Inspection on 12/01/06 for Pear Tree Lodge

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pear Tree Lodge 26/01/09

Pear Tree Lodge 01/02/07

Pear Tree Lodge 30/09/05

Pear Tree Lodge 28/02/05

Pear Tree Lodge 23/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE 340 Preston Road Shaw healthcare (Homes) Limited Pear Tree Lodge 340 Preston Road Kenton Middlesex HA3 0QH Lead Inspector Mr Ram Sooriah Unannounced Inspection 12th January 2006 10:15 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 340 Preston Road DS0000017483.V278231.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. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 340 Preston Road Address Shaw healthcare (Homes) Limited Pear Tree Lodge 340 Preston Road Kenton Middlesex HA3 0QH 020 8385 1640 020 8385 1642 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) Shaw healthcare Limited Mr Manny Tagulinao Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (0) of places 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th September 2005 Brief Description of the Service: Pear Tree Lodge belongs to Shaw Homes, a national provider of care services. It is registered to provide personal care to ten elderly service users of mixed gender with learning difficulties. It is about two minutes walk from local shops and facilities; and is easily accessible by public transport. There is a good bus service down the Preston Road and the Underground station is about five minutes walk away. There is limited parking on the grounds of the home, but additional parking can be found on the nearby roads. There is a maintained garden at the back and some lawn areas in the front and on the side of the building. The home is a converted big house on the Preston Road. Service users are accommodated in single bedrooms on 2 floors. Each floor has 5 bedrooms and a lounge/dinning area. The 1st floor has a small kitchenette; the main kitchen and the laundry are on the ground floor. At the time of the inspection there were nine service users in the home. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection for the period 2005-2006. It was unannounced and started at 10:15am and lasted for about five hours. During the course of the inspection, the inspector had the opportunity to look at a sample of care records, health and safety records, personnel and training records. He also toured some of the premises and checked for compliance with previous requirements and recommendations. He would like to thank the service users, the manager and his staff for a kind welcome to the home and for their support and cooperation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The kitchen’s flooring must be replaced, as there is a hole where food particles and dirt could accumulate. Staff needed to be clearer with regard to one practice in relation to infection control, identified during the inspection (standard 26). 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 6 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. 340 Preston Road DS0000017483.V278231.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 340 Preston Road DS0000017483.V278231.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 The home has a new format for the needs’ assessments of service users. Those, which have been completed, comprehensively described the needs of service users. EVIDENCE: There have not been any new service users in the home. The last service users in the home have had good assessments of their needs prior to admission to the home. At the time of the inspection the home was introducing a new format for care plans based on a ‘person-centred care’ approach. It was in big print and in symbols as well as in an ‘easy to read’ format. This new format was in place for some service users and the manager stated that they were in the process of updating all the care plans for all service users. The new format if completed appropriately would ensure a comprehensive assessment of the needs of service users. 340 Preston Road DS0000017483.V278231.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): 7and 8 The new format of the care plans comprehensively addresses the needs of service users. The health care needs of service users are appropriately being met in the home. EVIDENCE: Two care plans were inspected randomly. As described previously the home was in the process of introducing a new format for the care plans. The new care plans addressed the needs of service users and a clear plan of action was were in place to meet the identified needs of service users. These were generally reviewed monthly. The inspector was informed that some of the care plans, which were in the previous format, were being re-written so the plans had not always been reviewed monthly. There was evidence of a range of risk assessments, which were in place including risk assessments with regard to specific risks such as when out in the community. The inspector noted that service users have signed their care plans to show that they have agreed to them. In cases where it was not possible to involve the service users in the care planning process a note was made in the records. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 10 The health care needs of service users were being met. The home continues to keep health action plans and there was evidence that service users have been seen by a number of healthcare professionals. All service users appear to have a good standard of personal hygiene and were all appropriately dressed and groomed. 340 Preston Road DS0000017483.V278231.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): 12 and 15 The home in the main addresses the recreational and social needs of service users in an appropriate manner. Meals are provided in an appropriate manner and according to the choices of service users. EVIDENCE: The new format of the care records had sections addressing the recreational and social needs of service users. There were also care plans addressing these needs of service users. The inspector was informed that staff in the home would try and address the individual needs of service users. Some service users continue to attend day centres and one service user attends an evening club. One service user proudly showed the inspector some project that he was doing and which he said he enjoyed doing with the support of staff. The deputy manager stated that the management and staff in the home was looking at improving the ability of the home to meet the recreational and social needs of service users. The inspector observed lunch being served. All service users seemed to be enjoying their meals and individual records showed that the meals were 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 12 generally nutritious and suitable for the service users. Meals continue to be served according to the individual needs of service users. For example some service users were being encouraged with a high calorie diet while others were being encouraged to have a low calorie diet depending on their individual circumstances. While previously the menu for the week was decided in weekly meetings with service users, feedback seem to show that this approach was not working. The home has therefore decided that a four weekly menu would be drawn based on the recorded preferences of the service users. This is positive as it shows that the provision of meals in the home was based on a flexible approach according to the needs of the service users. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 13 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 and 18 Every effort is made to ensure that service users are aware of their statutory right to complain about the service. The home has systems in place to ensure the protection of service users. EVIDENCE: The complaint procedure has been reproduced in easy to read format and with symbols to facilitate understanding. Copies were available on the notice boards and in the service users guide. The home has not received any complaints since the last inspection. There was evidence that staff have had training on abuse and that they were aware about the signs/things, which may raise concerns about abuse. The home has not had a case of allegation or suspicion of abuse during the last year, but the manager and her staff were clear about the way to deal with any allegation or suspicion of abuse. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 14 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): 19, 24 and 26 The home had a programme for redecoration and refurbishment, which was being put in place. A few issues were identified which needed to be addressed to ensure that the home continues to provide a safe environment for service users. EVIDENCE: The grounds and exterior of the home were clean and tidy. They were in a maintained state even if it was Winter and this gave a favourable impression about the home. There has been some redecoration since the last inspection in the home. The lounges/communal areas have been repainted as well as some bedrooms. The manager showed the inspector a plan, which addressed the redecoration and refurbishment of the home until the end of March. The inspector noted that carpet replacement in the communal areas and the renewal of furniture for the lounge, were in the plan. While touring the premises the inspector noted a hole in the flooring in the kitchen. This could cause a problem with regard to thorough cleaning as there could be an accumulation of dirt and food particles 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 15 in the hole. As a result the registered person must ensure that the flooring in the kitchen is replaced. The bedrooms of service users continue to be personalised and homely. One service user stated that he wanted his room to be in a particular colour and the inspector noted that the home had respected his wishes. Some of the bedrooms have been repainted and the inspector noted that some pictures, which were on the wall, have not been replaced back on the wall. The deputy manager stated that the handy man would be addressing this issue when he is next in the home. The home, including communal areas and the bedrooms of service users were clean and free from odours. The inspector noted a used urine drainage bag in the bedroom of the service user. The manager was clear that this was not for reuse in the home and he arranged for the disposal of the urine bag. He agreed that these should be discarded as soon as they are disconnected from the catheter/leg bag. Training records showed that most members of staff have had training in infection control. Six members of staff were doing an NVQ level 2 in infection control at the time of the inspection. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 16 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): 27, 28, 29 and 30 The home has appropriately trained staff and in sufficient numbers to care for the service users. EVIDENCE: The home had four members of staff on duty during the inspection. The manager was supernumerary. Some service users stayed in the second floor lounge and some were in the ground floor lounge. There was a member of staff allocated to each lounge. The home continues to have about 75 of staff qualified to at least NVQ level 2. The deputy manager and a team leader have also completed the Registered Manager’s Award. One member of staff was studying for the Learning Disability Award Framework. There was evidence that all new staff have had four days induction and that they were enrolled on the induction and foundation programmes as per the advice from the General Social Care Council. Staff were also up to date with statutory training. Two personnel files were inspected. They were all up to date and contained all the records as required by Schedule 2 of the Care Homes Regulations 2001. There was evidence that staff were also offered one-to-one supervision. This was planned to be monthly, but records showed that at times this was not carried out. There was however evidence that in most cases staff received supervision at least six times yearly. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 17 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 and 38 The management approach in the home is open and inclusive. The home benefits from a comprehensive approach to quality. The home addresses health and safety issues appropriately to ensure the safety of service users. EVIDENCE: Management of the home continues to be of a very good standard and to offer a sense of direction. There was evidence of staff meetings and of service users meetings where opportunities were provided to these parties to contribute to the management of the home. The home has a quality policy. There is a system of audits, which is carried out at certain intervals. The inspector was informed that there is six monthly audit of the environment, quarterly audit of care plans, food and medicines. Reports of these audits were available for inspection. The deputy manager stated that some of the audits could be carried out by other home managers. Apart from 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 18 these audits there were also monthly visits as per Regulation 26 of the Care Homes Regulations 2001. The inspector was informed that satisfaction questionnaires are sent to stakeholders quarterly to gain information about the quality of service provided by the home. These were last sent in December. Once these are returned a report is normally prepared about the findings. The home also has an outside accreditation: it is accredited to Investors In People. The inspector checked some of the health and safety records. He concluded that the home had all the necessary safety certificates and that all equipment in the home was being maintained as required. There was also a health and safety risk assessment and a fire risk assessment. The health and safety representative for the home stated that she was in the process of developing contingency plans for the home. The above showed that the home takes health and safety issues seriously and deals with these appropriately. 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 19 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x X X 3 x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 3 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP26 Regulation 23(2)(b) 13(3) Requirement The registered person must ensure that the flooring in the kitchen is replaced. The registered person must ensure that all used catheter drainage bags are disposed as appropriate. Timescale for action 31/03/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 340 Preston Road DS0000017483.V278231.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. Extracts may not be used or reproduced without the express permission of CSCI 340 Preston Road DS0000017483.V278231.R01.S.doc Version 5.1 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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