Inspection on 05/04/05 for Albany Park Nursing Home

This inspection was carried out on 5th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Albany Park Nursing Home 19/05/09

Albany Park Nursing Home 24/05/07

Albany Park Nursing Home 20/06/06

Albany Park Nursing Home 07/11/05

Albany Park Nursing Home 30/09/04

Albany Park Nursing Home 04/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE ALBANY PARK NURSING HOME 43 St Stephens Road Enfield Middlesex EN3 5UJ Lead Inspector Tony Brennan Unannounced 5 April 2005 at 10.00 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 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. ALBANY PARK NURSING HOME Version 1.10 Page 3 SERVICE INFORMATION Name of service Albany Park Nursing Home Address 43 St Stephens Road, Enfield, Middlesex EN3 5UJ Telephone number Fax number Email 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 8804 1114 020 8804 7733 Barry Lambert for GSG Nursing Homes Limited Ms Milda Williams N Care Home with Nursing 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places ALBANY PARK NURSING HOME Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Room 12, ground floor, is unsuitable for wheelchair dependent service users. Date of last inspection 20th September 2004 Brief Description of the Service: Albany Park Nursing Home is a purpose built care home registered to provide nursing care for a maximum of forty-three older people. The Albany Park is registered to provide nursing care for older peaple. It is owned by GSG Nursing Homes Limited. The home is a detached, four storey building. All bedrooms have en-suite facilities. The home is situated in a residential area. It is close to shops, restaurants and public transport facilities located along the Hertford Road. ALBANY PARK NURSING HOME Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place as part of the annual inspection programme. The inspection took place over one day. The inspector was assisted by the registered manager. There were forty service users living at the home on the day of the inspection. The inspector spoke with nine service users, two relatives and five staff. As part of the inspection a tour of the building was carried out and records were examined relating to the care of service users, staff and the management of the home. What the service does well: What has improved since the last inspection? What they could do better: The care plans need to be agreed with service users and their representatives ALBANY PARK NURSING HOME Version 1.10 Page 6 Training needs to be provided on tissue viability. 50 of staff need to achieve NVQ level 2 in care. The staffing level needs to be reviewed in order to ensure that sufficient staff are available to meet the needs of service users. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ALBANY PARK NURSING HOME Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection ALBANY PARK NURSING HOME Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 Service users and prospective service users are provided with detailed information about the service. There is a comprehensive assessment process in place that ensures service users needs are identified. The registered manager is able to demonstrate that the home meets the assessed needs of service users. EVIDENCE: The inspector examined the statement of purpose and the service users guide, which contained all the required information. Service users with whom the inspector spoke had been given information on the service provided by Albany Park. The inspector examined six files of the most recently admitted service users and found that they had all received an initial assessment. Since the last inspection the assessment procedure has been improved so that more comprehensive information is obtained about the needs of Prospective service users. Service users spoken to were able to confirm that staff understood their needs. The needs identified in the initial assessment ALBANY PARK NURSING HOME Version 1.10 Page 9 were addressed in care plans. Staff spoken to understood the needs of service users and could explain how these would be met. The records of training showed that staff were equipped to meet the needs of service users. Service users confirmed that their needs were met and that staff had the necessary skills. ALBANY PARK NURSING HOME Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Care plans had not been agreed with service users or their representatives. The medical needs of service users are being met. The medication administration system ensures that service users are provided with the correct medicines. Staff treat Service users with respect and promoted their privacy. EVIDENCE: The six service user files seen all contained comprehensive care plans detailing the needs of service users. Since the last inspection work has been done to ensure that care plans are more comprehensive. The needs identified in the care plans are also cross-referenced with the risk assessments and the needs identified in the initial assessments. Care plans were being reviewed monthly. Service users spoken to say that the staff had a clear understanding of their needs. Service users felt that generally the care provided met their needs. Service users also stated that they had not been shown or discussed the contents of their care plans with staff. The care plans seen had not been signed by service users or their representatives to say that they agreed with the contents. ALBANY PARK NURSING HOME Version 1.10 Page 11 There were comprehensive daily records that showed how the care needs of service users were being met. The daily records also showed that medical and GP involvement was being recorded. A recent allegation of abuse highlighted need to ensure that service users admitted to the home are registered with a GP promptly. The registered manager has put in place a procedure to ensure that all service users are registered with a GP on admission to the home. The inspector found that all service users are currently registered with a GP. The risk assessments were in place and these were being reviewed. Fluid and food intake was monitored where assessment had shown this was needed. The assessment and care planning for the treatment of pressure sores had been improved so that a detailed assessment and care plan is provided for all pressure sores. This included a means to ensure that service users were provided with the required equipment. On touring the building the inspector saw that equipment such as ripple mattresses where in place. Since the last inspection the medicines administration system had been reviewed. The inspector observed nursing staff administering medicines and saw that this was done safely. The medicines policy is complete. The inspector found that all records for the safe administration of medicines were complete. The medicines administration record corresponded with the medicines seen for each service user. Records confirmed that staff had been on medicines training. The controlled medicines were recorded and these corresponded with medicines seen. All areas where medicines are stored had a temperature at or below 25C and this was being recorded. Service users spoken to confirmed that their privacy was respected. Service users said that staff knock on their bedroom doors. Service users also told the inspector that medical treatment was provided in their bedrooms. Staff spoken to demonstrated that they understood how to support service users to maintain their privacy. ALBANY PARK NURSING HOME Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals are balanced and offer chioce while catering for special dietary needs. EVIDENCE: The inspector spoke with service users who said that the food was generally good and that they were given a choice of meals. One service user who is vegetarian said that a variety of options are provided to meet her needs. The menu showed that a arange of meals were offered to service users. The inspector observed staff assisting service users with their lunch; this was done in a relaxed and supportive manner. Staff assisted service users and they took their time to ensure that each service user had the assistance they required. ALBANY PARK NURSING HOME Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 There is an effective complaints procedure and service user views are listened to. Service users are protected from abuse by effective adult protection procedures. EVIDENCE: Service users and relatives spoken to said that their views were listened to and they knew how to make a complaint. The complaints policy was found to provide guidance on how a complaint should be handled. There was a comprehensive record of all complaints and the actions taken to resolve them. The complaints recorded confirmed that all complaints were addressed within the twenty-eight day time scale. Service users spoken to said that they felt safe and knew what to do if they felt their rights were being infringed. There was a clear policy on how allegations of abuse should be handled. Staff spoken to understood what to do if abuse was suspected. ALBANY PARK NURSING HOME Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The environment is safe and well maintained. The home is clean and free from offensive odours. EVIDENCE: The inspector toured the building and found that it was safe and well maintained. The home was clean and free from odours. The inspector found that the wallpaper in bedroom 32 had been replaced. Since the last inspection the recommendations from the environmental health officers report had been implemented. ALBANY PARK NURSING HOME Version 1.10 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29,30 The staffing levels need to be reviewed to ensure they are sufficient to meet the needs of service users. The home has not met the target of 50 of all staff having the NVQ at level 2 in care. There is an effective recruitment procedure that protects service users. Staff need training on tissue viability. EVIDENCE: The inspector observed that groups of service users were left on their own. The inspector was told by service users that on occasion they felt that not enough staff were available to meet their needs. The rota showed that six care staff and two nurses were on duty throughout the day. The registered persons must assess the needs of service users and establish whether current staff levels are sufficient to meet the needs of service users. The rota showed that there was a low use of agency staff. Four staff files of recently appointed staff were seen to contain all the required documentation. There were two references, CRBs and proof of identity for each member of staff. The training records showed that staff had received training on the statutory required training. Service users said that staff generally understood their needs. The staff spoken to were able to explain how they worked with service users. A newly appointed member of staff confirmed that she had been inducted using the TOPSS induction programme. The inspector found that there was a need for tissue viability training, as this had not been provided. The registered manager explained that four care staff had already achieved ALBANY PARK NURSING HOME Version 1.10 Page 16 NVQ level 2 in care. The registered manager agreed to address this so that 50 of staff have achieved NVQ level 2 in care. ALBANY PARK NURSING HOME Version 1.10 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 37,38 Effective quality monitoring systems are in place to ensure the continued improvement in the quality of care. Staff receive regular supervision and support. Records are appropriately maintained. Service users and staff safety is promoted. EVIDENCE: Service users said that they had been consulted about their care. There is a quality monitoring system in place that audits the views of service users about the quality of care. The last quality audit was seen. There was evidence that issues had been responded to. Since the last inspection supervision records showed that it had been carried out regularly. There were records of group and individual sessions. Staff said that supervision was useful and provided the support they needed. ALBANY PARK NURSING HOME Version 1.10 Page 18 Records examined by the inspector were complete and accurate. Staff spoken to understood the importance of maintaining the confidentiality of information. The necessary procedures and training were in place to ensure the safety of service users and staff. The certificates for gas testing and electrical systems were all up to date. The legionella certificate was in date. The fire records showed that the fire alarm had been tested and drills had been held. The accident record showed that accidents were being recorded and risk assessments were carried out to ensure that risks were minimised. ALBANY PARK NURSING HOME Version 1.10 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 3 3 ALBANY PARK NURSING HOME Version 1.10 Page 20 No Are there any outstanding requirements from the last inspection? 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 7 Regulation 15(1) Timescale for action The registered persons must 1st May ensure that service users or their 2005 representatives are consulted about their care plans. The registered persons must 1st May ensure that a review is carried 2005 out of staffing levels to ensure that staffing is sufficent to meet the needs of service users. The registered persons must 1st ensure that 50 of staff achieve December NVQ level 2 in care. 2005 The registered persons must 1st May ensure that nursing staff receive 2005 training in tissue viability. Requirement 2. 27 18(1)(a) 3. 4. 28 30 18(1)(a) 18(1)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations ALBANY PARK NURSING HOME Version 1.10 Page 21 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI ALBANY PARK NURSING HOME Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!