Care Home: Edwin Lodge, 6 Victoria Court

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

What the care home does well The care home is very clean, and has a welcoming, warm atmosphere, and is well maintained. Comments from a relative/visitor feedback surveys included, `I admire the layout of the home that has been furnished to a high standard`. People using the service spoke highly of the meals provided. Comments from residents included, `the food is nice`, and `the meals are varied and suit my culinary taste including food from my country of origin`. Recorded feedback from relatives/friends included my relative `would be lost in a larger environment Edwin Lodge is ideal for her`, I feel reassured that Edwin Lodge would be responsive to my concerns`, the home is a `loving environment`, my relative `has always been supported with her religious views` and `I find the staff very professional in carrying out their duties`. Comments from surveys received by the Commission for Social Care Inspection included `I am always impressed by the level of caring and medical awareness of each client`s needs`, `the clients appear well cared for physically and psychologically in a well kept homely atmosphere`, residents `are treated with respect and have privacy`. Comments from residents included and `I am happy (living) here`, and `I like my room`. The registered manager/owner is experienced, and competent. He acknowledges the importance of providing a quality service to people living in the care home, and of continuing to put in place, systems and practice to improve and develop this service. What has improved since the last inspection? The requirements and recommendations from the previous inspection have been met. Systems for monitoring the quality of the service that is provided to people using the service have been improved and further developed. Several areas of the home have been redecorated. Record keeping has improved, which ensures that resident`s rights and best interests are safeguarded. There has been some further development in the provision of `in-house` activities for people using the service, to ensure that they lead a quality lifestyle of their choice. What the care home could do better: The format of documentation of particular interest and relevance to people using the service could be better to improve its accessibility to residents who have difficulty reading. Community based activities could be developed to ensure that all residents have more access to community amenities and facilities. There could be more recorded evidence of understanding the equality and diversity needs of people using the service. CARE HOMES FOR OLDER PEOPLE Edwin Lodge, 6 Victoria Court 6 Victoria Court Wembley Middlesex HA9 6QJ Lead Inspector Judith Brindle Key Unannounced Inspection 11th June 2008 09:05 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 Edwin Lodge, 6 Victoria Court DS0000017496.V361133.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. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edwin Lodge, 6 Victoria Court Address 6 Victoria Court Wembley Middlesex HA9 6QJ 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 8902 0303 020 8902 0303 Kristiina_37@msn.com Mrs Tiina Yasaratna Mr Sabaragamu Yasaratna Mr Sabaragamu Yasaratna Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th April 2007 Brief Description of the Service: Edwin Lodge is a care home providing personal care and accommodation for up to 4 older people. The home is an extended semi-detached house, located in a residential road off the main Harrow Road in Wembley. It is close to local shops and other amenities and is also easily accessible by public transport and by car. Parking is available on Victoria Court. The home has been opened for more than eight years, and belongs to Mr and Mrs Yasaratna. They have both worked for a number of years in the area of health and personal care. They live on the premises and have a separate living area for themselves, which consists of the second floor (the loft conversion). The main aim of the home is to provide personal care and support for older people in a homely and family setting. Accommodation for residents is provided in single rooms on the ground, and first floor. There is a bedroom on the ground floor, and three on the first floor. The home, including the internal and the external areas, is pleasantly decorated. The home has an enclosed, accessible, and well-maintained garden. Information/documentation about the service and the range of fees (£400£550) is accessible from the care home to residents and others. Additional costs are recorded in resident’s statement of terms and conditions, and in the service user guide. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The unannounced key inspection took place during a day in June 2008. There were no vacancies at the time of the inspection. I was pleased to meet, and spend a significant part of the inspection with the people living in the home. The registered manager/owner and co-owner were present during the inspection. Prior to this unannounced key inspection the manager supplied the Commission for Social Care Inspection (CSCI) with a completed Annual Quality Assurance Assessment (AQAA) document. The AQAA is a self- assessment of the service provided by the care home, which is carried out by the owner and/or manager. It focuses on the quality of the service, and how well outcomes for people using the service are being met by the care home. It also includes information about plans for improvement, and it gives us some numerical information about the service. Reference to some aspects of this AQAA record will be documented in this report. This document was completed comprehensively. A number of surveys were supplied to the care home prior to this inspection. These requested feedback from people using the service, relatives/significant others, health and social care professionals, and staff. At the time of writing this report, we had received two completed surveys from people using the service, six surveys from relatives/visitors, two surveys from staff, and three from healthcare professionals. Other information received by the Commission for Social Care Inspection (CSCI) about the service since the previous key inspection was also looked at. This included what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Also relevant information from other organisations, and from what other people might have told us about the service, was assessed. I spoke with all of the people using the service, some of whom have significant communication needs, with difficulty in responding to questions, so observation was a useful and significant tool used during this inspection. Care staff were also spoken with, during the inspection. Documentation inspected included, all the care plans of people using the service, risk assessments, staff training, and staff personnel records, and some policies and procedures. The inspection included a tour of the premises. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 6 Assessment as to whether the requirements and recommendations from that inspection had been met also took place during this inspection. The previous inspection requirements, and the recommendations were found to have been met. 25 National Minimum Standards for Older Persons, including Key Standards, were inspected during this inspection. The inspector thanks the people living in the care home, staff, the registered manager/owner, co-owner, and all those who supplied us with completed feedback survey forms, for all their assistance in the inspection process. What the service does well: What has improved since the last inspection? The requirements and recommendations from the previous inspection have been met. Systems for monitoring the quality of the service that is provided to people using the service have been improved and further developed. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 7 Several areas of the home have been redecorated. Record keeping has improved, which ensures that resident’s rights and best interests are safeguarded. There has been some further development in the provision of ‘in-house’ activities for people using the service, to ensure that they lead a quality lifestyle of their choice. 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. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 8 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 Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 9 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): Standards 1, 2, 3 and (6 is not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information needed to choose a home that will meet their needs. People using the service have their needs assessed prior to moving into the care home, which makes certain that the home knows about the person, and the support that they need. Some equality and diversity aspects of this assessment could be further developed. People using the service have a contract, statement of terms and conditions. EVIDENCE: The care home has accessible documentation, and information about the service provided by the care home. The service user guide is in written and pictorial format. This guide included comprehensive detail about the care home, and included information about the fees. These documents had been Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 10 recently reviewed. We were told that on admission each resident is given a file with information about the home, which includes a copy of the service user guide. A copy of this documentation was seen to be located in a resident’s bedroom. The home has an admission procedure. We were informed that following receipt of a referral (generally from a local authority), the manager/owner and/or joint owner carry out an assessment of the needs of the person. The manager spoke of the importance of carrying out this comprehensive initial assessment of each prospective resident’s needs, particularly with regard to the home being small, and so compatibility of people using the service being of particular significance. The manager confirmed that this process of assessment continues throughout the person’s ‘settling in’ period prior to confirmation/agreement with the person for permanent admission to the care home. Feedback/comment surveys from residents, and relatives, confirmed that people were involved in the admission process, comments included ‘there was a consultative assessment at the time of looking at the care home’. Visitors kindly spoke of having been involved with their relative (prospective resident) in the assessment/admission process prior to the person moving into the care home. This included visits to the home prior to admission. Care plans inspected recorded evidence of assessment of the persons needs carried out by the home, and funding authority. Assessment of each person included health, social, emotional, religious/cultural needs and personal care needs. Equality and diversity needs of prospective residents and of people using the service were discussed with the owner. Though it was evident that religious and cultural needs of individuals were assessed and understood, there could be inclusion of all aspects of equality and diversity such as sexuality, race, age, disability, and gender needs. The two feedback surveys from people using the service confirmed that they had received a contract/ statement of terms and conditions. A residents’ contract was available for inspection. A relative of the person had signed this. It should record in the resident’s contract, statement of terms and conditions the reasons why a person using the service is unable to sign the document himself or herself. Annual Quality Assurance Assessment (AQAA) documentation informed us that the care home continues to review and improve contracts/statement of terms and conditions documentation. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9, and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs that people receive are based on their individual needs. The principles of respect, dignity and privacy are put into practice. People using the service are protected by the home’s policies and procedures for managing and administrating medication to people using the service. EVIDENCE: Each person using the service has a plan of care. All the care plans were inspected. Due to their varied needs most residents were unable to provide me with information to determine as to whether they had knowledge of their care plan. The care plans, were individualised and included a positive informative ‘life history’ of each resident. This record includes information with regard to the person’s life prior to moving into the home, so helping staff to understand the person’s needs (particularly if that person is unable to communicate verbally this information). Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 12 The care plans included information about resident’s preferences in several areas, including activities, day and night routines, and diet. Other areas included in the care plans are, mobility, sensory, personal care, health, spiritual/cultural needs, dietary and medical needs. The care plans recorded evidence that individual resident’s needs, and changing needs are identified and action to meet each need is recorded, including information with regard to expected outcome. There was evidence of clear recorded, regularly reviewed staff guidance to ensure staff knew how to manage and meet resident’s identified needs. Most of the care plans were signed by a family member (if the resident has significant communication needs) and staff. It should be recorded in the care plans if a resident is unable to understand their plan of care, and include a record of methods used to aim to relay this information to the person. The format of the care plans could continue to be reviewed to improve and develop the accessibility of the information to residents who have difficulty reading and/or understanding the written word. Daily and night time individual progress notes with regard to each person using the service are recorded. Each care plan included evidence of individual risk assessment. These included risk of falls, moving and handling, nutritional, and pressure sore prevention risk assessments. Guidance to minimise any assessed risk was documented in the care plans. These showed evidence of having been reviewed regularly. The most recent review was in May 2008. Residents were observed to have signs of well being, and wore clothes appropriate to their age and culture. One resident had her hair styled by a staff member. It was evident that the staff had an understanding of this person’s cultural needs. A visitor confirmed that the cultural needs of their family member was met (with support from the family) by the home. The home has an equality and diversity procedure. The care plans could be further developed to ensure that the records reflect resident’s needs under the strands of diversity, including gender, age, and sexual orientation. It was evident from talking with the manager, and co-owner, and from AQAA documentation that the home had plans to provide staff with equality and diversity training and to develop and improve the recording of residents equality and diversity needs. Staff provided assistance and support to residents in a sensitive and respectful manner, and have an understanding of the importance of upholding their right to privacy. Staff were observed to regularly ask some residents if they wanted to use bathroom/toilet facilities. Comments from staff surveys included ‘ I am aware of elderly peoples needs, I am quite confident that I am able to provide a good standard of care’, and comments from resident surveys included ‘there is a strong supportive service, medical facilities and social integration are well handled’. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 13 Care plans included evidence of people’s choice being acknowledged and guidance (to meet these needs) being incorporated into their plan of care. One resident enjoyed a glass of sherry in the evening prior to living in the home. Records confirmed that this had continued when she was admitted to the care home. Resident’s nighttime routines/sleep patterns were recorded in care plans inspected. The preferred name of each person was recorded in his or her individual plan of care. Records confirmed that residents have their healthcare needs met. People using the service have access to care, and treatment from a variety of healthcare professionals, including a continence advisor, GP, dentist, optician, community nurse, and chiropody treatment and care. A care plan recorded evidence that a resident had recently received a continence assessment from a continence advisor. A visitor confirmed that the home ‘understood’ their relative’s ‘healthcare needs’. A relative told us that the manager’s experience and skills had led to his/her relative being diagnosed with a particular health need, and was now being prescribed medication to treat and manage this. Feedback via the three healthcare professional surveys included the comments ‘I have observed that all clients look well cared for’ and the care home is ‘exceptional in all respects during my visits’, ‘ I have found no fault in the quality of care given in the residential home’, there is ‘good communication’, ‘I am always impressed by the level of caring and medical awareness of each client’s needs’, ‘the clients appear well cared for physically and psychologically in a well kept homely atmosphere’, residents ‘ are treated with respect and have privacy’, Residents weight is monitored closely. The home has a medication policy/procedure, which has been recently reviewed. Medication is stored securely. The manager reported that he and the owner, and one or two other staff generally administer the medication. The signatures of those who administer medication are recorded. The owner spoke of the process/training carried out to ensure that staff are competent to administer medication to people using the service. Records confirmed that a staff member had received an assessment of knowledge of safe handling of medication. Medication administration records confirmed that there were no gaps in the recording of medication administered to people using the service. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 14 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): Standard 12,13 14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have the opportunity to take part in activities, but there could be further development in the provision of community based leisure pursuits. The visiting arrangements are flexible and meet the needs of visitors and residents, so as to ensure that residents have the opportunity to develop and maintain important relationships. People using the service are supported to make choices. Meals provided are varied, and wholesome. The menu could be more accessible to people using the service. EVIDENCE: Residents due to their communication needs were unable to provide much verbal feedback about activities that they participated in, so observation, feedback surveys, talking to staff and visitors and inspection of records was of importance to gain an understanding of the number and variety of activities that people using the service participated in. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 15 The home has an activity programme, (the format of which could be developed to improve the accessibility of information to some residents), which includes hand and feet massage, word games, knitting and exercise sessions. Activities that residents participated in during the inspection included reading a newspaper, reading the bible, watching television, listening to classical music, and short walks within the home. Completing a jigsaw puzzle with a staff member during a one to one activity session. A person using the service watched an Asian film on her television. Another resident spent some time at the piano. Some residents listened and watched a religious programme on the television for some time after breakfast. AQAA information informed us that the home had recently obtained a satellite television service to enable residents to access more varied programmes, including religious ones. Activities were discussed with an owner of the service. She spoke of her plans to continue to develop the variety and choice of leisure pursuits. She spoke of how she and the staff team had found out (through getting to know the person) that a resident (with communication difficulties) recently admitted to the home had a particular enjoyment of reading the newspaper for several hours each morning. In consequence, a daily newspaper is now accessible to the people using the service. The co-owner confirmed that she was looking into the provision of specific activities, which meet the particular sensory needs, of a person who has multiple care needs. Advice with regard to the provision of activities to older people and those with particular care needs could be sought from various organisations and charities. Some residents sometimes go out for walks with family members. Staff reported that there was the occasional trip out into the community for residents, which was organised by the home. Some feedback/surveys informed us that it would be of benefit to residents if they had more opportunity to spend some leisure time outside the home, comments included residents could ‘do more outside activities if the weather is good’. This was discussed with the manager/owner and joint owner. They confirmed that they would look in to this issue, and that more walks (or mobilising by wheelchair) by people using the service (supervised by staff) to the local shops and other amenities could easily take place if residents wish. This is positive. The visitor’s record book indicated that people regularly visited the home. Feedback surveys, and visitors confirmed that visiting times were not restricted, and told us that they visited their relatives/friends often at different times of the day. We were informed that they visitors always felt welcome, and that the atmosphere in the home was very homely and ‘warm’. Comments included ‘we are very happy with the home’, and we ‘are kept informed of our ‘relative’s’ progress’ and ‘I have always visited (my relative) without prior arrangement, and have always found her happy and comfortable’. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 16 Visitors and staff informed us that family members are regularly invited to join their family members for a meal in the home. Visitors, staff, and a resident confirmed that the home has regular contact with relatives/significant others, via telephone and email. The home has a menu. This was displayed and in written format. The home could examine ways of developing the format of the menu (such as including pictures and or photographs, to make it more accessible to people using the service that might have difficulty in reading or have English as a second language. The menu indicated that residents receive varied and wholesome meals. Staff spoke of the ways that they gain an understanding of the food and drink preferences of people using the service. This information is ascertained from talking with the resident (and possibly the relative or friend if the resident has communication needs) during the process of assessment, and on a daily basis. Food ‘likes’ and ‘dislikes’, and their nutritional needs were recorded in care plans inspected. Residents spoke of enjoying the meals. The joint owner confirmed that the home had knowledge and understanding of resident’s particular cultural dietary needs, and confirmed that these people using the service were provided with a variety of meals that they enjoyed, and that met their cultural and /or religious needs. The family members of two residents are fully involved in ensuring that their relative receives culturally appropriate meals, and confirmed that fresh food produce was used in the meals. Comments from staff surveys included the home ‘provides healthy varied meals, we respect residents choices they make’. Some people using the service needed a little help with their meal from staff. Staff interacted with them in a sensitive manner during their lunch. Most residents were seen to wear plastic aprons over their clothes during meal times. This looked rather unattractive, and their use should be reviewed, with the people using the service. Large napkins/serviettes were discussed with the manager/owner and other owner as a possible alternative for those who on occasions spilt food or drink, on their clothes. A variety of food items were stored. These included fresh, frozen, dried and tinned foods. Fresh fruit was available. Hot and cold drinks were regularly provided to residents during their meals and throughout the inspection. The co-owner reported that people using the service are offered a choice of snacks before their bedtime. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to an effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The care home has a complaints procedure, a summary of which is recorded in the service user guide, and a copy is displayed. The complaints procedure includes timescales with regard to responding to a complaint. The registered person/manager should examine ways (with people using the service) to improve the accessibility of the complaints procedure for those who have difficulty reading, (and for those possible future residents for whom English might not be their first language), to help anyone living in the care home to complain or communicate a concern. Two complaints were recorded which indicated that the staff team were approachable, listened to concerns/complaints took them seriously, and acted to resolve them promptly. This is positive. Staff who spoke with me had an awareness and understanding of the reporting and recording procedures with regard to responding to ‘concerns’/complaints, and/or any suspicion or allegation of abuse. Feedback from residents/visitors, Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 18 and staff surveys confirmed that they knew of the complaints procedure, comments included ‘I am aware of the complaints policy’. The home has a protection of vulnerable adults policy, and has the local authority safeguarding adult’s guidance. Records and staff confirmed that they had received training in abuse awareness. The home also has a whistle blowing, and a counter bullying policy/procedure. Accidents and incidents are recorded appropriately. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 19 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): Standard 19, 23, and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, warm, clean and comfortable. The premises are suitable for the care home’s stated purpose. Resident’s bedrooms, meet their individual needs, and are individually personalised. EVIDENCE: The care home is located within a few minutes walk from the local shops and bus and train public transport facilities of Wembley. The inspection included a tour of the premises. The front of the property is tidy and attractive looking. The care home is well maintained, homely, clean and airy. The living environment is appropriate for the particular lifestyle, and needs of people living in the home. Houseplants, ornaments, photographs and pictures, and books are located in the communal sitting/dining room of the home. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 20 The small garden area is enclosed and well kept. It contains a variety of flowering plants and shrubs. Seating is accessible to people using the service and their visitors. Staff confirmed that residents enjoyed eating some meals in the garden when the weather was warm. A comment from a relative/visitor feedback form include ‘I admire the layout of the home that has been furnished to a high standard’. The manager ensures that the home receives on-going maintenance. Redecoration of a resident’s bedroom and communal areas of the home have been carried out since the previous inspection. The carpet in the communal lounge/dining room has recently been cleaned. A resident kindly let me see her bedroom. This was individually personalised, with lots of photographs, and ornaments. She has her own television. She spoke of being happy with her room. Comments included ‘I like my room’. I was informed by the owners that residents are encouraged to bring personal items with them when they are admitted into the care home. The home has an infection control policy/procedure. Staff were observed to wear protective clothing including disposable gloves, as and when needed. Records confirmed that a staff member had received infection control training. Hand washing facilities are located throughout the home. There are accessible paper hand towels and soap in the bathrooms inspected. A visitor commented that the care home ‘was very clean’. Records confirmed that the home had recently scored a high 4* rating following an inspection by an Environmental Health Officer. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 21 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): Standard 27,28 29 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people using the service, and to support the smooth running of the service. People using the service are supported and protected by the care home’s recruitment policy and procedure. EVIDENCE: The staff rota was available for inspection. There are generally 2 to 3 staff including the manager/owner and other owner on duty in the home during the day. At night there is a ‘sleep in’ staff member on duty. On the day of the unannounced inspection there were three staff on duty (including the two owners of the care home), which was judged to be a sufficient number and skill mix for meeting the needs of people using the service. Comments from resident surveys included ‘staff are available onsite 24 hours a day’. Staff were observed to be very approachable, and interacted with residents in a particularly sensitive manner during the inspection. They spent a lot of time talking with people using the service, sitting with them and assisting them with their personal care needs. Residents were regularly asked if they needed to use the bathroom facilities. A staff member commented that she ‘loved her job’ caring for the residents. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 22 Comments from staff feedback surveys included, ‘there is always a good communication system at all times, daily information about the service users are shared and communicated’, and ‘there is always a staff member and a manager covering shifts’, and ‘shifts are well covered by permanent staff’. Comments from healthcare professional surveys included ‘ the carers know their clients well and keep good records’ and are ‘able to give detailed information about changes in their medical condition’, and ‘staff always appear to be competent during visits’, ‘staff accept and act upon advice given’. Comments from relative/visitor surveys included the care home provides ‘a loving home from home environment’ and ‘ I fell that staff treat my (relative) with the same love and care that they would afford their own relative’. Visitors during the inspection spoke positively of the care and support provided to their family members. Records, and staff confirmed that new staff receive a comprehensive staff induction programme. A comment from a staff survey was that the induction was ‘very good’, and the induction ‘covered all aspects of care’. This induction includes the Common Induction Standards from Skills for Care. We were informed by the management staff and the AQAA, that staff also receive induction about the service and the systems in place within the care home, which ensures that residents receive quality care and support. The home has a training plan. Records confirmed that staff receive appropriate training to ensure that they have the skills and knowledge to be able to carry out their role and responsibilities in meeting the needs of people using the service. Certificates indicated that staff training includes fire, 1st Aid, dementia care, infection control, food and hygiene, moving and handling and health and safety training. Further staff training planned in June and July included understanding dementia, and Mental Capacity Act training. AQAA documentation informed us that the home had plans to develop ‘more planned and systematic approach to staff training’. A staff member spoke of the training (including induction) that she had received, and confirmed that she had further training planned including plans to achieve an NVQ (National Vocational Qualification) level 2 in care. Staff surveys supplied to the Commission for Social Care Inspection, included confirmation that staff receive training relevant to their role, and that staff training helps ‘understand and meet the individual needs of residents’, and that staff are ‘encouraged to attend training sessions/study days’ so that they ‘can keep up to date with residents needs’ and ‘there is support and training given by managers’. In answer to a question in the feedback survey, what they think the service does well, there was the comment ‘service users are well cared for and they are comfortable, and their needs are attended to with great detail’. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 23 AQAA documentation told us that three out of four staff have achieved a NVQ level 2 care qualification. The care home has a recruitment and selection procedure. Three staff personnel files were inspected. These incorporated required documentation including an enhanced Criminal Record Bureau check to gain information as to whether potential staff have a criminal record. A feedback survey from a staff member included the comment ‘all my details were checked and references were received before I started work here’. Staff job descriptions were available for inspection. Records confirmed that the home has a staff code of conduct. The home has a staff supervision policy. The manager has recently received staff supervision training. Staff confirmed that they receive regular staff one to one staff supervision, which ensures that they are supported in carrying out their role and responsibilities for meeting the care and support needs of people using the service. Records confirmed that a staff member had recently received staff supervision. The owner spoke of carrying out on-going staff supervision. A comment from a staff survey feedback form was the manager ‘regularly comes and observes and coaches me, and questions me to make sure of my knowledge’. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 24 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): Standard 31,33,35, 36, and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager/owner, and co-owner. So far as reasonably practicable the health, safety and welfare of people using the service is promoted and protected, and their financial interests are safeguarded. EVIDENCE: The registered manager is also the co-owner of the care home, and has managed the care home for several years. He has achieved a NVQ (National Vocational Qualification level 4/ Registered Manager’s Award qualification. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 25 The registered manager reported that he undertakes periodic training to update his skills and knowledge. He has recently achieved a qualification in mentoring in the work place, infection control training, and has completed health and safety training. Both the manager, and co-owner are qualified NVQ assessors. The manager works in the care home most days, and told us that he was easily accessible by care staff for advice. AQAA documentation informed us that the care home is providing a quality service, but that the manager is also aware that there are some ways that the home could progress, and has plans to continue to improve the service. Examples of these plans discussed during the inspection and recorded in the AQAA, include, providing staff training to ‘explore how to promote equality and diversity in the home’, to also improve the accessibility of some documentation to people using the service, review and develop ‘service user contracts’, to have ‘more detailed discussions about death and dying- end of life care’, continue to ‘discuss activities and exercise with service users, and relatives’. It was evident from talking to the manager during and following the inspection that he (and the co-owner) are keen to provide a quality service to residents, and are happy to make changes to the service in order to develop and improve it. The home has a quality assurance policy procedure. Records confirmed that systems within the care home are monitored closely. Records and other documents are reviewed regularly. The AQAA documentation had been comprehensively completed, and it was evident that a quality assurance plan linked to the National Minimum Standards had been instigated since the previous inspection. We were informed that satisfaction surveys are supplied to stakeholders regularly. Some completed questionnaires were available for inspection and included positive comments about the service provided by the care home. The home does not manage resident’s monies. The personal financial affairs of the people using the service is managed by their relatives/significant others. Records of expenditure were available for inspection. The home has health and safety policies and procedures. Records and talking with staff and visitors confirmed that health and safety in the home is monitored closely. Fridge/freezer temperatures are monitored. Call bells receive regular checks to ensure that they are in working order. Fire safety guidance is displayed in the home. Records, and staff confirmed that required fire safety checks and fire drills are carried out. Fire equipment was observed to be freestanding. This could be of risk to the safety of residents, staff and visitors if the equipment fell. Following the inspection the manager promptly supplied the Commission for Social Care Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 26 Inspection, with photographs with regard to evidence that he had fixed the fire extinguishers to the wall. It was evident from speaking to the manager and from inspection of records that fire safety is monitored closely in the care home, and, meets Care Homes Regulations 2001, i.e. fire equipment is maintained, fire drills are carried out, people can be safely evacuated in case of fire and there are clear routes of escape, and that staff receive fire training. Though the Fire Regulations indicate that if less than five people are employed the service isn’t required to keep a formal record of any significant fire risk findings it is strongly recommended that the care home carry out a written fire risk assessment, to ensure that it is evident that all areas of fire risk to people in the home are assessed. If needed advice should be sought from the fire service. Following the inspection the manager confirmed that he would promptly put this in place, and the Commission supplied the home with some information with regard to the issue of fire risk assessment. Documentation told us that the equipment located in the home has been serviced or tested as recommended by the manufacturer or other regulatory body. Certificates of up to date required gas and electrical system service checks were available for inspection. The home lets us know about things that have happened; they have shown us that they have managed issues appropriately. The home has an accident policy/procedure. Records and AQAA documentation informed us that there have been few accidents in the care home. The home has an emergency plan, which includes information that staff need to take to keep residents safe in hot weather, fire, and in response to flu pandemic. This plan could be further developed to include unforeseen issues occurring such as loss of electricity, water or gas in the home. The home has up to date employer’s liability insurance. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP2 OP3 Good Practice Recommendations It should record in the resident’s contract, statement of terms and conditions the reasons why some people using the service are unable to sign the document themselves. Initial assessments and admission assessments could be further developed to include more questions with regard to the equality and diversity needs of prospective residents to ensure that it is evident that these needs are fully understood and met. The format of the care plans could continue to be reviewed to improve and develop the accessibility of the information to residents who have difficulty reading and/or understanding the written word. It should be recorded in the care plans if a resident is unable to understand their plan of care, and include a record of methods used to aim to convey this information to the person. Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 29 3 OP7 4 OP12 The home could further develop and improve the provision of community based activities for residents to take part in, if they wish. This could improve the quality of the lifestyle of some people using the service. The format of the activity programme could be developed to improve the accessibility of information to those residents who have difficulty in reading. The home could examine ways of developing the format of the menu (such as including pictures and or photographs, to make it more accessible to people using the service that might have difficulty in reading or have English as a second language. The use of plastic aprons by residents during meals should be reviewed with people using the service to ensure that they have a choice with regard to using a napkin/serviette instead if they wish. The registered person/manager should examine ways (with people using the service) to improve the accessibility of the complaints procedure for those who have difficulty reading, (and for those possible future residents for whom English might not be their first language), to help anyone living in the care home to complain or communicate a concern. It is strongly recommended that the care home carry out a written fire risk assessment, to ensure that it is evident that all areas of fire risk to people in the home are assessed. The emergency plan could be further developed to include unforeseen issues occurring such as loss of electricity, water or gas in the home. 5 OP15 6 OP16 7 OP38 8 OP38 Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Edwin Lodge, 6 Victoria Court DS0000017496.V361133.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!