Inspection on 20/05/05 for Tansi Lodge

This inspection was carried out on 20th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/09/05

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 Duncan Paterson Tom McKervey Unannounced 20 May 2005 at 09.12am 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 G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 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 8056 020 8922 8056 Dr Kaine Ikwueke Mary Kanyuchi PC Care Home only 4 Category(ies) of MD Mental Disorder registration, with number of places TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 February 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 Ms Mary Kanyuchi. Tansi Lodge is in a pleasant residential area of Hendon close to shopping and transport facilities. There are bedrooms for residents 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. There is a staff office on the first floor and a sleep-in bedroom for staff on the second floor. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took four hours. The registered manager, Ms Mary Kanyuchi, assisted and was present throughout. The two residents were spoken with, one with the assistance of an interpreter. One member of staff was spoken with in addition to the manager. Care and staff records were inspected as well as medication records, policies and procedures. There was a tour of the building. The home aims to provide the highest quality of care within homely surroundings. What the service does well: What has improved since the last inspection? What they could do better: The way the home is run and managed must be more open. An anonymous complaint about staffing matters had been received by the CSCI. The inspectors investigated the complaint during the inspection. The complaint was substantiated and uncovered the fact that the owner and manager had employed a member of staff without any appropriate checks having been made. This matter was concealed for a number of months from the CSCI. The manager at first denied the complaint but after the inspection the owner admitted it. As a result the owner has voluntarily agreed to cease admissions of new residents. CSCI will assess progress and will agree to new admissions of residents when there are more robust staffing arrangements in place. The owner has started the process by appointing two agency care staff. CSCI is taking legal advice about the matter. Legal enforcement action is being considered. Requirements are made about ensuring that there are sufficient staff working at the home for the needs of residents and for ensuring that the TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 6 proper recruitment checks, including Criminal Record Bureau checks, are carried out on staff. Other matters that could be better include the need to have a complaints record book or file in which to record complaints, the need to carry out minor repairs and to have a sanitary pad bin. Requirements are given about these matters. A recommendation is given for brighter lighting to be provided in the kitchen. 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 G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 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 G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 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) 1, 2, 3, & 4 The detailed information provided for new residents is detailed, and enables them to make an informed choice about where to live. EVIDENCE: There is a statement of purpose which provides residents with information about the home and the services provided. One of the residents spoken with said that she had visited before moving into the home. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 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, 9 & 10 There are detailed care plans for residents which set out clearly the needs of residents and the work being carried out to meet those needs. EVIDENCE: Both residents were spoken with, one with the assistance of an interpreter. Both resident’s care plans were inspected and discussions were held with the manager and one staff member about the care provided for residents. The care plans are detailed and provide a good range of information about resident’s needs as well as the ways staff work with them. Each care plan contained information from other professionals such as social workers and health care workers. It is recommended that care plans have an extra column in which staff can record, date and sign when they have reviewed the care plan objectives. Residents, on the whole, said that they were happy at the home, found the manager helpful and got on well with staff. One resident said that she felt safe at the home and that she was treated with respect. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 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 standard(s) 13, 15 & 17 The manager and staff have organised the home so that residents are enabled to take part in the community, maintain contact with families and to have food which they like and are used to. EVIDENCE: Residents said that they had family links and that they met with family members on a regular basis. One resident was planning a trip to the cinema the next day. Residents are part of the community using local facilities such as shops and local services. One resident said that she liked the food. That there was a lot of choice and that she did her own cooking. There was food available for residents which they liked and they were used to. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 11 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 & 20 Health and personal care provision is well organised with good relations between staff and residents. EVIDENCE: Care plans set out clearly the need for personal care and how it is provided. There is only a small amount of personal care provided with staff generally supervising and prompting. Care plans detailed the preventative health care services provided to residents. Residents said that staff assisted them well and were approachable and helpful. The medication records and storage arrangements were clear and well organised. None of the residents self-administer their own medicines. There is a current issue with refusal of medicines which is being addressed by the home and by the multi-agency team. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 12 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 There is a clear complaints procedure available for residents. EVIDENCE: The manager reported that one complaint, which had not been resolved at the time of the last inspection has now been concluded. The complaint concerned a staffing matter and the issue had been withdrawn at the second stage. There is no complaints book or means to record complaints that may be made. A suitable book or file must be held at the home to record complaints, their investigation and outcome. A requirement is given to ensure that such a record is held at the home. An anonymous complaint had been received by the CSCI concerning staffing arrangements at the home. This has been investigated and the complaint has been substantiated. More detail is provided below in the staffing section of the report. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 13 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, 25, 26, 27 28, 29 & 30 Residents live in a well maintained, clean 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. One resident said that she liked the home because it was, “clean and tidy”. The home is well maintained. A requirement is given for repairs to be made to a door lock and a chest of drawers. A recommendation is given for the lighting in the kitchen to be brighter. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 14 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) 31, 32, 33, 34 & 36 There is a lack of transparency about staffing matters as well as poor recruitment practices. EVIDENCE: The staffing arrangements are not clear. An anonymous complaint had been received by the CSCI concerning staffing arrangements at the home. The inspectors investigated this and the complaint was found to be substantiated. A person had been working at the home for a number of months without any appropriate recruitment checks having been obtained. This was concealed from the CSCI on more than one occasion. It was also concealed through the home’s records. For example, the staffing rota did not state the name of this worker other than to describe the person as a “care assistant”. The presence of this worker at the home was first denied by the manager and then admitted to by the owner of the home. In addition, one member of staff was working at the home without a Criminal Record Bureau (CRB) check having been obtained. One other member of staff and a newly appointed member of staff also did not have CRB checks. The manager and owner said that there was a gardener who also did not have a CRB check. This affects the service’s ability to run effectively to meet the needs of residents. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 15 Following the inspection a meeting was held with the owner. The owner voluntarily agreed to admit no further residents to the home until the staffing situation was resolved. An amended staffing rota has been provided to the CSCI. Legal advice is being taken by CSCI and enforcement action is being considered. The requirement given at the last inspection, to ensure that staff have CRB checks, has not been complied with. It is re-stated in this report with an amended timescale. The gardener must also have a CRB check. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 16 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) 37, 38, 40, 42 & 43 The management of the home has not been open and transparent, and therefore, service users cannot be confident that this is a well run home. EVIDENCE: The investigation of the anonymous complaint has revealed that the management of the home has not been running transparently. The staffing arrangements have not been open, recruitment practices have been lax and decisions about the running of the home have placed residents and their welfare second. The owner has admitted that the recruitment procedures were wrong and has assisted by voluntarily ceased admissions to the home thereby allowing time to set up a robust staffing structure. Agency staff have now been appointed. A requirement is given to have a sanitary pad bin available at the home. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 17 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 2 2 x 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 3 3 x 3 x 2 3 G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 18 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 22 Regulation 17 (20) Schedule 4 para. 11 Requirement The registered persons must ensure that there is a record book or file that can be used to record complaints, complaints investigations and their outcome. The registered persons must ensure that the following repairs are carried out. a) repair door lock in first floor bedroom b) repair chest of drawers in first floor bedroom The registered persons must ensure that, at all times, there are sufficient staff on duty to meet the needs of residents. The registered persons must ensure that all staff have Criminal Record Bureau certificates including checks aganst the Protection of Vulnerable Adults (POVA) list for new staff. The previous timescale of 01 February 2005 has not been met. This requirement is repeated with a new timescale. The registered persons must ensure that a sanitary towel bin is provided. Timescale for action 15 June 2005 2. 24 23 (2) (b) 01 July 2005 3. 33 18 (1) (a) 20 May 2005 20 May 2005 4. 34 19 (1) (b) (i) Schedule 2 5. 42 13(4) c 01 July 2005 TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 19 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. 2. Refer to Standard 6 24 Good Practice Recommendations The registered persons should consider adding an extra column to care plans for staff to sign and date when they have reviewed the care plan objectives. The registered persons should consider providing brighter lighting in the kitchen. TANSI LODGE G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 20 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 G59 S41232 Tansi Lodge V225969 20.05.05 Stage 4.doc Version 1.30 Page 21 - 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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