professionals to complete. Some improvements have taken place since the new manager and deputy manager have arrived at this home and many requirements have been met from the previous inspection visit. However there are still areas that need to be addressed and any improvements that have been made will have to be sustained. This means that there is still a lot of work that the organisation must carry out to continue to raise standards at this home. What the service does well: Staff were seen to have a good rapport with residents. Residents spoke warmly about staff and said that they are well-cared for. They also said that staff respect their privacy. Residents looked well-groomed and many spoke positively about life at the home. There is now a relaxed and calm atmosphere at the home. Residents say they are given a choice of food at mealtimes. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Park Lodge Care Home DS0000019112.V352466.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 Care Home DS0000019112.V352466.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): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments are in place but need to be easier to read so that staff can follow them and help to meet the needs of the residents. EVIDENCE: Assessments were in place in all the residents files looked at and they contained details about their health and social care needs. However, the writing in some of them was difficult to read in places and needs to be more legible so that they can be easily followed by staff. Assessments are also carried out by social services staff before residents are admitted to the home to help decide if this home can meet their needs. It was bought to our attention during the inspection visit that the long-term future of this home is uncertain. The organisation needs to ensure that Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 9 residents and relatives are involved in any decision regarding the future of the home. Also, the progress started must be maintained to ensure that residents are well cared for and live in comfortable surroundings. The deputy manager reported that they like to celebrate cultural diversity and have been promoting ‘transcultural’ nursing at the home as there are a number of people from different cultures and backgrounds working and living in the home. A photo-board depicting these values was seen containing photographs of the staff and residents. One resident commented that they were ‘very lucky’ to live at the home and that they were ‘well looked after.’ A relative said that they ‘couldn’t fault the home’ and that the ‘staff do a wonderful job.’ Another said that staff at the home have ‘nursed back to life’ their family member and that they are ‘happy and settled’ at the home. They also said that they would like to say a ‘huge thank you to all the staff as they do a wonderful job and make (their relative) feel like it’s worth living.’ They stated ‘the staff provide tender loving care and ‘know what is important’ to their relative.’ Another relative commented that ‘since the new manager has taken over there have been lots of improvements at the home.’ Park Lodge Care Home DS0000019112.V352466.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 adequate This judgement has been made using available evidence including a visit to this service. There have been improvements in the residents care plans, they are up-todate and contain a lot of detail about the residents. They are well organised and contain a lot of information about residents health care needs. However, they are not always clear and legible enough for staff to be able to follow them. People who use the home have access to health and social care services. Residents privacy is respected. Pharmacy Inspectors Judgement: At the last inspection in May 2007, medication management was poor. Previous requirements had not been met and although residents were not at risk at the time of the inspection, there were a number of issues with recording and supply of medicines which needed to be addressed in order to protect the health and well being of residents. At this inspection, there is evidence that significant improvements have been made. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 11 EVIDENCE: There have been improvements to the residents care plans since the last inspection and they contained a lot of information. There was also evidence of residents/relatives involvement in the care plan. Also there have been improvements in the recording of wound care - photographs and wound care charts had been completed to help show the progress of a wound. Information was also seen to be regularly updated. Risk assessments had been completed for many areas including: pressure areas, moving and handling, continence and falls. The main issue with the care plans was that they were difficult to read in places and they must be more legible so that staff can follow them and meet the needs of the residents. In one residents file one entry stated that their allergy status was ‘none known’ however it was then documented on another page that the resident was allergic to certain medication. Care must be taken to ensure that records are accurate to ensure that residents are not placed at risk. There was evidence to show that staff are now receiving training in wound care and continence care. This is an improvement from the previous inspection visit. The deputy manager reported that they had not yet managed to provide training in diabetes care but this was to be organised. It is important that staff receive training in these areas so that they can meet the need of the residents and provide care based on the based up-to-date practice. There was evidence in the care plans of visits from GP’s and other health professionals such as chiropodists. An optician service was seen to be visiting the home on the day of inspection to provide services for the residents. The home has a ‘link social worker’ from the London Borough of Wandsworth’. They help to monitor the review of residents care at the home and also the quality of the care on offer. A relative commented that their relative ‘looks clean and healthy.’ A health professional complimented the home on their medicine management. The manager reported in the annual assessment of the home (AQAA) that they are going to ‘assign staff roles as link nurses for infection control, incontinence and wound care management.’ The Pharmacy Inspectors findings are documented below: The Medication policy contains all of the required information, the supplying Pharmacist carries out regular inspections, the home is now conducting medication audits on a monthly basis until all issues are resolved, there is Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 12 evidence of the action taken when an issue is picked up, and the home has started on a medication re-training programme for staff, which includes a workbook then a competency assessment. The GP visits twice a week, and carries out regular reviews on medication, there is input from a psychogeriatrician, storage facilities are good and temperature monitoring is carried out on all medication storage areas to ensure that medication is stored under the right conditions Records of receipts, administration and returned medicines are accurate in the majority of cases providing an audit trail for medicines in and out of the home. Stock checks and records for Controlled Drugs are accurate. All prescribed medicines are in stock and compliance with medication is good. Issues to be addressed: There were a few gaps on medication administration record (MAR) charts from earlier in the month. Stock checks confirmed that the medication had been given but staff had forgotten to sign the chart. The home must ensure that staff administering the next dose follow up on any gaps in recording to identify whether or not the dose has been given. The quantity received for one medication was missing. This medication had been received part way through the month. The home must ensure that the receipt of all medication is recorded. The MAR chart for one prescribed item says “course completed”. There must be written evidence when a prescribed item is discontinued unless this is medication which is prescribed as a course e.g. antibiotics. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 13 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 good This judgement has been made using available evidence including a visit to this service. The activity provision for the residents has started to improve and the employment of a full-time activity co-ordinator will help to improve this area further for the residents. Family and friends are welcomed into the home. Residents are offered more choice at meal-times than they were previously given and mealtimes are now taken in a quiet relaxed atmosphere. EVIDENCE: We were informed by the deputy manager that there is now someone to provided activities for the residents from Monday to Fridays. This is an improvement, however a permanent post of activity co-ordinator needs to be in place to help make sure that activity provision continues to improve and develop. Currently there are two staff members who carry out this role but one stated that they had not been employed as an activities co-ordinator. A health professional commented that some residents ‘would benefit from day centre activities.’ Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 14 We spoke to one of the staff now responsible for organising activities. They reported that they enjoyed their role very much and organised activities such as painting and craftwork, bingo, quizzes and music sessions. They said that they try to gain as much information as possible about each individuals needs and try to ensure that individuals are always given a choice whether to participate in activities or not. One resident said that they ‘liked singing and watching the TV’. They said that an entertainer visits the home and encourages them to sing along. Residents and relatives meetings have been held twice since the new manager started at the home. Issues discussed included what’s happening at the home, activities, food trips and the summer fete. Relatives spoken to reported that they are always welcomed to the home. Relatives were observed to be welcomed by staff and staff were seen to have a good rapport with them. Many of the residents spoken to said that staff always knock on their door before entering their bedroom to help maintain their privacy. Other residents spoken to said the same. One resident commented that they can go out ‘whenever they like.’ Residents were seen to eat their meals in a relaxed atmosphere. The manager has made improvements to mealtimes such as ensuring that the dining tables are laid with tablecloths and matching crockery. Fabric flowers are placed in the middle of the tables. This helps to create a pleasant dining experience for the residents. Some residents said that they are now offered more choice at mealtimes and the food served looked appetising and nutritious. A resident commented ‘we have a choice of food since the new manager has come to the home.’ Another said ‘the food is nice – there is a good selection.’ The deputy manager reported that the home has had a recent inspection by the Environmental Health which is good and a copy of the letter about the visit was given to us. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 15 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 adequate This judgement has been made using available evidence including a visit to this service. Residents and relatives are given information about how to make a complaint. Information is kept at the home about the complaints that have been made and how the home has addressed any issues raised. There is training and procedures in place to help teach staff the importance of reporting suspected abuse. However, the Local Authority Safeguarding Vulnerable Adults procedures are not always followed which could place residents at further risk. EVIDENCE: A complaints log is kept at the home and contained details of nine complaints made this year. The information included the outcome and any follow up required. The complaints policy was seen to be displayed on the wall in the units visited and this enables residents and relatives to know how to make a complaint. A copy of the London Borough of Wandsworths’ Safeguarding Vulnerable Adults Procedures is kept at the home. However we discussed with the manager that further copies should be obtained, discussed with staff and placed in areas at the home where staff will be able to read them. This helps staff to know about the procedures to follow if any instances of abuse are suspected. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 16 A safeguarding vulnerable adults issue has been referred to the London Borough of Wandsworth for investigation. Instances of unexplained injuries/bruising were seen in three residents files and these had not been referred to the London Borough of Wandsworth using its current procedures. Also a relative had not been informed in one instance. It was discussed with the deputy manager that all incidents must be referred to the Local Authority to allow them to make the decision how to proceed. The service manager reported that these issues would be reported immediately. It was noted that in each case an unexplained injury form had been completed and a GP called. These issues had also been documented in the daily notes. A relative reported that they are contacted if the home had any concerns about their family member. Another said that they are contacted ‘even for relatively minor issues and ailments.’ Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There has been improvement to some areas of the environment. However this improvement needs to continue to help to make sure that the home provides comfortable and homely place for resident to live. The cleanliness of the home is improving. EVIDENCE: The organisation has begun to decorate areas in the home. The entrance area has now been redecorated and new carpets have been laid. New furniture has also been purchased and these changes have greatly improved this area. The smell of urine that used to be so strong when we walked into the home has now largely disappeared from this area and this is much more pleasant for the residents. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 18 In some of the first floor areas there was still a faint smell of urine and this will need to be addressed. However it is noted that this has improved from the previous inspection visit. The manager stated in their self assessment of the home (AQAA) that the home has employed new housekeeping staff. The conservatory has now been turned into an activity room and contains comfortable chairs, different types of lighting and a Christmas tree – although we were informed that this is used as a ‘sensory’ tree. A large room on the ground floor has been turned into a ‘cinema’ completed with a new very large flat screen television for the use of residents. There is also a ‘café’ area in this room for the use of residents and relatives. One relative reported that they had recently attended a party there held for their family member and themselves. The maintenance person was very helpful and showed us around some of the newly refurbished ground floor and said that he felt the home’s environment was improving. The service manager reported that further improvements are planned and that a £20.000 local authority grant is to be used to provide one new bathroom and two new shower areas to replace the outdated facilities currently in use. Many areas throughout the home still require decoration including the lounge areas, toilet and bathing facilities. The furniture throughout the home remains ill matched and many carpets are stained. The home will need to supply us with a business plan to inform us when this work is to be carried out. Two residents showed us their bedrooms and other’s were seen during the inspection. They were personalised and looked comfortable and clean. One resident said that they ‘really liked’ their room. However feedback from one relative stated that the home could improve by making ‘the rooms more personal – they are soulless and rundown. Pictures of family have been knocked off shelves and walls and broken and then just left with useless frames.’ A relative commented ‘it is clean, comfortable and the staff are caring and friendly.’ Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 19 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 adequate This judgement has been made using available evidence including a visit to this service. There is a lack of evidence that the appropriate recruitment checks have been carried out on staff. Staff training has improved at the home and this enables staff to have the skills needed to care for the residents. EVIDENCE: Residents spoke highly of the staff and it is clear that some residents are very fond of the staff that care for them. One resident said that there were ‘two lovely staff’ on their unit. Another reported that the ‘carers are really lovely, they are so, so caring.’ Another commented ‘all the staff are very friendly – you can tell them anything.’ The deputy manager informed us that there is currently one vacancy for a care worker. He reported that any shortfall in staff numbers on a shift is usually covered by a member of the home’s ‘bank’ staff. From observation on the day of inspection there were sufficient numbers of staff on duty. However it is recommended that the home keeps its staffing levels under review according to the residents needs and dependency levels. The deputy manager reported that levels of staff sickness and ‘emergency’ annual leave can sometimes present a problem and the organisation need to be aware of this and use Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 20 appropriate systems to monitor staff leave and absence. A health professional commented that the home ‘needs more staff.’ They also stated that ‘staff are dedicated and do their work well.’ Staff training has improved at the home and a large training file with evidence of the training organised for staff is now kept at the home. This showed that staff attend a rolling programme of mandatory training including moving and handling, first aid and food hygiene. Some staff have also received training in areas such as dementia care, however more staff need to attend this training to ensure that the needs of the residents can be met. The deputy manager reported that more staff will attend this training. A health professional commented that they felt staff training could be improved in ‘pain management and understanding’ and ‘ulcer care.’ Four staff recruitment files were looked at and found to contain most of the required checks. However, not all of them contained evidence that either POVA First (Protection of Vulnerable Adults) checks or CRB (Criminal Record Bureau) checks had been carried out before staff had started work at the home. This information was unclear on the forms contained in the files. These forms need to be fully completed with clear dates and signed by a representative from human resources to indicate that the appropriate checks have been carried out. Evidence of safe recruitment checks helps to protect residents from harm, so it is important that this information is fully complete. There was also a lack of colour photos of staff and these must be kept in the staff files to aid identification. Regular staff meetings are held to allow information to be passed on and for views to be aired. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 21 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, 36, 35, 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are still many areas in this home that need to improve. However, the manager and deputy manager have worked hard to try to raise standards. They have already made progress in some areas such as mealtimes, staff training and the information in the resident’s files and they know where improvements still need to be made. There is not enough evidence of how relatives and residents views are taken into account regarding the running of the home. EVIDENCE: The manager was not on duty during the inspection visit. The deputy manager reported that both he and the manager were working hard to improve Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 22 standards at the home. It is evident that some changes have already taken place such as an improvement to staff training, care plans and to the environment at the home. The manager needs to register with the Commission for Social Care Inspection as the registered manager of this home. A staff member reported that the ‘new management is very positive’. The deputy manager currently works two days a week in his role as deputy manager and three days a week as nurse in charge on the nursing unit. The deputy manager’s role need to be reviewed to ensure that he is more involved in the management of the home and can provide support to the manager. There are many areas that still need to improve the home need to prevent any deterioration in standards. The work needed is a large task and will be time consuming. The manager will also need to delegate responsibilities to the deputy manager. The organisation must review its management arrangements at the home to ensure that there is a full-time deputy manager at the home. The deputy manager would then also be able to supervise staff in the clinical area without having the additional responsibility of being the nurse in charge. Although the organisation has quality assurance systems in place, however evidence of this was not available on the day of inspection. As stated in the previous inspection report the care plans are audited monthly to help assess if they are completed adequately and that the residents needs can be met from the information in this documentation. Also a team audit process (TAP) and remedial action plan (RAP) are carried out. The remedial action plan contains information about areas that need addressing including: the environment of the home, activities, domestic issues and laundry. These audits help to show what areas the organisation are going to address. Since the manager has been in post there has only been one residents and one relatives meeting. The frequency of these meetings needs to increase to help make sure that they are aware of any changes and of developments at the home – it would also allow them to discuss any issues. The deputy manager reported that owing to time constraints one-to-one staff supervision is not taking place as often as it needs to be - this needs to occur more regularly to ensure that all staff have the support and direction they need to carry out their roles. The deputy manager said that this will be addressed and he recognises the importance of one-to-one meetings for staff. Checks relating to safety including: gas safety, electrical installations and portable appliance testing were up-to-date. The log of fire drills could not be found during the inspection visit. The deputy manager thought that it may have been lock away for safekeeping by the Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 23 manager. This must be available for inspection and it is important that it can be easily found as fire drills may need to be held in the absence of the manager. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 24 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 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 25 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 2 3 Standard OP3 OP7 OP7 Regulation 14 15 (1) (2) 15 (1) (2) Requirement Assessments must be legible to ensure that are easy to read. Care plans must be legible to ensure that they are easy to read and easy for staff to follow. Care must be taken to ensure that accurate and up-to-date information – for example details of allergies - is contained within the care plans. This is to make sure that residents are not placed at risk. All staff involved in the care and assessment of residents with diabetes must receive training in this area. To ensure that residents needs are met in this area and they receive the most up-to-date care. Previous timescale of 01/09/07 not met. Advice about diabetes issues and care must be sought from a suitably trained individual such as a diabetes nurse specialist. Individual residents must be referred for assessment when needed. This is to make sure that residents needs in this area DS0000019112.V352466.R01.S.doc Timescale for action 01/12/07 01/12/07 01/11/07 4 OP8 18 (1) 01/03/08 5 OP8 13 (1) (b) 01/12/07 Park Lodge Care Home Version 5.2 Page 26 6 OP9 13(2) 7 OP9 13(2) 8 OP12 16(2)m & n 9 OP18 13(4&6)1 8(1)c 10 OP19 23(2)b & d 18 (1) (c) 11 OP28 12 OP29 19 (4) (a) (b)Schedu le 2 are properly assessed and they receive the most suitable treatment or intervention. Previous timescale of 01/06/07 not met. The Registered Manager must ensure that all records relating to the receipt and administration of medication are accurate. The Registered Manager must ensure that there is written evidence when a prescribed medication is discontinued. An appropriately trained full-time activity co-ordinator must be employed. Previous timescales of 01/12/06 and 01/08/07 not met. All staff must be aware of and follow the London Borough of Wandsworths Safeguarding Vulnerable Adults procedures. All suspected abuse and unexplained injuries must be reported to the London Borough of Wandsworth. The organisation must submit a 12 month refurbishment plan to the CSCI to demonstrate how the premises will be maintained. Staff involved in the care of people with dementia must receive up-to-date training in this area. This is to help make sure that they can meet their needs. Previous timescale of 01/08/07 not met. Accurate information must be available at the home to demonstrate that staff files contain all the necessary checks and documentation. This must be signed by the individual responsible for checking the documentation. This is to help ensure the safety of the people who use the service. DS0000019112.V352466.R01.S.doc 01/12/07 01/12/07 01/01/08 01/11/07 01/12/07 01/03/08 01/12/07 Park Lodge Care Home Version 5.2 Page 27 13 OP31 8 14 OP31 8 15 OP33 24 (3) 16 OP36 18(2)a 17 OP38 23 (4) Colour photographs must be contained within the staff recruitment files. The manager must register with the Commission for Social Care Inspection. Previous timescale of 01/07/07 not met. The organisation must review the deputy manager’s role to ensure that he is more involved in supporting the manger. The organisation must look at ways of involving residents and relatives more directly in the quality assurance process. This could be by use of surveys. Previous timescale of 01/09/07 not met. All staff must receive one-to-one supervision at least six times a year (pro-rata for part time staff) and this must be fully recorded. Previous timescales of 01/12/06 and 01/08/07 not met. The fire drill log must be available at the home for inspection. 01/01/08 01/12/07 01/01/08 01/02/08 01/11/07 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 OP27 Good Practice Recommendations It is recommended that staffing levels at the home are kept under review to ensure that the needs of residents can be safely met. Park Lodge Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Care Home DS0000019112.V352466.R01.S.doc Version 5.2 Page 29 - 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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