Inspection on 10/10/07 for Tansi Lodge

This inspection was carried out on 10th October 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tansi Lodge 26/08/09

Tansi Lodge 13/06/06

Tansi Lodge 02/09/05

Tansi Lodge 20/05/05

Tansi Lodge 01/02/05

Tansi Lodge 09/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Tansi Lodge 125 Audley Road Hendon London NW4 3EN Lead Inspector Teferi Degeneh Key Unannounced Inspection 10th October 2007 10:10 Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 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 Tansi Lodge DS0000041232.V353140.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 Adults 18-65. 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. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tansi Lodge Address 125 Audley Road Hendon London NW4 3EN 020 8922 0856 020 8922 0856 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) Dr Kaine Ikwueke Ms Mary Kanyuchi Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Tansi Lodge is a care home registered to provide care for four people who have mental health needs. The home is owned by Dr. Kaine Ikwueke. The registered manager is Mary Kanyuchi. Tansi Lodge is in a pleasant residential area of Hendon close to shopping and transport facilities. There are single bedrooms for the service users on the ground and first floors. A lounge and a dining/kitchen area are on the ground floor. There is a garden to the rear of the home. The staff office is on the first floor and a sleep-in bedroom for staff use on the second floor. Information about the home and a copy of the inspection report can be obtained by contacting the owner or the manager. The current weekly fees for the home range from £750-£1000. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home had not been told beforehand that this inspection was about to take place. The manager, Ms Mary Kanyuchi, a member of staff and three people who live at the home were present during the inspection. The home had sent some information about the services, facilities, staff and the people who live at the home before the inspection. The inspection consisted of the analysis of this information and discussions with the people who use the services and an interview with a care member of staff. The manager also answered a number of questions put to her as part of the inspection. The home’s records such as health and safety, medication, staff rotas, and management related information were reviewed. Information about the people who use services was seen in the three files examined. The premises and facilities of the home were seen during a walk around the building with the manager. What the service does well: What has improved since the last inspection? Risk assessments have been developed for people who keep and take their medication. The manager has planned for fire drills to take place regularly. The electrical appliances at the home have been checked and are safe to use. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective people who use the service can be confident that their admission to the home is based on the outcome of their assessment and the ability of the home to meet their needs. EVIDENCE: Three peoples’ files were examined. All these contained evidence of detailed assessment by health professionals and care co-ordinators. Records in the files showed that people who use services have visited the home before admission. One person said they had known the home before their admission and they are happy living there. The manager confirmed that people whose needs cannot be met by the home are not admitted. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home have benefited from the risk assessments and the opportunities available to them to freely decide on the activities they wish to participate in. The care plans can be improved with the active involvement of people who use the service and their representatives. This will ensure that care plans reflect individual personal needs. EVIDENCE: All the people who use the service look after their own money. The owner pays one person their money on a fortnightly basis. Records of these payments are maintained. Another person has their bank account, which they manage. Risk assessments are completed for all the people who live at the home. Care plans are reviewed six monthly by the manager. There was no evidence to confirm that people who use the service or their representatives have been involved in the reviews of care plans. Some of the records in the care plans had mistakes; for example, a date for one review was recorded as being (10/10/07), the day this inspection took place. All residents have front door and bedroom door Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 10 keys and are able to go out and return independently. Discussions with the manager revealed that a partner of one person who lives at the home was not allowed to visit the home due to health and safety risks to the people who use service and care staff. The manager confirmed that this decision was relayed to carers and a care coordinator. It was stated that an agreement was reached between all involved for the person to see their partner outside the home. There was no written document or risk assessment to confirm this was the case. Therefore, the people who live at the home are not safeguarded. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, and 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home enjoy activities that meet their needs. However, people’s aspirations to gain skills for independent living have been restricted. This is evidenced by the fact that they have no opportunity provided to them to go to the shops to buy food items of their choice. EVIDENCE: Daily records and discussions with a person who lives at the home confirmed that people who use the service are engaged. One resident said they go to a college and do a voluntary work during the weekdays. They said they use public transport including the London Underground to travel to and from their college and work place. On weekends they attend a place of worship. On the day of the inspection, another service user was observed going out to attend a social group. It was evident from observations and discussions with the manager; staff and people who live at the home that people make their own meals. In an interview, one service user explained how they enjoyed going out Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 12 to places and local cafés. There is a television set in the lounge for all the people to watch and some people have their own televisions in bedrooms. The manager said a service user and their family agreed for one service user not to have a television in bedroom so that they can socialise with the others in the lounge. From the files and discussions it was evident that people who live at the home do visit their families. As stated above, the manager said that a relative of one person is not allowed to visit the home due to risks to the other people who live and work at the home. There was no recorded evidence to confirm that this risk assessment had been completed. As mentioned earlier people who live at the home do prepare their meals with staff support. The food items are purchased from a supermarket and delivered to the home weekly on a Thursday. Each person writes their weekly provisions’ list and passes it on to the provider. It was understood that a petty cash of some £70.00 is kept for an emergency. However, the manager said this petty cash could only be used with the provider’s permission. From past experiences the manager has on a few occasions asked the provider for permission to spend petty cash on cleaning materials. There was no evidence to suggest that the home has bought bread or fresh milk in between the shopping week. From records and discussions with the manager and a service user it was clear that the home makes an effort to meet the diverse cultural and special dietary needs of the people who use the service. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have benefited from the wellorganised provision of personal and health care. Residents feel safe and empowered by the home’s system of medication administration. EVIDENCE: The files of the people who use the service indicated that the home works closely with health professionals and each person regularly sees their doctor. The record of one person has a detailed description of the efforts made by a consultant to organise a supply and monitoring of medicines for one person who had to travel abroad for a holiday for a long period of time. Most of the people who live at the home are independent in looking after their personal care. From records and discussions it was evident that the staff prompt residents with their personal care where needed. Medication is stored in a locked cabinet in the office. The staff administer and record medication for two people. The medication administration record sheets and the medicines were checked and found to be in order. The staff files showed that the staff have Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 14 attended training in medication. One of the people who use services keeps their medication for which a risk assessment has been carried out. Two people who were observed looked relaxed and comfortable. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are confident that they are protected by the availability in the home of trained staff and satisfactory complaints and adult safeguarding policies. EVIDENCE: The home’s complaints procedure is included in the service users’ guide. A copy of this procedure is also displayed at the home. No complaints have been recorded since the last inspection. A service user spoken to said they know how and who to complain to if they have concerns. The home has policies and procedure in place to safeguard people who use the service. The files of a number of staff showed that they have attended training in adult protection. A member of staff who was spoken to gave a satisfactory description of the kinds of abuse and how they can deal with a suspected or real abuse. They said they are currently undertaking training to achieve a national vocational qualification (NVQ) level 2 in care. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the efforts of the staff to keep the home clean and tidy, the needs of the people who use the service are not fully met. This is evidenced by the fact that the rooms are in need of painting and decoration and the standard of the furniture was inadequate. EVIDENCE: The home was clean, bright, tidy and free from bad smells. One person spoken to said they like their room and keep it clean. The manager said the home has a plan to redecorate all the rooms and replace the kitchen floor. It was seen in the lounge that wallpaper has started wearing off and is in need of attention. The wash hand basin in the lounge was not being used and the handles were missing. The presence of the wash hand basin in the lounge makes the room appear odd. The toilet, the bath, and the kitchen were all clean on the day of the inspection. The back garden, which is designated as a smoking area, was also well looked after. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The recruitment practices and training programmes of the home have enabled people who live at the home to be supported by committed, knowledgeable and reliable staff. EVIDENCE: Five staff files, which were seen, contained evidence of satisfactory enhanced criminal record bureau (CRB) checks and two written references. Jobs are advertised and recruitment of new staff is made after interviews. The home has a recruitment and equal opportunities policy. All new staff undergo induction programme before they start working at the home. Two of the current five staff have achieved national vocational qualification (NVQ) level 2 in care and one member has embarked on training to achieve a similar qualification. The home has a training programme and staff have attended various courses including health and safety, first aid, adult protection, medication, fire safety, manual handling, infection control and basic food hygiene. A member of staff spoken to demonstrated their good skills, knowledge and commitment to supporting people with mental health needs. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The welfare and health and safety of the people who use the service are ensured by the homes policies, procedures and good management systems. EVIDENCE: The manager has achieved a national vocational qualification (NVQ) level 4 in management. She has also undertaken various training related to the management of a care home. The residents and staff spoken to said that the manager is supportive and approachable. The office is well managed except that the manager has not been given decision-making authority in relation to the management of the petty cash, for example, not being able to decide on spending money in an emergency. There is a fax machine and a telephone Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 19 service as well as a computer in the office. It was discussed that the office would benefit from connecting to the Internet. The manager needs to make the inspection report available to the staff and people who live at the home. The registered person was reminded to contact the registering authority and obtain a new certificate of registration. Discussions with the manager revealed that the home has not yet developed a quality assurance system. The manager is now aware that there is a need to review the quality of the service by consulting the people who use the service, their representatives and the other people connected to the home. No accidents have been recorded since the last inspection and this shows that the people live in a safe place. All food items were appropriately stored and records were available that portable electrical appliances were checked and were safe to use. The fire equipment and fire alarms are regularly tested. Fire drills are planned and take place regularly. Certificates were seen to confirm that the gas boiler and electrical wiring of the home have been checked and are safe. Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 21 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 YA6 Regulation 15(1) Requirement Timescale for action 31/03/08 2. YA24 3. YA39 The Registered Person must develop and review service users’ care plans by consulting service users and, as appropriate, their relatives and other representatives. This will ensure that the needs of the people are appropriately reflected and met by the home. 23(1)(2) The registered person must ensure that all parts of the home are kept in good state of repair and decorative order. The lounge must be redecorated; the kitchen floor must be replaced and the wash hand basin in the lounge must be removed. This will improve the comfort, safety and quality of the home for people who use the service. 24(1)(2)(3) The registered person must establish and maintain a system for reviewing at appropriate intervals; and improving the quality of care provided at the home by consulting people who live at the home, their relatives and professionals. The registered person must supply DS0000041232.V353140.R01.S.doc 31/12/07 31/03/08 Tansi Lodge Version 5.2 Page 22 the Commission a report in respect of the quality review and make a copy available to service users. The quality assurance system will enable people who use the service to make comments and help the home to improve the services. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA15 Good Practice Recommendations The registered person should enable that people who live at the home maintain links with their relatives. Where people see their relatives or friends outside the home, appropriate risk assessments and records must be maintained. The registered person should ensure that people who live at the home are supported to go to the shops to buy food items as part of their aspirations to gain skills for independent living. The registered person should ensure that the office has an internet facility. The registered person should obtain a new certificate of registration from the Commission for Social Care Inspection. The registered person should ensure that the manager has authority and responsibility to manage the home’s finances including the petty cash as set out in the job description. 2 YA17 3 4 5 YA37 YA37 YA37 Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Tansi Lodge DS0000041232.V353140.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!