Inspection on 10/01/06 for Kingsley House

This inspection was carried out on 10th January 2006.

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

Kingsley House 03/05/07

Kingsley House 24/04/06

Kingsley House 12/05/05

Kingsley House 05/11/04

Kingsley House 10/06/04

Kingsley House 12/01/04

Kingsley House 25/07/03

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

CARE HOMES FOR OLDER PEOPLE Kingsley House 115 Kingsley Avenue West Ealing London W13 0EH Lead Inspector Paula Eaton Unannounced Inspection 10th January 2006 08:40 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 Kingsley House DS0000027755.V270624.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. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kingsley House Address 115 Kingsley Avenue West Ealing London W13 0EH 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) 0208 998 9708 0208 991 5256 Mrs Margaret Nyambura Lane Mrs Margaret Nyambura Lane Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 2005 Brief Description of the Service: Kingsley House is a care home for seven older people. It is situated in West Ealing, in a quiet residential area. There are shopping centres at West Ealing, Greenford and Ealing Broadway that can be reached from the home. West Ealing main line station and Ealing Broadway underground station are a short distance from the home. The home is currently owned and managed by the proprietor Mrs Margaret Lane who also owns and manages a nursing home in Ealing Broadway. The house is semi-detached and accommodation is two storeys. There are four bedrooms, on the ground floor there is one shared bedroom and there are two shared bedrooms and one single bedroom on the second floor. There is no passenger lift and none of the facilities are wheelchair accessible. There is a bathroom on the first floor with a separate toilet and a small shower room and toilet on the ground floor. There is a kitchen and lounge/dining room but there is insufficient space for all seven service users to dine at the same time. There is no private space available for visitors. There is a small garden, which has outbuildings for the laundry and the food store. There are no facilities for staff such as lockers or a changing area. There is no office and the files are stored in the kitchen. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory inspection took place over four hours in the morning. One member of staff was on duty and the Registered Provider did arrive at the home for a short period of time but did not stay for the inspection. There was only one service user living at the home at the time of the inspection who was spoken to at length. The member of staff on duty was also spoken to. Records, policies and procedures were examined, however, some records were not available for inspection on this occasion. What the service does well: What has improved since the last inspection? What they could do better: 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 Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Kingsley House DS0000027755.V270624.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 Kingsley House DS0000027755.V270624.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): 3 and 5 The home has an adequate system in place to assess the needs of service users prior to admission to ensure the home is able to meet their needs. However, recorded assessments are not always detailed enough and not all risks are assessed. Service users have an opportunity to visit the home prior to admission. EVIDENCE: At the time of the inspection there was only one service user living in the home. An ‘Initial Resident Assessment’ was in place for this service user that covers medical history, falls, allergies, physical care needs, family and social contacts, religious and cultural needs and hobbies/social activities. A further assessment had then been completed on admission to the home. Although the assessment documentation was satisfactory there was a lack of detail and personalisation of this information. It was also noted that the initial assessment of the service user did not include a risk assessment for falls even though the Care Management documentation on file highlighted that the service user had a history of falls. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 9 The service user spoken to said that she had been able to visit the home prior to moving in and that she had received a copy of the terms and conditions for the home and also had a copy of the Service Users Guide. It had been a planned admission and a trial period of six weeks had taken place. A review meeting had taken place and the minutes of this meeting were viewed. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10 There is a satisfactory care planning system in place to provide staff with information about the needs of service users. The systems for the administration of medication are not always satisfactory. The size of the home limits the amount of privacy service users can have if the home is full to capacity. Staff do not always treat service users respectfully. EVIDENCE: A care plan had been developed for the service user in the home. This document covered all the care needs of the service user and the service user had read, commented on and signed the document. The care plan had been reviewed and daily records were also being maintained for the service user. Although the care plan contained details of all the care needs of the service user there was not enough detail with regard to certain aspects. For example, the care plan highlights that the service user has a history of falls but does not include any detail regarding the reason for this or ways of minimising the risk of falls other than a comment ‘will need help with Zimmer frame’. The health needs of the service user were being met. A moving and handling risk assessment had been completed on the day of admission, however as mentioned above more detail is required. The District Nurse was visiting the Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 11 service user on a weekly basis. The records relating to the District Nurse visits were seen. The District Nurse had recommended that the home provide the service user with a footstool, which the home had done. Any medical appointments are recorded on a separate page in the service users daily logbook. Risk assessments for falls, nutrition and risk of pressure sores had been completed. Although these are based on scoring systems and do not include any written information specific to the individual. The medication policy and procedure was viewed. The policy states that only a qualified nurse should administer medication, however there is not always a qualified nurse on duty at the home. The medication policy also does not contain enough detail. For example, there are not clear guidelines on the procedure to follow for the receipt, storage, administration and disposal of medication. The receipt and disposal of medication record was viewed and was satisfactory. There were no controlled drugs being administered in the home at the time of the inspection. The medication in the home is stored in a locked cupboard in the kitchen, although appropriately stored it was noted that a pharmacist label had been altered on one item of medication. There was also a gap in the medication administration record sheets. There is a lack of space in the home for service users to see visitors in private. Three out of the four bedrooms are double rooms and there is only one small lounge/dining room. The service user spoken to said that some of the staff that work at the home knock on her door before entering but that not all staff did this. The service user also said that a member of staff had embarrassed her on one occasion when assisting with a personal care task. On the day of the inspection the service user was having a private telephone installed in her room. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 15 The home considers service users preferences with regard to daily living but the home needs to give more thought to the social and leisure needs of the service user group. Staff encourage service users to maintain contact with family and friends. Meal provision at the home is satisfactory EVIDENCE: The service user spoken to said that the routines in the home were relaxed. She said that she is able to get up and go to bed when she wishes and that she could choose whether or not to participate in activities. The service user said that she is happy with the activities she does. She said that she doesn’t like crowds and that she prefers to sit and read, write, knit and talk to friends. The service users interests were recorded in her care plan. The home will need to reconsider the social and leisure activities provided in the home as more service users are admitted. The service user spoken to said that she had had visitors at the home and said that they had been welcomed and offered refreshments. She also said that she is regularly able to speak to friends and family on the telephone. As mentioned earlier the service user was having a private telephone installed in her room on the day of the inspection. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 13 The service user spoken to said that the food in the home was good. She said that she is able to choose what she has. The service user said that she usually had a breakfast of toast and porridge or another breakfast cereal and that at lunchtime she usually has chicken, lamb or fish and fish and chips on Fridays. The service user said that the oven had not been working for approximately three weeks at the time of the inspection so only the gas hob could be used for cooking. The member of staff on duty confirmed this. The service user said that Christmas dinner had been brought to her from the Registered Provider’s other registered service as she had chosen not to go there on Christmas day. This raises issues regarding food hygiene practices, for example, the food would not have stayed hot for the journey and would have needed reheating. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 the following standard(s): The home has an adequate complaints procedure in place however a judgement could not be made regarding the response to complaints, as the record was unavailable. The policies and procedures and systems in place in the home are not adequate to ensure the protection of service users. EVIDENCE: The home has a satisfactory complaints procedure in place. The complaints record was not available and the member of staff on duty did not know where it was. The Adult Protection policies and procedures in the home need to be updated so that they correspond with the Local Authority guidelines and also to ensure that they provide adequate guidance to staff regarding the procedures to follow. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 24, 25 and 26 The environment was maintained to a satisfactory standard. The home has many limitations due to the age and design of the building and therefore may not be suitable for service users with mobility problems. Service users bedrooms are satisfactorily maintained and the home was clean and tidy. EVIDENCE: The home is situated in a quiet residential area of West Ealing. Local shopping centres are a short journey from the home and there are good transport links. There were no maintenance issues noted at the time of the inspection. The small rear garden was in a reasonable condition. The small lounge/dining room is the only communal space available to service users and is used for relaxation, dining and activities. The space is not adequate for service users to all dine together if the home is full to capacity. It was noted that this room was very cold on the day of the inspection. Although the service user spoken to said that she did not feel cold the temperature of the room was not satisfactory. It appeared that the cause of this was the French doors in the lounge, which are quite old and not double glazed as the Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 16 radiator in the room was working. As mentioned earlier there is nowhere for service users to see visitors in private unless a person is occupying the one single room in the home. There is no passenger lift in the home and the home has a fairly narrow staircase that would be difficult for a service user to manage if they had any problems with mobility. Therefore it is important that the mobility of service users using the first floor is constantly monitored to ensure that service users are not isolated in their rooms due to reduced mobility or a lack of confidence in using the stairs. There is a small shower room with a toilet on the ground floor that is situated directly to the left of the front door to the home. This facility was satisfactory and is partially assisted as it has a seating area in the shower. However, this facility is very small and would not suit many service users who need assistance with showering, as there is very little space for staff and the service user to manoeuvre especially with the door closed. The service user living at the home at the time of the inspection said that she does not use the shower, as it is easier for her to just have a wash. Upstairs an assisted shower facility has recently been installed and there is a separate toilet. There are no baths in the home. The bedrooms were all adequately furnished and clean and tidy. Only one room was being occupied at the time of the inspection and the service user said that she was happy with her room. The service users room had a degree of personalisation. The lighting and ventilation in the home were adequate and the water temperatures were satisfactory. As discussed earlier the temperature in the lounge area was not satisfactory, however the rest of the home was adequately heated. The home was clean and tidy and there were no malodours. The laundry facilities are outside in an outbuilding. On the day of the inspection the laundry from the proprietors other home was being washed at the home because the washing machine at that home had broken down. There were several bags of laundry stacked up in the laundry area that were blocking the hand washing facilities. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 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 There are satisfactory numbers of staff employed by the home EVIDENCE: At the time of the inspection there was only one member of staff on duty as there was only one service user residing at the home. Staff numbers will need to be increased as more service users are admitted to the home. The staff rotas were seen, some of which did not have dates on so it was impossible to ascertain the period to which they related. There were also gaps in the rotas. There is no hand over period between shifts for staff included on the rotas. It was not possible to look at the recruitment records for the home, as the Registered Person was not present during the inspection. However, the majority of the staff working at the home also work at the Registered Persons other local home and these recruitment records had been recently viewed. It was also not possible to view the records relating to staff training, as the member of staff on duty did not have access to this information. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 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): 31 and 38 The management arrangements for the home are not satisfactory. It was not possible to assess if the health and safety of service users and staff were being promoted and protected as many of the required records were not available. EVIDENCE: The Registered Person had promoted a member of staff to act up as manager of the home. However, a permanent manager has not been employed and put forward for registration, this is unsatisfactory. It was not possible to access the personal monies and records for the service user residing at the home, as the Registered Provider was not present. There were no notable health and safety issues at the time of the inspection. However, the documentation relating to health and safety issues was not available for inspection. For example, servicing and maintenance records, staff Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 19 training records and records of fire safety equipment checks were not available. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 21 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 OP3 Regulation 12(1)(a) Requirement Risk Assessments for falls must be completed as part of the preadmission assessment for service users. Care plans must contain detailed information regarding the needs of service users and the action staff should take to meet these needs. The medication policy for the home must be updated to ensure it is accurate and contains sufficient detail. Pharmacist labels on medication must not be altered. There must not be any gaps in the medication administration records for the home. If medication is not administered the reason for this must be recorded. Services users privacy must be respected at all times. Service users dignity must be respected at all times The oven must be repaired or replaced. Food hygiene practice must be of an acceptable standard at all DS0000027755.V270624.R01.S.doc Timescale for action 10/02/06 2 OP7 15(1) 01/03/06 3 OP9 13(2) 01/03/06 4 5 OP9 OP9 13(2) 13(2) 10/01/06 10/01/06 6 7 8 9 OP10 OP10 OP15 OP15 12(4)(a) 12(4)(a) 23(2)(c) 13(3) 10/01/06 10/01/06 13/02/06 10/01/06 Kingsley House Version 5.0 Page 22 10 11 12 13 14 OP18 OP25 OP26 OP27 OP31 13(6) 23(2)(p) 13(3) Schedule 4 (7) 8(1)(a)(b) (iii) times. The Protection of Vulnerable Adults policies and procedures for the home must be updated. All rooms in the home must be adequately heated at all times. Hand washing facilities in the laundry area must be accessible at all times. The staff rotas for the home must be clear, accurate and up to date at all times. Suitable arrangements for the day to day management of the home must be made. (Previous timescale of 09/06/05 not complied with) 01/03/06 10/01/06 10/01/06 10/01/06 01/04/06 15 OP38 13(4) Records relating to health and safety must be available for inspection. 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 OP12 Good Practice Recommendations The assessment documentation for the home should include more detail and be more personalised. The home should consider widening and varying the activity provision for the home and explore available activities suitable for the service user group. Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 Page 23 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 Kingsley House DS0000027755.V270624.R01.S.doc Version 5.0 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. 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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