CARE HOMES FOR OLDER PEOPLE
Kolbe House 18-19 Hanger Lane Ealing London W5 3HH Lead Inspector
Robert Bond Unannounced Inspection 10th February 2006 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 Kolbe House DS0000027733.V278320.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. Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kolbe House Address 18-19 Hanger Lane Ealing London W5 3HH 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 992 4978 0208 992 4978 admin@KolbeHouse.co.uk Kolbe House Society Ms Lidia Williams Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Kolbe House is a residential care home that is registered for 25 older people. It is operated by The Kobe House Society and originally opened in 1984, mainly to accommodate for Polish refugees. The majority of the service users continue to be Polish and Catholic. The home is situated on the North Circular Road, close to Ealing Common but a distance from the shops and services of Ealing Broadway. The building comprises two large three storey houses amalgamated as one. Bedrooms are on all three floors but only one on the top floor is currently occupied as the lift does not extend to that floor. All bedrooms are single rooms, five of which are en-suite. The home has a conservatory and a large and attractive garden that has a ramp into it. The staff are Polish speaking and the diet, culture and church services held on the premises all focus on meeting the needs of the Polish service users. Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second unannounced inspection of the inspection year. The emphasis of the inspection was assessing the performance of the home against the key standards of the Department of Health’s National Minimum Standards (NMS), and ascertaining whether the home has met the requirements and recommendations made at the last inspection. The Inspector met with the Registered Manager and other members of staff. He toured the home, observed service users (many of whom do not speak English), and examined records, policies, and files. 22 service users were present, and the home is fully staffed. The Inspector assessed the home against 22 of the NMS and found that 20 outcomes were fully met or exceeded, but 2 were only partly met. The Inspector made 4 requirements. What the service does well: What has improved since the last inspection?
Staff have been trained in using a revised medication administration system. A member of staff and the pharmacist both now sign the register when medication is returned to the pharmacy. Staff have been trained in adult protection. More activities such as concerts are provided in the home. Most service users are now seen in their own rooms by the doctor or nurse rather than in one of the offices. Trees in the car park at the front of the home have been pruned back. Kolbe House DS0000027733.V278320.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. Kolbe House DS0000027733.V278320.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 Kolbe House DS0000027733.V278320.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 Adequate and satisfactory assessments are undertaken before a service user moves in. EVIDENCE: The Inspector examined in detail (case-tracked) the care file of the most recent service user to move in. This service user had been admitted for respite care. A full assessment had been completed by the Registered Manager. A risk assessment had also been undertaken. Kolbe House DS0000027733.V278320.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 and 9 Satisfactory and adequate care plans are produced on service users. Medication administration records are kept in a satisfactory manner. The medication storage arrangements are not wholly satisfactory. EVIDENCE: NMS7: The care file examined in detail by the Inspector contained an appropriate and detailed care plan. NMS9: The Inspector examined the medication records and storage arrangements. All were in order except: the Inspector found that controlled medication was locked in a box that was not secured to the wall as is usual (Requirement 1); the Inspector found that medication that required refrigeration was stored in a locked box placed in a refrigerator that was also used to store food and drink, the fridge door was frequently opened and the temperature inside was seen to be 10 degrees Centigrade, whereas the medication must be stored at or below 8 degrees. (Requirement 2);
Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 10 the revised medication policy is only available in Polish. (Requirement 3). The Inspector provided the Registered Manager with a CSCI produced checklist of what must be in a medication policy for a care home. Kolbe House DS0000027733.V278320.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 and 15 The social and cultural needs of service users are fully met in a most satisfactory way. EVIDENCE: Polish culture, language, religion and food were all seen by the Inspector to be predominant, in a way that is commended. The Inspector witnessed an appetising lunch being prepared. The dining tables were seen to have fresh fruit and flowers on them which is also commended. Kolbe House DS0000027733.V278320.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 policy, procedure and practice are satisfactory. The home’s adult protection policy is not wholly satisfactory. EVIDENCE: NMS16:The Inspector examined the one complaint that had been received (via the CSCI) since the last inspection. It concerned a potential service user who was correctly turned down as the home is not registered to meet his needs. The complaint had been appropriately recorded, investigated and responded to. NMS18: The Registered Manager reported that the Deputy Manager had undertaken POVA training in English and had passed the knowledge on to staff in Polish. The Inspector examined the home’s POVA procedure and found it did not refer to the need for the manager of the home or the management committee to pass on any allegations they receive, to the appropriate named authorities. Requirement 4. Kolbe House DS0000027733.V278320.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 to 26 The home’s environment is safe, well maintained, clean, hygienic, well decorated. Furnished and equipped. EVIDENCE: The Inspector toured the home and found no issues to report on. Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 14 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 to 30 The home is adequately staffed by people who have been properly recruited, and trained. EVIDENCE: The Inspector examined the current staffing rota, and a recruitment file chosen at random. All appropriate checks had been undertaken. The Registered Manager reported that the home had no staff vacancies. Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 15 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, 36 and 38. The Registered Manager is competent and able to discharge her responsibilities fully. Staff are appropriately supervised. Service users are adequately protected by the home’s health and safety measures. EVIDENCE: The Registered Manager has taken appropriate steps to meet the requirements made at the last inspection. She is currently undertaking the Registered Manager’s Award. The Inspector examined a sample supervision record.
Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 16 No health and safety issues (other than medication ones reported elsewhere) were discovered by the Inspector. Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 17 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 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 3 3 3 3 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 3 x x x x 3 x 3 Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 18 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 2 Standard OP9 OP9 Regulation 13 (2) 13 (2) Requirement Timescale for action 01/04/06 3 4 OP9 OP18 13 (2) 13 (6) Controlled medication must be securely stored. Fasten storage container to the wall or floor Medication that must be 01/04/06 refrigerated must be stored securely, separately from food and drink, and kept at the correct temperature. The home’s medication policy 01/04/06 must be translated into English so that the CSCI may consider it. The registered person shall 01/04/06 prevent service users from being placed at risk of harm by having a satisfactory POVA policy in place. 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 Kolbe House DS0000027733.V278320.R01.S.doc Version 5.1 Page 19 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
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