Inspection on 03/05/07 for Kingsley House

This inspection was carried out on 3rd May 2007.

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 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 24/04/06

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 Key Unannounced Inspection 11:00 3rd May 2007 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.V334606.R01.S.doc Version 5.2 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.V334606.R01.S.doc Version 5.2 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 3 Category(ies) of Dementia - over 65 years of age (3) registration, with number of places Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 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. The first floor consists of two single bedrooms, a communal room, a specialist shower room and a separate toilet. There is one single bedroom on the ground floor. A lounge/dining area. Separate kitchen and an en-suite shower/toilet/washbasin. 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 wheelchair users. There is no office or staffing facilities such as lockers and designated sleep-in or changing room. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out between 11:00 am and 4:30 pm on 3rd May 2007. The Registered Provider, one Registered Nurse/carer and three residents were at the home. During the course of the inspection, records, documents, policies and procedures were viewed. Observations were made and a tour of the building was undertaken. Three residents and one Registered Nurse/carer were spoken with. Four requirements that were made at the last Additional Visit and all key Standards were examined. The Registered Provider was co-operative and provided appropriate assistance throughout the inspection. Separate cultural and religious needs are being met at the home. What the service does well: The people who use the service appeared calm, appropriately dressed and well cared for. Those who who were spoken with expressed satisfaction with the care they received. Al records, policies and procedures were up to date and indicated that written measures had been put into place to minimise risk and safeguard the health and welfare of the people who use the service. Care staff members received appropriate training for meeting the needs of the service users and a Registered Nurse who covered duty at the time of the inspection was observed being competent in meeting the needs of the residents. Overall, the home was clean and well maintained. The atmosphere was calm and homely. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 6 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 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.V334606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Needs led assessments that had been carried out by placing Authorities and the home were inspected and all were satisfactorily detailed. EVIDENCE: The records relating to three residents were inspected and it was evidenced that background information and detailed need led assessments that had been carried out by placing Authorities were submitted the home at the point of referral. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 9 It was indicated also, that subsequent assessments were undertaken by the home and that relatives, care managers and medical professionals were involved in the process of assessing the suitability of the home in meeting specific needs, interests and/or aspirations of prospective residents prior to their admission. An intermediate care service is not provided at the home. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans relating to three residents were viewed and were found to be satisfactorily drawn up. It was indicated within care plans that the health, personal and social needs of the residents were being met. The home’s policies and procedures for dealing with medicines were in place. Residents that were spoken with confirmed that they were being treated with respect. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans that related to three people who use the service were examined and it was indicated that individual personal and health care needs were assessed and social interests were identified. Action plans and set goals were put into place and related risk assessments had been carried out. These included moving and handling, leaving the home unescorted and smoking on the premises. All care plans and risk assessments were regularly reviewed. Prescribed medication was appropriately stored and medication administration sheets were reflective of medcines being safely administered. The Inspector was informed by a Registered Nurse/carer that the people who currently used the service were unable to self-administer their medication. The home’s policies and procedures on medication were in place. Three residents spoke to the Inspector and reported that their privacy and dignity were respected at the home. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12. 13. 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were reflective of the social, cultural and religious needs of the religious needs of residents being satisfactorily met. The home’s visiting policy is in place and people who use the service confirmed that they received regular visits from relatives. People who use the service were observed being comfortable and relaxed. They moved freely around the home and were able to make choices regarding their daily living routines. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 13 Wholesome meal options that included cultural preferences are being provided at the home. EVIDENCE: People who use the service are encouraged to maintain religious practices and are accompanied by staff during Sunday Church Services. People are able to smoke in appropriate areas whilst being supervised. Individual interests also include reading and music. One resident confirmed that he/she was regularly taken to the hairdressers. The home has an open visiting policy and contact with relatives and/or friends are encouraged and residents are able to meet with visitors in their separate bedrooms. One resident reported that he/she received regular visits from close relatives. Residents were observed moving freely and comfortably around the home and were able to choose what they wore, hairstlyes and make up. Personal choices and interest were also reflected within separate bedrooms. Residents were observed resting in their separate bedrooms, watching television in the lounge or having make-up applied - on request – by a Registered Nurse/carer. Varied and wholesome meals were listed on the menus and appealing and nutritional cooked lunch choices that included cultural preferences were offered to residents at the time of the inspection. One person chose to have lunch delivered to his/her bedroom. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was in place and satisfactory. Care staff have received training on the Protection of Vulnerable Adults and policies and procedures that are in place indicates that people who use the service are being protected from abuse. EVIDENCE: The complaints procedure was clear, concise and accessible to all those who use the service and their relatives. The Inspector viewed the complaints book and it was indicated that no complaints had been made to the home since the last inspection. The home’s policies and procedures on Abuse are comprehensive and the London Borough of Ealing Manual on the Protection of Vulnerable Adults was in place. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 15 The records reflected that staff training on the Protection of Vulnerable Adults had been delivered. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and adequately maintained and the environment was calm and homely. EVIDENCE: The home is adequately spacious, appropriately furnished, in good decorative order and suitable for shared or individual activity. The rear garden is accessible to people who use the service and is adequately maintained. There were no issues regarding the laundry. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 17 The overall environment was clean, hygienic, calm and homely. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service require personal care and must be closely supervised at all times. As a consequence the ratio of staff to residents during waking hours is not satisfactory. All recruitment files that were viewed at random were satisfactorily kept and contained all the required documents. The records indicate that staff members have received appropriate training for meeting the needs of the people who use the service and a staff member was observed being competent in her role. EVIDENCE: It was reflected on the duty rotas that one carer covered duty during waking hours and that there was one waking staff cover at night. The Registered Provider visits the home each morning and may be available to transport or escort people who use the service to separate activities in the local community such as the Hairdressers or Sunday Church Services. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 19 However, a Registered Nurse/carer who covers duty during waking hours holds overall responsibility for providing personal care and preparing meals. Due, therefore, to the specific needs and additional risks associated with the people who use the service, the home must be appropriately staffed at all times to make sure that residents are being safeguarded and that separate needs are met satisfactorily. The records indicated that one member of staff was in the process of receiving level 2 NVQ training and that staff training delivered during 2006/7, included Manual Handling, Protection of Vulnerable Adults, Infection Control, Food Hygiene, Health and Safety, Elderley Care and Dementia. Three recruitment files were inspected at random and were found to contain all the required documents such as CRB disclosure certificates, photoidentification, application forms, job descriptions, references and signed contracts/statements of terms and conditions. A Registered Nurse/carer was observed being sensitive and competent in responding to the needs of two residents during the course of the inspection. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not being satisfactorily managered as a Registered Manager has not yet been appointed. Systems for quality assurance are in place and indicates that the best interests of people who use the service are being addressed. Individual financial records relating to personal allowances of people who use the service are satisfactory. All health and safety records and checks are up to date and reflective of the health and welfare of people who use the service being satisfactorily protected. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home did not have a Registered Manager at the time of the inspection. This was discussed with the Registered Provider who reported that a suitable person was being considered for the post. Systems were for quality assurance were in place and the records indicated that questionnaires had been sent out to health care professionals and relatives. Although the home does not hold overall financial responsibility for the people who use the service, personal allowances are being held in safekeeping. Individual financial records were examined and no discrepancies were identified. All health and safety records were up to date and environmental risks assessments had been carried out. Kingsley House DS0000027755.V334606.R01.S.doc Version 5.2 Page 22 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 3 X X 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 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 X 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.V334606.R01.S.doc Version 5.2 Page 23 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 OP27 Regulation 18(1)(A) Requirement The Registered Person must ensure that appropriate numbers of staff are on duty during waking hours to ensure that the safety and welfare of people who use the service are protected. The Registered Manager must appoint an individual to manage the home. This is being restated from the last inspection. Previous timescale 31/07/07. Timescale for action 10/06/07 2 OP31 8(1)(a)(b) (iii) 31/07/07 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.V334606.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V334606.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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