Inspection on 22/05/08 for Kingsley House

This is the latest available inspection report for this service, carried out on 22nd May 2008.

CSCI found this care home to be providing an Good service.

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

Kingsley House 24/04/06

Kingsley House 10/01/06

Kingsley House 12/05/05

Kingsley House 05/11/04

Kingsley House 10/06/04

Kingsley House 12/01/04

Kingsley House 25/07/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Kingsley House 115 Kingsley Avenue West Ealing London W13 0EH Lead Inspector Ms Jean Bovell Key Unannounced Inspection 22nd May 2008 11:00 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 Kingsley House DS0000027755.V364387.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. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley House Address 115 Kingsley Avenue West Ealing London W13 0EH 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) 0208 998 9708 0208 991 5256 Mrs Margaret Nyambura Lane Care Home 3 Category(ies) of Dementia - over 65 years of age (3) registration, with number of places Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 Brief Description of the Service: Kingsley House is a care home for three older people with dementia. It is situated in a quiet residential area of West Ealing and within close proximity to West Ealing and Ealing Broadway main line/underground stations and shopping centres. The home is currently owned and managed by the proprietor Mrs Margaret Lane who also owns and manages a nursing home in Ealing Broadway. The house is semi-detached and accommodation is on two floors. The first floor consists of two single bedrooms, a communal room, a specialist shower room and a separate toilet. There is one single bedroom on the ground floor. A lounge/dining area. Separate kitchen and an en-suite shower/toilet/washbasin. Laundry facilities are within an outbuilding at the rear of the back garden. The home does not have a passenger lift and communal areas are not accessible to wheelchair users. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection was carried out between 11:00am an 3:00pm on 22nd May 2008. One Registered Nurse, a Care Assistant, three residents and one visitor was at the home. During the course of the inspection a tour of the building and garden were undertaken. The home’s records, documents, policies and procedures were viewed and observations were made. Three residents, two care staff and three visitors were spoken with. A completed Annual Quality Assurance Assessment document and surveys received were considered. The requirements that were made at the last inspection and all key Standards were examined. The Registered Provider visited the home at the time of the inspection and provided appropriate assistance. What the service does well: The home provides a service to people of different cultural, religious and linguistic needs. A comprehensive needs led assessment is carried out prior to the admission of new residents. People are treated with respect and their separate personal and healthcare needs are met satisfactorily. Staff members are suitably qualified and have received appropriate training/refreshers for meeting the needs of the people who use the service. All records viewed including care plans, risk assessments and health and safety checks were clearly detailed and up-to-date. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 6 Residents appeared appropriately dressed, well cared for and content. They expressed satisfaction with the care and support they received. Visitors are welcomed and those spoken with reported positively regarding the standard of personal care and meals that provided at the home. Overall, the home was clean, hygienic and reasonably well maintained. The environment was safe, calm and homely. What has improved since the last inspection? What they could do better: A requirement at the last two inspections regarding the appointment of a Registered Manager for the home had not been complied with. This was discussed with the Registered Person who has been unable to recruit to this post. The Registered Person visits the home on a daily basis most days of the week and is the Registered Manager for her other home a short distance away and she is easily contactable should any need arise. The Registered Person must confirm in writing, separately, the management arrangements for the home and inform CSCI when there is any change. Requirements relating to medication and activities were identified at this inspection. Attention must be given to ensure that Medication Administration Sheets are clearly dated and care staff must sign to confirm that prescribed medication had been administered at the required time. Dates of opening bottled medicines and signatures should be recorded on labels. It is recommended that routine indoor activities should be put in place and residents should receive support in participating in regular activities of their choice within the local community. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 7 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. Kingsley House DS0000027755.V364387.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 Kingsley House DS0000027755.V364387.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of people are appropriately assessed prior to admission. Intermediate care is not provided at the home. EVIDENCE: The personal records of three residents were inspected. It was indicated that an assessment undertaken by Care Managers from placing Authorities had been submitted at the point of referral. A subsequent needs led assessment was carried out by a representative from the home in relation to each resident. Prospective residents, relatives and/or carers, healthcare professionals and social workers were involved in the process of determining the home’s capacity to meet separate identified needs. Kingsley House DS0000027755.V364387.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are being appropriately drawn up. People’s health care needs are met satisfactorily and their privacy and dignity are respected. Medical record sheets are not clearly dated or signed as required. Dates of opening bottled medication are not being noted. EVIDENCE: Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 11 The changing personal, healthcare and social needs of the people who use the service were reflected in separate care plans and action plans and set goals were in place. Risk assessments had been undertaken in relation to activities identified within care plans such as falls and moving and handling. Fire risk assessments had also been carried out. All care plans and risk assessments viewed were reviewed on a monthly basis. Separate healthcare needs were identified within care plans. It was indicated that people were given access to healthcare professionals as required. They were accompanied by care staff during medical appointments and received annual dental and optical checks. A resident was taken to a GP appointment at the time of the inspection. Visiting relatives commented positively about people being able to keep their own GPs following admission into the home. Prescribed medication was appropriately stored but dates of opening bottled medicines were not recorded on labels and/or signed. Medicines that were out of date were returned to the Pharmacist. Policies and procedures on medication were in place and records were reflective of staff training on medication being delivered. Medication administration sheets were not, however, clearly dated and it was indicated that care staff did not at all times enter their signature after administering medication to residents. The people who use the service do not have capacity to self-administer medication. Care staff were observed being respectful in their interactions with residents and knocked on bedroom doors prior to entering. A policy on privacy and dignity was in place. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s religious and social needs are being adequately met. Contact with relatives and/or friends are encouraged and facilitated. People are supported in having choice and control over their lives. Varied and nutritious meals are provided. EVIDENCE: The Registered Provider confirmed that residents had not expressed an interest in attending Church Services. However, a cleric from a local Christian denomination visited the home on a monthly basis. Organised activities included reflexology, regular visits to the hairdresser and residents being occasionally taken to sing-along sessions at another home owned by the Registered Provider. One resident attended a day centre each week. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 13 People were observed sitting in the garden, watching television, reading and meeting with relatives and/or friends. A short session of reflexology was provided to one person at the time of the inspection. A resident expressed an interest in being supported to take daily walks and visitors that were spoken with said that people who use the service should benefit from additional indoor and outdoor activity. This was discussed with the Registered Provider who assured us that activities, particularly in the local community would be increased. Visitors are welcomed at the home and people were seen meeting with relatives and friends during the inspection. People received individual choice regarding clothing, hairstyles, meals and activities. They moved freely around the home and garden and were able to meet with visitors in separate bedrooms. Varied and nutritious meal options that were prepared by care staff were reflected on menus. Wholesome lunch choices were observed being served at the time of the inspection and people reported being happy with the quality and quantity of food they received. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 14 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is appropriately detailed and accessible. People are being satisfactorily protected from abuse. EVIDENCE: The complaints procedure was clearly detailed and accessible to the people who use the service and their relatives. The complaints book was viewed and indicated that no complaints were received at the home following the last inspection. Incidents and accidents had been accurately recorded. There was recorded evidence that training on Safeguarding Adults was delivered in August 2007. Care staff members that were spoken with confirmed their knowledge of whistle blowing. Policies and procedures on Safeguarding Adults were in place. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately maintained. The environment is calm and homely. EVIDENCE: The communal areas at the home are adequately spacious, appropriately furnished and suitable for shared and/or individual activity. The garden was reasonably well maintained and accessible to residents. There were no issues regarding the laundry. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 16 Overall, the home was clean, hygienic and adequately maintained. The environment was safe, pleasant and homely Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory. Care staff members are suitably qualified and have received appropriate training for meeting the needs of people who use the service. The recruitment policy and procedures are satisfactory. EVIDENCE: It was reflected on staff rotas that one Registered Nurse and one Care Assistant covered duty on each shift during waking hours. There was one waking staff cover at night. We were informed by the Registered Provider that three Care Assistants were employed at the home. One Care Assistant had achieved level 3 National Vocational Qualification in health and social care and two were receiving NVQ training. Separate training programmes were viewed and indicated that care staff received induction training. Subsequent training and refreshers delivered during 2007/2008, included Dementia Care Awareness, Moving and Handling, Safeguarding Adults, Fire Safety, Infection Control and Food Hygiene. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 18 Three staff recruitment files were viewed at random and were found to contain all required documents such as CRB disclosure certificates, photo identification, two references and signed contracts/statement of terms and conditions. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 19 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, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Registered Manager has not yet been appointed for the home. The Annual Quality Assurance – self-assessment – has been satisfactorily completed. The financial interests of people are being safeguarded. People’s safety and welfare are protected at the home. EVIDENCE: Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 20 A Registered Manager has not yet been appointed. The home is managed by the Registered Provider who visits on a daily basis. Staff are able to contact her should the need arise. We discussed this ongoing issue and the Registered Provider must write to CSCI confirming these current management arrangements and to inform CSCI if they change. The Annual Quality Assurance Assessment – self-assessment - document was completed and detailed what the service did well, what had improved, what could be done better and how. Numerical information was also provided. Personal financial allowances are being safeguarded at the home. Individual financial records were viewed and no discrepancies were identified in relation to income and outgoing expenditure. Health and safety records were up-to-date and included checks for gas maintenance, portable appliances, fire safety and water temperature. Fire drills were undertaken every three months and clearly recorded. Environmental risk assessments had been carried out. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 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 X X 3 Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 22 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. Standard OP9 Regulation 13(2) Requirement The Registered Manager must ensure that MAR sheets are clearly dated. Timescale for action 12/06/08 2. OP9 13(2) The Registered Person must make sure that MAR sheets are signed immediately after medication is administered to ensure that people’s health and welfare is protected. The Registered Person must make sure that dates of opening bottled medicines are recorded and signed on labels. 12/06/08 3. OP9 13(2) 12/06/08 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 Good Practice Recommendations DS0000027755.V364387.R01.S.doc Version 5.2 Page 23 Kingsley House 1 Standard OP12 It is recommended that routine indoor activities should be put in place and residents should receive support in participating in regular activities of their choice within the local community. Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Kingsley House DS0000027755.V364387.R01.S.doc Version 5.2 Page 25 - 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!