Inspection on 05/12/05 for Ealing Manor Nursing Home

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ealing Manor Nursing Home 09/10/06

Ealing Manor Nursing Home 21/06/05

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 Mrs Rekha Bhardwa Unannounced Inspection 5th December 2005 11:15 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 Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8840 3490 020 8579 4595 Messrs Narain and Rajesh Mittal Mrs Lydia Ngusoron Kur Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0), Terminally ill (0) Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to include up to 6 TI and up to 35 in total All Service Users to be over the age of 40 Date of last inspection 21st June 2005 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 27 single and 3 double bedrooms. At the time of the inspection building work to the remaining double bedrooms was in progress. 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 DS0000010963.V268248.R01.S.doc Version 5.0 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. The inspection was undertaken on the 5th December 2005 and the 13th December 2005. A total of 7 hours was spent on the inspection process. The Inspector carried out a tour of the home, inspected service user plans, staff records, service users records and servicing records. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. A number of staff, service users and visitors were spoken with as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls identified in wound management must be addressed as a matter of priority. Assessments in relation to service users must be accurate and up to date. Generally the medications are well managed, but the shortfalls identified must be addressed. The need to have more frequent fire drills must be addressed. Regular water temperatures must be undertaken to ensure that service users are not at risk. Quality monitoring systems must be in place in order to seek the views of the service users living in the home. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 DS0000010963.V268248.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 the following standard(s): 2&4 All service users have a written agreement/contract, so as to be clear about the services the home provides to meet their needs. Staff have received training to meet service users needs, including specialist needs. EVIDENCE: The home has specific contracts for each service user. At the time of the inspection there were no service users who were privately funded. Staff with palliative care training are available in the home in order to meet the palliative care needs of a number of service users. There was evidence of specialist training for staff to enable them to manage service users with specific healthcare needs, for example, tissue viability. Staff had received training in topics relevant to the care of the elderly. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7,8 & 9 Service users plans were generally comprehensive and identified the assessed needs of the service user and were being met. Shortfalls in wound management can place service user at risk of not having their needs fully met. Service users assessments must be accurate and up to date. Generally medications were being well managed, so as to ensure that service users medication needs are met. Shortfalls identified in relation to the dating of liquid medication must be addressed to ensure service users safety. EVIDENCE: Two service user plans were viewed in detail at the inspection. Systems for care planning are based on a nursing model. Overall these were comprehensive and detailed how the service users assessed needs were to be met. One service user plan evidenced that regular reviews were taking place. The other plan viewed did not evidence that monthly reviews were taking place. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 10 Nutritional assessments, risk of falls assessments, continence assessments, moving and handling assessments and pressure sore risk assessments were available on the files viewed. The Inspector noted that for one service user there was no weight recorded on the moving and handling assessment. A body map was not complete and pressure relieving equipment had not been identified on the pressure sore risk assessment. In one instance the total score of the pressure sore risk assessment was higher than that of the score recorded in the assessment. A wound care plan was viewed during the course of the inspection. The plan related to a pressure sore on the left heel, daily records viewed also indicated that there was a pressure sore on the right heel. No wound care plan was available for this wound. It was not clear from the records when the wound started. The wound care plan for the left heel was not clear and stated that ‘change dressing twice a week but also on alternate days’. The need to have clear and specific instructions in relation to dressings and wound management was discussed with the Registered Manager at the time of the inspection. On the second day of the inspection the Registered Manager reported that the wound care plan for this service user had been reviewed and was up to date. The records also indicated input from the GP, optician, chiropodist and other health care professionals. Samples of the Medication Administration Records were viewed. Medication received into the home is recorded on the Medication Administration Record sheet. For one service user who required medication via a percutaneous endoscopic gastronomy tube ((PEG), the Medication Administration Record did not reflect this. Liquid medications did not have the date of opening recorded. The Registered Manager stated that no Controlled Drugs were in use at the time of the inspection. Systems for the disposal of waste medication were in place. Daily medication fridge and clinic room temperatures were being undertaken. Room temperatures were still above 25°c. The Registered Provider stated that plans are in place to have an air conditioning unit fitted within the clinic room once the main building work has been completed. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 14 & 15 Service users choices in their care and routines are respected within the homes capabilities. Dietary needs of service users are well catered for with food choices provided and food available that meets service users preferences. EVIDENCE: The service users are encouraged to bring personal possessions with them. Several of the rooms viewed contained photographs, pictures, ornaments and small items of furniture. At the time of the inspection no service users were receiving advocacy services, the Registered Manager if required would arrange this. The majority of service users are on the electoral roll should they wish to vote. Some service users choose to spend time in their bedrooms rather than the communal areas. Choices are offered in each aspect of the care provision and routine of the home. Food hygiene training had been undertaken by all staff that work in the kitchen. At the time of the inspection preparations were in place for the service users Christmas party. The kitchen was briefly viewed and found to be clean and well ordered. Fridge/freezer temperatures were being taken daily and Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 12 records of cleaning schedules were available. The Registered Manager stated that she audits the kitchen monthly and shortfalls identified via the audit are addressed. A meal with the service users was not taken at this inspection. The cook stated that choices of meal are offered. Cold and hot drinks, with snacks are available throughout the day. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 the following standard(s): 16 & 18 The home has a clear complaints procedure in place to address any concerns raised by service users and their visitors. Systems are in place for the protection of vulnerable adults so as to protect them from possible risk of harm or abuse. EVIDENCE: The home has a clear complaints procedure, which includes contact details of the CSCI. There had been no complaints since the last inspection. Relatives who spoke with the Inspector confirmed that they were aware of the complaints procedure. The home follows the Ealing Protection of Vulnerable Adults (POVA) procedures. The Registered Manager confirmed that staff working within the home have received training in POVA. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 the following standard(s): 19,21,23,24,25 The standard of the environment within this home is good, providing service users with an attractive place to live. Individual bedrooms are well maintained and safe for service users to live in. Shortfalls in undertaking regular water temperature checks potentially place service users at risk. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. The Registered Manager stated that fifteen bedrooms had been redecorated and that plans were in place to decorate all the corridors, lounge and replace the carpets in these areas. She was aware of the areas of the home which required decorative attention. Generally the home was well maintained, clean and odour free. Since the last inspection two of the bathrooms have been refurbished and are now shower rooms. These were well maintained and contained the required adaptations. Toilets are available close to the lounge and dining areas. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 15 Building work was still in progress and nine double bedrooms have been converted into single bedrooms. There are three double bedrooms in the home. Privacy screening is available. The number of single bedrooms has increased from twelve to twenty seven single bedrooms. The Registered Manager reported that all the beds used by the service users are height adjustable. Bedrooms viewed were suitably furnished and had been personalised with photographs, ornaments and personal items. Generally the lighting was satisfactory throughout the home. Radiators in service users bedrooms were guarded. The home was warm and the Registered Manager reported that there had been issues with the heating. The maintenance person undertakes water temperature checks. The records viewed indicated that the last water temperature check had been carried out on the 30/3/05. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 The home is appropriately staffed to meet the assessed needs of the service users. Systems for the vetting and recruitment of staff are in place, thus safeguarding service users. EVIDENCE: The staffing levels at the time of the inspection met the assessed needs of the service users. The Registered Manager reported that she does keep staffing levels under review in line with the dependency levels of the service users. Two staff files were viewed at this inspection. Both contained the information required in the Care Homes Regulations 2001. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34, 37 & 38 The systems for quality assurance need to be kept up to date to ensure that the home moves forward in line with the wishes and needs of the service users. Overall, systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. The exception is the fire drill training, which needs to be reviewed to ensure all staff are kept up to date. EVIDENCE: The Registered Manager undertakes audits of the medication system and the service users records. No feedback questionnaires had been completed by the service users and their representatives since November 2004. The Registered Provider stated that feedback questionnaires would be undertaken once the building work was complete. Service users and their representatives are encouraged to voice any issues they wish. Regulation 26 Visits had been taking Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 18 place and a report of the visits undertaken had been forwarded to the Commission. A business plan for 2004-2005 was available. The Registered Provider stated that plans were in place to develop a business plan for 2006. The homes accounts were in the process of being audited. The Registered Provider stated that he would forward these to the Commission once he had received them. This Standard will be examined in full at the next inspection. The service users records are kept in the nursing office, which can be locked if staff are not present. Overall the systems for records and record keeping were found to be satisfactory. Servicing records were viewed at random and those viewed were up to date. Fire maintenance records were viewed and were up to date. Fire alarm tests were being undertaken. The fire drill records viewed indicated that night staff undertook a fire drill in May 2005 and day staff in July 2005. The need to have more frequent fire drills to ensure that staff are familiar and confident with the processes to be followed in the event of a fire were discussed with the Registered Manager. Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 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. 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 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 3 2 X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 X X 3 2 Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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. 2. 3. Standard OP7 OP8 OP8 Regulation 17(1)(a) 13(4)c 12(1)a,b, 17(1)a 13(2) Requirement The service user plan must be kept up to date. All assessments in relation to service users must be accurate, fully completed and up to date. Wound documentation must be in place for each wound. This must be clear, up to date and accurate. 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 28 degrees, accurate readings must be recorded. (Previous timescale of01/08/05 not met) The Registered Manager must ensure that the date of opening is written on all liquid medicines (Previous timescale of 15/07/05 not met) Water temperatures must be taken and recorded at regular intervals. Quality monitoring systems based on seeking the views of DS0000010963.V268248.R01.S.doc Timescale for action 16/01/06 16/01/06 16/01/06 4. OP9 16/01/06 5. OP9 13(2) 16/01/06 6. 7. OP25 OP33 13(4)c 24 16/01/06 06/03/06 Ealing Manor Nursing Home Version 5.0 Page 21 6. OP38 23(4) service users must be in place. All staff must receive regular fire drill training, including night staff. The times of when a fire drill takes place must be recorded. 16/01/06 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 Standard Good Practice Recommendations Ealing Manor Nursing Home DS0000010963.V268248.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection West London Area Office 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 DS0000010963.V268248.R01.S.doc Version 5.0 Page 23 - 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. 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