Inspection on 09/10/08 for Sedra Nursing Home

This is the latest available inspection report for this service, carried out on 9th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Sedra Nursing Home 66 Gordon Road Ealing London W5 2AR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Bovell     Date: 0 9 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Sedra Nursing Home 66 Gordon Road Ealing London W5 2AR 02085668701 02089980997 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Bimla Bains Type of registration: Number of places registered: Dania Care Homes Ltd care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is: 22 Date of last inspection Brief description of the care home Sedra Care Home (Nursing) is a 22-bedded care home sited in a converted detached building providing nursing care for service users within the categories of old age, physical disability, and physical disability over the age of 65. The home comprises of three floors, which are accessed via a stairway and a lift. The home is situated in a residential area, within close proximity to Ealing Broadway and some local shops. Disability access is available at the front via a ramp. There is parking for approximately Care Homes for Older People Page 4 of 26 Over 65 22 0 0 22 Brief description of the care home three cars on the front patio and street parking is also available. The closest public transport and shopping facilities are about a five to ten minute walk away. A local GP Practice provides medical input to the home. Where additional specialist medical services are needed, service user would be referred through the GP. Chiropody services are available at a charge. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out between 10:00 am and 4:30 pm on the 9th October 2008. The Registered Manager, one registered nurse, three care workers and eighteen residents were at the home. During the course of the inspection, records, documents, policies and procedures maintained at the home were viewed. A tour of the building was undertaken and observations were made. Two registered nurses and three care workers who covered separate shifts at the time of the inspection were spoken with. Care Homes for Older People Page 6 of 26 A completed annual quality assurance assessment document (AQAA) was considered. Requirements that were made at the last inspection and all key Standards were examined. The reported findings of an Expert by Experience who was also present at the time of the inspection is being incorporated into this report. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Care Homes for Older People Page 9 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care needs of prospective residents are assessed appropriately prior to admission Evidence: The personal files relating to six residents were inspected at random. Each file contained an initial written needs led assessment that had been carried out by the home and indicated that relatives, social workers and health care professionals were involved in the process of assessing and determining the capacity of the home to meet separate identified needs. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of relatives are being met satisfactorily and their privacy and dignity are being upheld. The homes policy and procedures on medication are satisfactory. Evidence: A number of care plans were viewed at random. It was reflected that the changing personal, social and health care needs of people who use the service were being assessed and that action plans and set goals were put into place. Assessments regarding identified risks associated with the delivery of personal including falls and patient handling, and in relation to the use of equipment such as cotsides, bathsides, hoists and wheelchairs had been carried out. Wound assessments and weight charts were in place. Care Homes for Older People Page 12 of 26 Evidence: Training records were reflective of staff training on Continence and Catherization and Pads training being delivered. The changing healthcare needs of residents were identified within care plans and indicated that people received access to health care professionals as required. It was noted on training records that care staff received training on Dementia Care and Tissue Viability. Medication held at the home was safely stored and medication administration sheets were accurately recorded and signed. We were informed by the Registered Manager that none of the residents self-administered their medication and that prescribed medicines were administered by registered nurses. A Pharmacists from Boots Chemist carried out an audit of medication stored at the home during the course of the inspection and confirmed that no serious issues were identified. Medication audits were being carried out on a four monthly basis. Records were indicative of staff training being delivered on medication. The homes policies and procedures on medication were in place. The homes policies on Privacy and Dignity were satisfactorily detailed. Care workers were observed interacting with residents in a respectful manner. Care workers that were spoken with confirmed that peoples privacy and dignity were at all times upheld during the delivery of personal care. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The social and religious needs of residents are being met. Contact with relatives and/or friends are encouraged and facilitated. People receive choice in relation to their daily routines. Varied and nutritional meals are provided. Evidence: Individual social, cultural and religious needs of residents were identified within individual care plans and the home employs an Activities Co-Ordinator. These areas were observed by an Expert by Experience at the time of the inspection. An Expert by Experience reported: The Activities Co-Ordinator showed me a timetable of activities which was very full and varied including skittles, board games, bead making and reminiscence sessions. I did note that the activities Co-Ordinator made a conscious effort to engage every resident in the lounge in some sort of activity ... Care Homes for Older People Page 14 of 26 Evidence: The residents spiritual needs are respected and met by representatives from the local churches e.g. Catholic, Church of England etc who visit the home regularly. People who use the service are able to maintain contact with relatives and friends and visitors are welcomed. An expert by Experience reported: I did have the opportunity of speaking to three visitors who were visiting their relatives. All reported positively on the care that was being provided to their respective relative. The Registered Manager confirmed that people received choice regarding meals, activities, clothing, make-up and hairstyles. An Expert by Experience reported: I was introduced to a resident who was able to keep her cat in her room. Residents had different hairstyles and were attractively dressed in outfits that reflected individual choice. Personal interests and choices were reflected in residents bedrooms. A professional cook and an assistant cook are employed at the home. Menus were indicative of varied and nutritional meals being provided. Energy drinks were also available. The Registered Manager confirmed that residents were able to have meals delivered to their bedrooms. An Expert by Experience reported: The majority of residents had their lunch on individual trays. The residents that needed assistance with their lunch were given it in a calm, unhurried manner..... We were informed by an assistant cook that people were able to have separate meals and that drinks and/or snacks were readily available. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure is satisfactorily detailed and people are being protected from abuse. Evidence: The complaints procedure was concise, clearly detailed and accessible. The complaints book was viewed and indicated that no complaints had been made following the last inspection. The incident and accident book was appropriately documented and Regulation 37s were being submitted to the CSCI as required. Policies and procedures on the Protection of Vulnerable Adults were in place and comprehensive. The Registered Manager confirmed that the personal allowances of residents were being secured at the home. The financial records of six residents were viewed at random and no discrepancies in relation to incoming and outgoing expenditure were identified. Records were indicative of staff training on Safeguarding Adults being recently Care Homes for Older People Page 16 of 26 Evidence: delivered. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being adequately maintained and the environment is safe, calm and homely. Evidence: The home is spacious, reasonably well decorated, comfortably furnished and suitable for shared and/or individual activity. The garden was being maintained. An Expert by Experience reported: The garden is accessible from the lounge via a vamp or walkway and I noted that the paving stones on some of the walkways presented a tripping hazard as some areas are uneven. I visited the laundry which seemed to be running very efficiently. Overall, the home was found to be clean, hygienic and adequately maintained. The environment was safe, calm and homely. Care Homes for Older People Page 18 of 26 Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are adequate and care workers are suitably trained and qualified for meeting the needs of residents. The homes recruitment policies and practices are satisfactory. Evidence: It was indicated on staff rotas that three care workers and one registered nurse were on duty during the morning period. Two care workers and one registered nurse were on afternoon/evening shifts. One registered nurse and one care worker covered waking duty at night. Issues relating to staff deployment for ensuring that peoples needs were met during peak periods were discussed with the Registered Manager and we were assured that appropriate action would be taken. We were informed by the Registered Manager that six registered nurses and eight permanent care workers were employed at the home, and that all permanent care workers had achieved NVQ level 2 or above. Six staff recruitment files were viewed at random and each file contained all required Care Homes for Older People Page 20 of 26 Evidence: documents. A training programme was in place and reflected that appropriate staff training and refreshers for meeting the needs of residents were regularly delivered. Care workers were observed being competent and attentive in meeting the needs of residents and those spoken with expressed satisfaction with the level of training they received for meeting the needs of residents. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Manager is suitably qualified and experienced. Quality assurance has been satisfactorily undertaken. The home is not responsible for the financial affairs of residents. The health, safety and welfare of people who use the service are being safeguarded. Evidence: The Registered Manager is appropriately trained, qualified and experienced. We were informed that she had tended her resignation and would be vacating her position on 22nd October 2008. A Manager Designate had been appointed and would be taking up his position on 23rd October 2008. Care Homes for Older People Page 22 of 26 Evidence: An annual quality assurance assessment document was satisfactorily completed and returned to the CSCI at the required time. The Registered Manager confirmed that the home does not hold overall financial responsibility for any resident. However, personal allowances were being safeguarded on residents behalf. All health and safety records were up-to-date and legionella tests had been carried out. Records were reflective of fire drills being regularly undertaken. Environmental risk assessments were in place. It was indicated on training records that care staff received training on Health and Safety, Fire Safety, Moving and Handling, Infection Control and Food Hygiene. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 The Registered Person must make sure that paving stones on walkways leading to the garden are evenly placed. To avoid risks to the safety and welfare of residents. 01/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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