Inspection on 24/11/05 for Ingestre Road (12)

This inspection was carried out on 24th November 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

Ingestre Road (12) 05/10/07

Ingestre Road (12) 16/08/06

Ingestre Road (12) 18/05/05

Ingestre Road (12) 14/09/04

Ingestre Road (12) 21/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ingestre Road (12) 12 Ingestre Road 12 Ingestre Road Tufnell Park London NW5 1UX Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 24th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ingestre Road (12) DS0000037254.V250336.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. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ingestre Road (12) Address 12 Ingestre Road 12 Ingestre Road Tufnell Park London NW5 1UX 020 7267 4713 020 7267 0769 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) London Borough of Camden Ms Paula Peake Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th June 2005 Brief Description of the Service: 12 Ingestre Road is a care home provided by London Borough of Camden. The home is located in Tufnell Park and that is the nearest underground station (Northern Line). The home can be accessed by car via Burghley Road and there is a frequent bus service either to Highgate Road (214, C2) or Tufnell Park (4, 10, 134). The home is sited within a council housing complex and it is sign posted. The home caters for older persons and is able to accommodate 48 people. The home provides full personal care only. Health care needs are met by community heath services. The accommodation for service users is on two floors, at basement level and ground floor; there is an annexe, which is used for staff sleeping-in accommodation and an office. There is level access into the building and a shaft lift allows access between floors. The facilities are arranged around a large landscaped courtyard. At basement level there is a seating area to the front of the building. The home is divided into six units. Each unit is self-contained with bedrooms, a small kitchenette, and a sittingcum-dining room and served by toilets and bathrooms. There is a quiet lounge on the lower floor. Five of the units are home to older persons with long-term care needs, the sixth unit provides specialist intermediate care (rehabilitation). The units are staffed separately with each one having its own dedicated staff. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in November 2005 and lasted about four and a half hours. The manager was interviewed and assisted with the inspection. A tour of the home was made and about 10 of the service users were spoken to. Several staff were also spoken to, including a relative who was visiting at the time. A variety of records were looked including care plans, financial records, menus and medication administration sheets. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could be doing better were discussed with the manager. The care plans need to contain more relevant details about the preferences of service users in routines of daily living, meal choices, leisure activities and Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 6 religious observance. A more formal method of gaining service user’s views and opinions is also needed. 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. Ingestre Road (12) DS0000037254.V250336.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 Ingestre Road (12) DS0000037254.V250336.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): Standard 3 When people move into the home, there is a comprehensive assessment process, which shows the needs and wishes of the service user. EVIDENCE: All service users are referred through the care management programme. There is a copy of the assessment on each of the six care files checked as part of the inspection. Staff also complete risk assessments to ensure that any risk identified could be managed by the home. All the service users spoken to say that they liked living in the home and felt well looked after. Ingestre Road (12) DS0000037254.V250336.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): Standards 7, 8, 9 & 10 There is a care planning system in place but this does not always adequately provide staff with the information they need to satisfactorily meet the needs of the service users. Service users know their healthcare needs will be well met by the arrangements in place in the home. The systems for the administration of medication are much improved. There are comprehensive arrangements in place to ensure that service users’ medication needs are met. Personal support is offered in the home in such as a way as to promote and protect service user’s privacy and dignity. EVIDENCE: The records for six service users were looked at and indicated that for each one there is a care plan. This sets out the needs of the service user and how they are to be met by the home. Although there is evidence that these are being reviewed regularly, one of the care plans did not contain sufficient detail; and it did not reflect the outcomes of the assessment. The following areas were not included:• the need to monitor the personal hygiene of the service user despite requiring minimal assistance Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 10 • • • • • that the service user has shortness of breath and whether that affected their ability to\ go for walks or join in activities. there was no indication that the service user has a history of falls; the service user has moderate dementia but this was not reflected; the need to communicate via the right ear only was not included; nor what action should be taken if the service user displays overtly sexual behaviour. On another care file, the outcome of a falls risk assessment was recorded as high but this was not reflected in the care plan. Likes and dislikes are not always recorded on each care plan. Discussions with staff and service users confirmed that staff are aware of service users needs and these are being met but not recorded in sufficient detail. A more person centred approach is required. Feedback from the service users was very positive about the commitment of the staff to keeping service users as well as possible. Each service users is registered with a GP and records show that service users receive the services of opticians, dentists, chiropodists and districts nurses. The home also has access to the Camden REACH team, which gives them access to occupational therapy and speech and language therapy. The medication trolleys have been made more secure. The manager discussed the possibility of putting a medicine in each unit. The location would be the lounge-cum-dining rooms. Consideration will be given to making the cabinet look like part of the integrated cupboards in each location. The manager and staff are keen to reduce the clinical impact of a medication cupboard in a social care setting. The home has a medication policy and procedure. A date has been set for staff to attend accredited training. The medication administration records were seen to be up-to-date and accurately recorded. Staff observed administration medication, were following correct policy and procedure. Discussions with staff showed that they understood the concepts of privacy and dignity. Observation of their work showed that they are able to transfer theory to practice. The principles of privacy and dignity were reflected in some of the care plans. Service users confirmed that staff knock on doors, keep them closed and pull curtains whilst attending to personal care. Ingestre Road (12) DS0000037254.V250336.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): Standards 12 & 15 Personal support is offered in such a way as to allow service users to follow their own preferred lifestyle. The meals in the home are satisfactory offering both choice and variety. Special dietary needs are catered for. EVIDENCE: Discussions with staff and service users showed that service users are able to follow a flexible routine. An example of this is one service user who prefers to rise late and have their main cooked meal in the evening. Staff accommodate this practice and work around her needs. A lunch of her choice is saved and reheated according to guidelines for her evening meal. Likes and dislike are recorded in the care plan although this is better recorded in some care plans than others and a more consistent approach is needed. A calendar of social activities is posted and service users have the choice to participate or not. One area of choice is meal preferences. The menu is not on display but it is available and shows that service users have a choice in the meals they eat. Service users complimented the food and said that they enjoy their meals. On the day of the inspection, it was chicken curry for lunch. The inspector observed that there was some wastage and service users said that they liked the taste but there were too many bones to deal with. This aspect was Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 12 discussed with manager as a safety issue as well as some service users may be at risk from choking. The staff team are addressing the issue of food and diet in the home and have attended a training session. The inspector had the opportunity to see some of the feedback from the attendees. The trainer was impressed by the strong commitment of the staff team to the training session and their enthusiasm and ideas to improve the catering service in the home. Some of the suggestions for improvement were individual meal lists for service users, cultural foods being more readily available, more flexibility around when service users want to eat and a greater involvement of the service users in menu choice. Ingestre Road (12) DS0000037254.V250336.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): Standard 18 The service users are protected by the home’s policies and procedures relating to adult protection. EVIDENCE: The home has an adult protection policy and procedure. Staff have attended training in respect of adult protection. Staff also confirmed that they have attended training in relation to challenging behaviour and as a result feel more confident to manage potentially difficult situations in an effective and positive way. There are further safeguards in place with regard to recruitment and selection, which is robust and thorough and financial management of service users personal monies. Discussions with staff highlighted that they were aware to report any untoward incidents immediately. Ingestre Road (12) DS0000037254.V250336.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): These standards were not assessed EVIDENCE: Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 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 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): Standard 28, 29 & 30 There is a high level of staff trained to NVQ level 2 ensuring a good standard of care to service users. There is a robust and thorough recruitment process to ensure the safety of service users. The arrangements for induction and training of staff are good with the staff showing a clear understanding of their role. EVIDENCE: Discussions with the manager highlighted that 80 to 90 of staff have achieved the NVQ level 2. The organisation has a rolling programme of core and specialist training. All new staff have an induction and this was confirmed by a new member of staff. The home has a recruitment and selection policy and procedure that is underpinned by equal opportunities. The manager is supported by a human resources department. Discussions with a newly recruited member of staff confirmed that all the relevant checks were carried out including the taking up of references, CRB and a POVA First check. There is a rolling programme for newly employed staff, which includes induction and foundation training. A new member of staff confirmed that training options had been discussed with him as early as the interview stage. There is a commitment to invest in the training and development of staff. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 16 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): Standard 31, 33 & 35 The home is run by an experienced manager. Service users’ views are sought from time to time and acted upon locally but this is not done through a formal process. Service user’s finances are protected by the home’s policies and procedures but on occasions these safeguards are not used. EVIDENCE: The current manager is registered and achieved the Registered Manager’s Award to a very high standard. The manager has confirmed in writing that she intends to take a sabbatical and alternative management arrangements have been put in place. There will be a handover period from the registered manager to the acting up manager. The manager has confirmed that arrangements are in place to review policies and procedures. Service users are asked for their comments about the service they are receiving through reviews, meetings and comment cards. Feedback has not been actively sought from service users about the services provided through using anonymous user satisfaction questionnaires. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 17 The home has a policy on handling service user’s personal finances. There is a secure facility for safekeeping monies and valuables in the downstairs office. Service users have lockable facilities in their rooms. All transactions are recorded. This is done on computerised records, which can be printed off. Generally the administrator deals with any personal monies held in safekeeping but arrangements are in place to enable service users to obtain money evening and weekends. The records show debits, credits and balances, which offer an audit trail. Receipts are retained. The financial records did not have a list of staff’s initials and signatures. A look at a sample of records showed that there were not always two sets of initials by each transaction however it was evident that the accounts had been audited. On the day of the inspection four individual accounts were checked and the balances were all correct. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X X Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 19 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. Standard OP12OP7 Regulation 15(1) 16(2)(n) Requirement Timescale for action 30/03/05 2. OP33 3. OP35 The care plans for all service users must include their preferences in respect of: • routines of daily living • likes and dislikes of food, meals and mealtimes • leisure, social activities and cultural interests • religious observances • personal and social relationships. 24(1)(2) The registered persons must 30/03/05 & (3) seek the views of service users, relatives and stakeholders as a means to reviewing the quality of the care in the home and the overall service. Regulation The registered person must 31/12/05 17(2) – 9 ensure that there are two signatures to witness each financial transaction recorded in writing on behalf of service users. Ingestre Road (12) DS0000037254.V250336.R01.S.doc Version 5.0 Page 20 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 OP35 Good Practice Recommendations It is recommended that a list of staff’s names with their signatures and initials be maintained on the file used to record service user’s financial transactions. 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