Inspection on 02/09/05 for Tansi Lodge

This inspection was carried out on 2nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tansi Lodge 26/08/09

Tansi Lodge 10/10/07

Tansi Lodge 13/06/06

Tansi Lodge 20/05/05

Tansi Lodge 01/02/05

Tansi Lodge 09/08/04

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Townley Road, 2-3

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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 Unannounced 2 September 2005 @ 09.00 am 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 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 Stationary 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 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tansi Lodge Address 125 Audley Road, Hendon, London NW4 3EN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8922 0856 020 8922 0856 Dw Kaine Ikwueke Mary Kanyuchi PC Care Home only 4 beds Category(ies) of MD Mental Disorder registration, with number of places Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 May 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. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took five hours. The registered manager assisted and was present throughout the inspection and the registered provider visited for part of the time. Two service users were spoken with, one briefly, and the other in some depth through an interpreter and in rudimentary French. Two members of staff were spoken to in addition to the registered manager and registered provider. Care and staff records were inspected as well as medication records, general home records, and policies and procedures. 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. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Detailed information is provided for prospective service users, which enables them to make choices about where to live. EVIDENCE: A statement of purpose, which gives service users information about the home and the services, is provided. There is evidence of clear and detailed preadmission assessments by the placing authorities, the home and by community mental health teams. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 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: All care plans were inspected and found to have good evidence of the assessed and changing needs of service users. Care plans now have an additional column for review, as required at the previous inspection. Discussions with registered manager, staff and the service users provided sound information on how needs are assessed and care delivered to match those needs. Each care plan contained detailed information from social workers, mental health teams and other health workers. A care manager visiting the home on the day of the inspection said that Tansi Lodge provided good support for her client, who had come to the home after leaving a long stay in hospital. All service users have access to their own monies looked after by the home, meeting a requirement from the last inspection. The manager discussed the reasons why food cupboards are locked in the kitchen. She said that this was mainly because one service user often takes food and stores it in an Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 10 unhygienic manner in her room. The manager said that all service users do have immediate access through staff to food, by asking for the cupboards to be unlocked. Service users are fully supported to make choices and decisions in their lives. They are free to come and go as they please and manage all aspects of their daily lives, with support as required. This was evident on the inspection from the way in which each service user was spending their day. All service users have full and specific risk assessments. One new service user is on an extended trial period to assess whether the home can support him and manage the risks associated with providing his care. The registred manager described how they have recruited a volunteer through MIND to assist another service user who is mainly housebound, to try and develop capacity to go out of the house. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 16 and 17 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 have the food they like and are used to. EVIDENCE: Staff and the service users spoken to have active family links which the home supports them to maintain. Staff described the depth of service users’ contact with families and how they also work with them to maintain healthy and supportive contact. On the day of the inspection, one service user was out volunteering at a community-based event. This service user is busy with volunteering activities because she is unable to work while her asylum claim is being considered. The home is gradually being resourced for in-house activities. For example, Dr. Iweuke said he has purchased a pool table for the home. The service users generally cook their own food, which the home buys in. They all share a Sunday roast together weekly. Dr. Ikwueke described how he Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 12 purchases most food over the internet and has it delivered to the home. Specific African foods are purchased fresh from suppliers. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Heath and personal care and support are well organised in the service users’ interest. Medication policies and procedures are appropriate for the home and the issue of refusal of medication and consent is being fully explored. EVIDENCE: All the service users’ care plans were examined. These contained full details of personal care provided, which is minimal, mainly prompting and supporting. One service user spoken to at length said that the support received from the home is helpful and appropriate. Staff described how they worked as key workers with service users and were knowledgeable about their needs. Medication policies and procedures were in order. The issue of medication refusal by service users is still ongoing and being dealt with by the home and the multi-agency team. A hospital referral has been made to address the issue of consent by one service user. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 standard(s) 22 and 23 There is a clear complaints procedure available to the service users. Staff are well versed in adult protection procedures. A substantiated complaint concerning staffing which did place service users at risk has been resolved. EVIDENCE: Staff are undertaking POVA training and were able to describe how they ensure service user safety and how they would protect service users in alleged cases of abuse. As required at the last inspection, a complaints book is now available to record complaints, investigations and outcomes. A complaint regarding staffing was substantiated. The situation left service users vulnerable to unscreened individuals about whom the home had no formal background knowledge. This is now resolved. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 standard(s) 24 and 30 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. Minor repairs required at the last inspection have been done and the lighting in the kitchen brightened. The cleaning is done by staff, with service users responsible for cleaning their own rooms. It was very clean and hygienic on the day of the inspection and felt very airy and bright. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 33, 34, 35 and Service users can now be confident that the home has appropriately recruited and there are sufficient staff to meet their needs. These staff are well trained and well supported by the manager. EVIDENCE: A complaint concerning staffing matters received and investigated by CSCI was substantiated and resulted in enforcement action. Formal cautions were issued to both the Registered Manager and the Registered Provider. All staff records were checked on this inspection and were all in order. All staff have CRB clearances and POVA checks. Staff rotas were checked and there are now sufficient staff on duty for the needs of the service users. This meets a requirements from the previous inspection. Staff have received mandatory training and are working on or have achieved NVQ Level 2 or 3. Staff reported that they were well supported by the manager, who acted as a good mentor and coach to them. All staff said they received regular, constructive supervision. Supervision records examined backed this up. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 17 Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42, 43 Service users can be confident that their health and safety is promoted and protected by the home’s policies and procedures. EVIDENCE: Fire safety records and policies were examined and were all in order. Regular fire drills take place, an evacuation plan has been produced in response to a fire inspection in June 2005. Staff are receiving 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, PAT testing, water tank maintenance were all checked and were in order. Health and safety policies and procedures were appropriate for the home. A recommendation is restated that the internal finances of the home be examined and small amounts of money be available through a petty cash system, especially now that the home is operating at full capacity. The need Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 19 for this was noted at the previous inspection and the home is now busier than at that time, and the registered manager said that they would benefit from having some petty cash available. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tansi Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 2 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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 Regulation Requirement Timescale for action 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 43 Good Practice Recommendations It is recommended that the internal finances of the home be examined and small amounts of money be available through a petty cash system, especially now that the home is operating at full capacity. Tansi Lodge 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 20050902 Tansi Lodge X00023 UN Stage 4 S41232 V245260 G59.doc Version 1.40 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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