Inspection on 24/04/06 for Kingsley House

This inspection was carried out on 24th April 2006.

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

Kingsley House 03/05/07

Kingsley House 10/01/06

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 Ms Jean Bovell Unannounced Inspection 24th April 2006 2:15 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 Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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.V290597.R01.S.doc Version 5.1 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.V290597.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Kingsley House is a care home for seven older people. It is situated in a quiet residential area of West Ealing and within close proximity to West Ealing and Ealing Broadway main line/underground stations and shopping centres. 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 on two floors. There are two shared bedrooms, one single bedroom, a bathroom and separate toilet on the first floor. One shared bedroom, en-suite shower/toilet/washbasin, kitchen and lounge/diner are on the ground floor. Laundry facilities are within an outbuilding at the rear of the back garden. The home does not have a passenger lift and communal areas are not accessible to wheelchairs. There is no office or staffing facilities such as lockers and designated sleep-in/changing room. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 2:15pm and 4:45pm on Monday 24th April 2006. The Registered Manager, one care support worker and one service user were present. During the course of the inspection records, policies and documents were viewed. A tour of the building was undertaken and observations were made. The requirements that were made at the last inspection and all key Standards were examined. The Registered Manager and one member of the care support staff team were co-operative and provided appropriate assistance throughout the inspection. What the service does well: What has improved since the last inspection? Of the fifteen requirements that were made at the last inspection, fourteen had been complied with. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 6 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 contacting your local CSCI office. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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.V290597.R01.S.doc Version 5.1 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 6. Prospective service users are appropriately assessed prior to admission. EVIDENCE: A service user’s file was inspected and found to contain an written initial needs led assessment that had been undertaken prior to admission. It was evidenced that separate personal, mental, physical and health care needs were assessed and social interests were identified. It was indicated that the prospective service user, relative, social worker and medical professionals were involved in the assessment process. Information relating to the home’s capacity to meet specific assessed needs was attached to an appropriately signed contract/statement of terms and conditions. Intermediate care is not provided at the home. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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 and 10 There is a satisfactory care planning system in place to provide staff with information about the needs of the one service user currently in the home. The home’s procedures do not reflect that the service user self administer their own medication. Staff treat the current service user with respect and sensitivity. EVIDENCE: The home has a detailed care planning system in place which include a personal profile, physical and mental health needs and social and leisure interests. There was evidence of regular monthly reviews with the service user being involved in this process. The health needs of the service user continue to be met. The care plan included assessments on mental health, risk of developing pressure sores, nutritional needs and risk of falls. A District Nurse visits on a regular basis. All medication is stored securely and the medication administration sheets were all complete. The service user is currently administrating her own pain Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 10 control medication. The home did not have a risk assessment in place for this practice. The service user spoken with was generally satisfied with the standard of care given to her and expressed the view that staff did their best to meet her needs. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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): 12, 13, 14 and 15 The home is able to meet the service user’s life and social needs in a satisfactory way. The service user is able to exercise full choice and control over all aspects of her life. Meal provision in the home is satisfactory. EVIDENCE: The Inspector spoke in detail with the current service user in the home. The service user confirmed that she is able to follow her own interests that include letter writing, watching television and reading magazines. The service user has her own telephone, which she uses to manage her affairs and contact friends. The service user is fully able to communicate her wishes to staff and they do their best to ensure they are met. The service user is fully consulted about her meals and told the Inspector that the food prepared by staff was to an acceptable standard. Fresh fruit was available in the service user’s room. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 12 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 and 18. The home’s complaints procedure is satisfactory and service users are being protected from abuse. A requirement made under Standard 18 at the last inspection has been complied with. EVIDENCE: The home’s complaints procedure was clear, concise and easily accessible to service users and their relatives. The complaints book was viewed and was suggestive of no complaints being made to the home since the last inspection. It was evidenced that the home’s policies and procedures on the protection of vulnerable adults had been updated and met with a requirement at the last inspection. A health and safety poster was on display and the London Borough of Ealing manual on the protection of vulnerable adults was in place. It was reflected on training certificates that training on the protection of vulnerable adults had been delivered to all members of the care support staff team. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 13 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, 23, 24 and 26 The home was maintained to a satisfactory standard. The service user’s room was comfortable and personalised and met her needs. The home must ensure that all areas within the garden are adequately maintained and that hand/paper towels are available within toilet/hand washing facilities. EVIDENCE: The home was well maintained, neat, clean and tidy. There were no noticeable odours but paper towel containers within toilets/hand-washing facilities had not been filled and hand towels were not available. Currently there is only one service user in the home, which is registered for seven service users. There is limited communal space, which could present space difficulties if the home were ever to become full. In addition, there is no passenger lift and the home has a narrow staircase that would be difficult for a service user with mobility problems to manage. Future service users will need Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 14 to have their mobility needs constantly monitored to ensure that they are not isolated in their rooms due to reduced mobility or lack of confidence in using the stairs. The service user expressed general satisfaction with her room, which was downstairs, and its level of personalisation. There were no issues regarding the laundry but litter surrounded the large waste bins in the garden and a mouse was seen in the vicinity. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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): 27, 28, 29 and 30. Appropriate training for meeting the needs of the service users is being delivered to the care support staff team and the home’s recruitment policy and practices are satisfactory. A requirement made under Standard 27 at the last inspection had been met. EVIDENCE: The staff rotas were viewed and found to be clear and up to date. This complied with a requirement that was made at the last inspection. It was reflected on the rotas that one care support worker was on duty at each shift during waking hours and that one care support worker covered waking duty at night. The home does not employ ancillary staff and care support workers are responsible for tasks such as cooking, cleaning and laundry. The Registered Manager confirmed that one member of the care support staff team had obtained Level 2 - National Vocational Qualification and another was in the process of being trained. The personnel files of two care support workers were examined and contained required documents including photo-identities, application forms, references, job descriptions and signed contracts/statement of terms and conditions. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 16 CRB clearance certificates were separately filed. It was evidenced on records inspected that new members of staff received Topps certified induction training and that subsequent training delivered included, health and safety, protection of vulnerable adults, medication, diabetes, moving and handling and infection control. A care support worker was observed being attentive and competent in meeting the needs of a service user. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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): 31, 33, 35 and 38 The home does not have a registered manager, which has been an ongoing situation. Currently the home is being run in the best interests of the sole service user. The service user’s financial interests are being safeguarded and there are no health and safety issues. EVIDENCE: The home does not have a registered manager. The Registered Person has been unable to fill this vacancy because of the low level of occupancy which means candidates do not feel other enough stimulation. The Registered Person told the Inspector that it is her intention to re-advertise the post of manager when more service users have been admitted to the home. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 18 Currently there is one member of staff on duty, day and night, to meet the needs of the only service user in the home. This is a very good staff / service user ratio which is very beneficial to the service user. The service user manages all her own financial affairs. A check was made of a number of health and safety documents and there were no outstanding issues. Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 13(4)(c) Requirement The Registered Person must ensure that hand/paper towels are at all times available in toilet/hand-washing facilities. The Registered Person must ensure the area around waste bins in the garden are tidily maintained and free from vermin. The Registered Manager must appoint an individual to manage the home. Timescale for action 30/05/06 2 OP26 23(2)(o) 30/05/06 3 OP31 8(1)(a)(b) (iii) 01/10/06 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 Kingsley House DS0000027755.V290597.R01.S.doc Version 5.1 Page 21 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.V290597.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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