Inspection on 13/06/06 for Tansi Lodge

This inspection was carried out on 13th June 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 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 10/10/07

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 Margaret Flaws Key Unannounced Inspection 13th June 2006 09:00 Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 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.V292060.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 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.V292060.R01.S.doc Version 5.1 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.V292060.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 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 bedrooms for the service users on the ground and first floors. There is a lounge and a dining/kitchen area 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. The fees for the home range from £750-£1000. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. The Registered Manager assisted and was present throughout the inspection. Three service users were spoken to, one through an interpreter and two members of staff were spoken to. Care and staff records were inspected, as well as medication records, general home records, and policies and procedures. Three comment cards were received, along with a very thoroughly completed pre-inspection questionnaire. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 6 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.V292060.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Detailed information is provided for prospective service users, which enables them to make choices about where to live and decide whether the home would be suitable for them. EVIDENCE: A statement of purpose, which gives the service users information about the home and its services, is provided. There is evidence of clear and detailed preadmission assessments by the placing authorities, the home and by community mental health teams. One service user, who was on a temporary placement at the home, had his needs appropriately and fully assessed and reviewed throughout his visit and moved on when it was clear that the home could not continue to meet his needs. The pre-admission process for a prospective service user was case tracked and found to be thorough. Trial visits, including overnight stays, formed part of the assessment process. Careful matching of staff to service user was considered as part of the admission process. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are detailed care plans for service users, which clearly set out their needs and the work carried out by staff to meet those needs. Service users are supported to make decisions about their lives on a daily basis and to take appropriate risks. EVIDENCE: Three care plans were inspected, along with the file for a prospective service user. There was very good evidence on file of the assessed and changing needs of service users. The care plans were very comprehensive and contained detailed information from social workers, mental health teams and other health workers. They were regularly reviewed and there was evidence of how they were consulted. The good management of one serious incident with involving a service user was well documented. Risk assessments were up to date and reflected the changing needs of the service users, while enabling them to make decisions about stretching their limits. Two service users spoke about wishing to improve their independence by eventually moving into supported living situation. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 9 Service users are fully supported to make choices and decisions in their lives. They said that they are free to come and go as they please and manage all aspects of their daily lives, with support as required. One service user chooses to stay at home most of the time. Her needs are regularly reviewed and the home makes every effort to ensure that she is enabled to lead a full life, within the constraints that she sets for herself. A service user described how the home is providing support to help her better manage her own finances; otherwise the home is not responsible for any service users’ finances. Service users spoken to were positive in assessing how the home supports them and meets their needs. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15,16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is organised so that service users are enabled to take part in the community, maintain control over their own lives, have contact with their families and eat the food they like and are used to. EVIDENCE: Three service users were spoken to and described the pattern of their daily lives and how the home supports them. Two service users lead active lives outside the home, while another service user prefers to stay at home. One service user attends college, regularly visits friends and is studying English. All the service users described the varying degrees of family contact that they have. Service users tend to pursue their own interests when in the home, which include creative sessions, crafts, watching DVDs and reading. Service users’ spiritual needs are well supported – one service user attends church and another is visited regularly by her local priest. The service users actively participate in planning their meals and assist with cooking. Each person has an individual menu, which incorporates their dietary and cultural needs. The food cupboards, fridges and other food storage Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 11 locations were inspected and there was a good range of food available, including fresh food. The home has good health and safety practices in the management of food in the home, records date and times products are opened and correctly discards any leftover food. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Heath and personal care and support are well organised in the service users’ interest. Medication policies and procedures are appropriate for the home but need to be supported by appropriate risk assessments. EVIDENCE: All the service users’ care plans were examined. These contained full details of personal care provided, which is minimal, mainly prompting and supporting. Staff key workers were able to provide a good understanding of the service users’ needs. There was detailed information documenting the input of healthcare professionals and multidisciplinary teams supporting the service users and evidence of good care coordination. Medication policies and procedures were examined and found to be in order. MAR charts were appropriately completed and medication stored correctly. One service user, who self medicates, described the process and the support given by staff. However, there is no specific risk assessment to cover this service user’s situation and this is required. A service user has had a decline in health status, but refuses medical intervention. The Registered Manager described how this has been handled by Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 13 staff and by other health care professionals involved. This is a very thorough and ongoing process. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There is a clear complaints procedure available to the service users. Staff are well versed in adult protection procedures and service users can now be confident that their interests will be protected. EVIDENCE: Staff have received Protection of Vulnerable Adults training and were able to describe how they ensure service user safety and how they would protect service users in alleged cases of abuse. The manager has completed a Train the Trainer course for adult protection. The complaints book was inspected. Two complaints have been received since the last inspection, both of which were appropriately investigated, resolved and documented. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a clean, well maintained and attractively decorated home. EVIDENCE: The home is bright, nicely decorated, reasonably spacious and well presented throughout. Bedrooms are well equipped and there is a lounge, dining room and kitchen. The home is well maintained. A hedge has been replaced with a new fence to improve privacy at the front of the building. The home has purchased a fridge for one service user to keep some food and drink items safely in an accessible place, in line with her needs. The cleaning is done by staff, with service users responsible for cleaning their own rooms. It was clean and hygienic on the day of the inspection. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users can now be confident that staff in the home are appropriately recruited but there are some risks to service users from impending staffing gaps. These staff are well trained and well supported by the manager. EVIDENCE: All staff records were inspected and were found to be in order. All staff have CRB clearances or POVA checks, full reference checks and good evidence of induction. Interviews for new staff are well documented and included detailed testing on scenarios that included equality issues for service users. Three new staff have been recruited since the last inspection. Several staff have left the home in the recent past and the Registered Manager said it has been difficult to recruit new staff. Agency staff currently cover gaps and the home continues to actively recruit but there are some risks to continuity of care if the home experiences staff shortages. Staff training is good and well recorded. Staff have received up to date mandatory training and are working on or have achieved NVQ Level Two or Three. They have also received internal training on adult protection, areas of mental health practice, person centred planning, diabetes and epilepsy. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 17 Staff reported that they were well supported by the manager, who acted as a good mentor and coach to them. Staff said they received regular, constructive supervision. Supervision records examined backed this up. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users can be generally confident that their health and safety is promoted and that they are protected by the home’s policies and procedures. EVIDENCE: The home’s administrative systems are thorough, carefully planned and well managed. The Registered Manager has developed sound models to ensure that the home is well run and systematically managed. Fire safety records and policies were examined and were all in order. Regular fire drills take place but a requirement is given that one drill be held at night. The home has an evacuation plan and staff have received fire training. Incidents and accidents were correctly recorded. All food was safely stored and fridge and freezer temperatures checked daily. All certificates for gas, electrical installation and central heating were all checked and were in order. However, a portable appliance certificate is Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 19 required. Health and safety policies and procedures were appropriate for the home. New hazard assessments are in place and were being regularly used. The home holds meetings for service users, which are well documented and cover a broad range of issues. Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 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 3 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X x 2 X Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 21 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement The Registered Persons must ensure that a risk assessment is produced for service users’ who self medicate. The Registered Persons must ensure that a portable appliance testing certificate is obtained to ensure electrical safety in the home. The Registered Persons must ensure that at least one fire drill per year is held at night. Timescale for action 30/08/06 2. YA42 12(1) 30/08/06 3. YA42 23(4) 30/08/06 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 Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Tansi Lodge DS0000041232.V292060.R01.S.doc Version 5.1 Page 23 - 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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