Inspection on 21/06/05 for Ealing Manor Nursing Home

This inspection was carried out on 21st June 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

Ealing Manor Nursing Home 09/10/06

Ealing Manor Nursing Home 05/12/05

Ealing Manor Nursing Home 17/01/05

Ealing Manor Nursing Home 19/07/04

Ealing Manor Nursing Home 12/08/03

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ealing Manor Nursing Home 5/6 Grange Park Ealing London W5 3PL Lead Inspector Rekha Bhardwa Unannounced 21st June 2005 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. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ealing Manor Nursing Home Address 5/6 Grange Park, Ealing, London W5 3PL 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 8840 3490 020 8579 4595 Messrs Narain & Rajesh Mittal Mrs Lydia Ngusoron Kur Care Home 35 Category(ies) of Terminal Illness (0), Physical Disability (0), registration, with number Physical Disability-over 65 years of age (0), Old of places age, not falling within any other category (0) Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1, Service Users to include up to 6TI and up to 35 in total 2, All Service Users to be over the age of 40 Date of last inspection 17/1/05 Brief Description of the Service: Ealing Manor Nursing Home is a converted detached house in a residential area of Ealing. It can be accessed by bus, underground and main line train services. The accommodation consists of 11 single and 12 double bedrooms. At the time of the inspection double bedrooms were in the process of being converted to single bedrooms. The main day room has three areas for service users to utilise, plus there is a separate quiet lounge available. There are local shops within 10 minutes walk and the Ealing Broadway Shopping Centre is accessible by bus or a longer walk. Local transport facilities are available in the form of buses and Ealing Broadway underground and mainline station. The home offers a good social and leisure activities programme. The home has a designated information board for visitors and this information is comprehensive. At the time of the inspection there were 30 service users. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 7.10 hours were spent on the inspection process. The Inspector undertook a partial tour of the premises and inspected staff records, service user plans, staff files and servicing records. Service users, visitors and 5 staff were spoken to as part of the inspection process. At the time of the inspection there were thirty service users accommodated at the home. What the service does well: What has improved since the last inspection? What they could do better: The staff files must contain all the information as required in the Care Homes Regulations 2001. Instructions in relation to the monitoring and recording of blood sugars must be followed by the staff. Shortfalls that have been identified in the management of medication must be addressed. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 and 5. The home does not have intermediate care. Service users and their representatives are provided with information about the home in order that they can make an informed choice about where they want to live. The pre-admission assessment process for prospective service users enables the home to ensure it can meet the needs to include specialist care needs of each individual. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: Service users, their relatives and representatives are provided with information regarding the home in the form of a Service Users Guide and Statement of Purpose. These documents were to be reviewed following the completion of the building works to contain up to date information. Prior to admitting prospective Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 9 service users, a pre-admission assessment is carried out by the Registered Manager. Samples of these were viewed and had been clearly completed. An NHS registered nurse carries out the assessments for NHS funded nursing care. The home does not accept emergency admissions. Whenever possible prospective service users are encouraged to visit the home, meet other service users and staff. Where this is not possible the representative of the service user visits on their behalf. One service users representative confirmed that he had visited the home prior to his relative being admitted. Two representatives of a prospective service user spoke with the Inspector and stated that they had received information about the home and had viewed the facilities. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 &11 The home has a clear and consistent care planning system in place to adequately provide staff with the information that they need to satisfactorily meet service users needs. Overall the health needs of service users are well met with evidence of good multi-disciplinary working taking place on a regular basis, shortfalls that have been identified require addressing to ensure that the service users current needs are fully met. Generally medications were being well managed, so as to ensure that service users medication needs are met. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. EVIDENCE: Individual service user plans were available and samples were viewed. These were generally comprehensive and detailed how the service users’ identified health. The service user’s plan was being reviewed monthly or sooner if the needs of the service user had changed. Daily records were available and detailed the care provided. One diabetic chart viewed indicated that blood Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 11 sugars were to be monitored prior to the administration of insulin. Blood sugar levels had not been recorded. Documentation for wound care was viewed and found to be comprehensive and identified the plan of treatment to be followed. The progress of the wound was also recorded and any advice given by the tissue viability nurse. Assessments for nutrition, moving & handling, risk of falling, continence and pressure sore risk were in place. The policy and procedure in relation to medication had been reviewed since the last inspection. The home uses the Boots Monitored Dosage System. The Medication Administration Records were viewed at random, the Inspector noted that one service user had not been supplied with Frumil tablets from the 16th June 2005 to 21st June 2005. On another MAR chart the manufacturer had not been able to supply Doxazosin Mesilate. It was not clear what the home had done to address these issues with the supplying chemist. Liquid medications did not have the date of opening recorded. One service user had been prescribed Chlorpromazine one to be taken twice a day when required. This had been administered three times a day on one occasion. The Controlled Drugs Register was well maintained. The medication fridge temperature was recorded as 28 degrees, it was not clear whether this was actually the temperature of the clinic room. The clinic room temperature was recorded as being 26 degrees in the morning and the fridge temperature as being 25 degrees. Records viewed indicated that service users have input from other healthcare professionals, to include Macmillan nurse specialist. Service users and visitors spoken with were satisfied with the standard of care provided and the attitude of the staff. Staff were seen to address service users in a courteous manner. Some service users choose to spend their time in their bedrooms rather than in the lounge area. Any examinations undertaken by the GP are carried out in the service users bedrooms. All toilets and bathrooms are lockable. Where service users like their bedroom door to be kept open, these have a Dorgard mechanism in place. The home is registered to care for six service users with a terminal illness. The Registered Manager has a post graduate qualification in care of the dying. Other care staff have also received training in care of the dying. The home consults with the service users and their representatives concerning their care in their final days. Policies and procedures for death and dying are in place. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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) 12,13 and 15 Social activities are in place in accordance with the service users wishes. Visiting is encouraged and this enhances the service users lives and maintains contact with their families and friends. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home has an activities organiser who works 30 hours a week. She is flexible with her time and will also work over the weekends. Information on the activities provided by the home was available. This includes group and individual activities. Photographs of outings and activities were displayed in the lounge area. Service users have access to the homes collection of books and newspapers are delivered daily. A trip to Kew Gardens had been planned for the summer. Visiting hours to the home are open. Visitors were seen visiting throughout the day. Service users can choose to see whom they wish to see and their wishes are respected. Visitors spoken with said that they are made to feel welcome and tea, coffee and soft drinks are offered. The Roman Catholic Priest visits the home fortnightly and Holy Communion is provided. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 13 The lunch was sampled at the inspection this was well presented and tasty. A choice of meals is offered and some service users commented that the meal provision was satisfactory. Small snacks, hot and cold drinks were observed being provided throughout the day. Diabetic and pureed diets are provided. One service user was observed helping peel potatoes and vegetable preparation. Where service users required assistance with feeding this was undertaken sensitively and in keeping with the service users needs. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 The home has a satisfactory complaints system with evidence that service users and representatives are listened to and acted upon. Service users rights are protected and service users are able to exercise their legal rights directly. Systems are in place for the protection of vulnerable adults, so as to protect service users from possible risk of harm or abuse. EVIDENCE: The home has a detailed complaints procedure, which is available in the Statement of Purpose and the Service User Guide. No complaints have been received by the home since the last inspection. Visitors spoken with stated that they would speak to the Registered Manager or the Nurse in Charge if they wished to raise any concerns. Advocacy services are provided via Ealing Age Concern or other advocacy services. At the general election in May 2005 service users had the opportunity to vote through the postal voting system. The Protection of Vulnerable Adults procedure was available and dovetailed with the Local Authority POVA documentation. The Registered Manager confirmed that staff had received training in POVA procedures. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22 and 26 The home was clean and tidy and the environment was safe for the service users, this provides service users with a comfortable and safe environment for those living in the home and visiting. Equipment and adaptations to meet service users needs are in place. Systems were in place for the prevention of the spread of infection and were being adhered to. Thus safeguarding service users. EVIDENCE: On the day of the inspection builders were on site converting five double bedrooms to five single bedrooms. The bathrooms on all floors were also in the process of being refurbished. A tour of the premises was undertaken, a sample of bedrooms were viewed and these were well maintained. The Registered Manager said that all communal areas and bedrooms would be redecorated once the building works were completed. A spacious lounge/dining area is available on the ground floor. The rear garden can be accessed from the lounge area. Suitable adaptations to meet the needs of the service users were available throughout the home. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 16 The home was clean and odour free throughout. Gloves, aprons, soap and paper towels were available in the toilet and bathroom areas. Ongoing training on infection control was in place. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 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 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 home was adequately staffed to meet the needs of the service users. The vetting and recruitment practices need reviewing to ensure they are complete so as to safeguard the service users. Staff training is ongoing to ensure that staff have the skills to meet the needs of the service users. EVIDENCE: Staffing levels on the day of the inspection met the needs of the service users. Staffing levels are kept under review by the Registered Manager to ensure that the changing needs of service users are met. Ancilliary staff are employed in appropriate numbers. Staff absence is covered within the homes bank staff team or overtime. Agency staff are not used. There are 3 care staff qualified to NVQ level 2. Another 4 care staff were currently undertaking the NVQ level 2 training and were due to complete in November 2005. Evidence of other training to include mandatory training sessions was seen and there is an ongoing investment in the training provision for the home by the Registered Manager and Registered Provider. Induction and Foundation training for staff is to recognised standards. The staff employment files viewed were generally up to date with the exception of one employment file which did not contain a proof of identity. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 18 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) 31,32,35,36, and 38 The home is well managed and the Registered Manager and Responsible Individual have an open style of management. The Registered Manager is supported well by the all the senior staff in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. The home has a stable staff team with a mixture of skill offering consistency of care within the home. EVIDENCE: Service users, visitors and staff spoken with commented that the Manager manages the home well, has good leadership and communication skills and maintains a regular presence throughout the home. Visitors spoken with were complimentary about the attitude and approach of the staff. Small amounts of money are kept by the home for some service users. The records of these were available with accompanying receipts. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 19 Staff were receiving supervision every two months, records were available and had been signed and dated. A training and development plan was in place, the home is part of the West London Training Consortium. Servicing records were viewed at random and were up to date. The fire records identified that fire drills had taken place, to include night staff. A fire risk assessment and generic risk assessments were available. Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x 3 3 x 3 Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 21 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 8 Regulation 12(a) Requirement Blood sugar readings must be undertaken as per the required frequency, these readings must be recorded. The Registered Manager msut demonstrate the action taken when service users have not been supplied with their prescribed medication. The Registered Manager must ensure that the room temperatures are reduced to below 25 degrees.The Registered Manager must ensure that the fridge temperatures are brought down to the required 2-8 degrees, accurate readings must be recorded The Registered Manager must ensure that the date of opening is written on all liquid medicines The Registered Manager must ensure that the prescribers instructions in relation to as required medication are followed The Responsible Individual must ensure that all records required under Schedule 2 of the Care Homes Regulations 2001, are in place. Timescale for action 15/07/05 2. 9 13(2) 15/07/05 3. 9 13(2) 1/8/05 4. 5. 9 9 13(2) 13(2) 15/07/05 15/07/05 6. 29 Schedule 2(1)7,9,1 9 15/07/05 Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 22 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 Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 Ealing Manor Nursing Home G61-G10s10963 Ealing Manor v214426 210605 Stage 4.doc Version 1.30 Page 24 - 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. 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