Care Home: Tansi Lodge

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What the care home does well The home is located in a quiet residential area but within walking distance of local amenities such as shops, post office, banks, a public library and a London underground station. Also the size of the home is small which means that the needs of each resident can be monitored and met. The residents are engaged with a range of activities planned and provided for them by the staff. What has improved since the last inspection? Significant improvements have been made since the last inspection. For example, the home has provided locked cabinets where medicines are stored. We were also able to see that medicines are administered and recorded as prescribed by doctors. We were satisfied to note that staff have had training on how to administer medication. At the last inspection we asked the owner of the home to ensure that care plans and risk assessments are regularly updated. The home has now updated care plans and risk assessments. The home is also organising annual review meetings for the residents by inviting all relevant people such as social workers and the residents` families. What the care home could do better: The sofas are worn out and are not safe for sitting on. The owner said he would replace them without delay. The process of providing or buying food items for the home needs improvement. We encourage the owner to put an easy and transparent system which allows necessary food items to be available all the time. The acting manager needs to apply to the Care Quality Commission in order to be registered as a manager. The owner needs to do more to improve the quality assurance system in order to involve the residents and their representatives to share their views about the quality of the services. It is important that the views of the people who use the service are actively sought and used to improve the services. Key inspection report Care homes for adults (18-65 years) Name: Address: Tansi Lodge 125 Audley Road Hendon London NW4 3EN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Teferi Degeneh     Date: 0 7 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 22 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 22 Information about the care home Name of care home: Address: Tansi Lodge 125 Audley Road Hendon London NW4 3EN 02089220856 02089220856 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Dr Kaine Ikwueke Name of registered manager (if applicable) Type of registration: Number of places registered: care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home 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. Currently there is no registered manager. 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 Care Homes for Adults (18-65 years) Page 4 of 22 2 6 0 8 2 0 0 9 4 Over 65 0 Brief description of the care home from £750-£1000. Care Homes for Adults (18-65 years) Page 5 of 22 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The home had not been informed in advance that we were visiting. We arrived at the home at 9:00 am and left approximately after 1:30 pm. The new acting manager was present throughout the inspection. The owner of the home, Dr Kaine Ikwueke, came to the home half way through and stayed up to the end of the inspection. As part of this inspection we had received a self assessment form known as the annual quality assurance assessment (AQAA) from the home. An AQAA is a form which we request from care homes every year to complete and send back to us. It gives care homes an opportunity to tell us how they are planning to improve the service. The AQAA we received from the home was clear and gave us all the information that we asked for. During the inspection we examined residents files, the homes policies and procedures, and we observed and talked to a resident and the staff. We also used all the other information we have about the home and the last inspection report as part of this inspection and our judgement of the quality of the service. Care Homes for Adults (18-65 years) Page 6 of 22 Care Homes for Adults (18-65 years) Page 7 of 22 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 22 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 22 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are confident that the home admits them only if it has the facilities and services that can meet their needs. Evidence: The home has not admitted a new resident since the last inspection. From a discussion with the person in charge and an examination of two residents files it was clear that new residents are assessed before admission. The AQAA, which we received from the home, confirms that new residents have full information about the home to help them decide their needs are met by the home. The AQAA reads: We carry out the needs and assessments prior to accepting applicants. We match their assessed needs to our resources to ensure we can meet their needs. Hence, we draw up person centred care plans. We present the service user with our service user guide and make the latest CSCI [Commission for Care Inspection] report available to view. Give the prospective service user the opportunity to stay on trial basis. A resident we spoke to said they had visited the home before coming in to live permanently. Care Homes for Adults (18-65 years) Page 10 of 22 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The are good systems of care planning and risk assessments. These have enabled the residents to receive care that meets their needs. Evidence: It was evident from the two residents files that care plans and risk assessment have been reviewed. The acting manager said reviewing and updating care plans and risk assessments was one of her important tasks at the home. She said she was in the process of organising full review meetings by inviting residents families, social workers and the residents. She said each resident has a key worker who discusses ongoing care issues with them and supports them to access services within and outside the home. A resident we spoke to said they are happy living at the home. They said they regularly go out with the staff to shops, a library and for walks in the park. The AQAA confirms that the home develops person-centred care plans for the service users. Care Homes for Adults (18-65 years) Page 11 of 22 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents can be sure that there are good arrangements for them to be engaged as well as to choose meals that meet their needs. Evidence: The resident we spoke to confirmed that they are happy at the home and that they are supported to go out to different places including shops, parks or the library. They said they also use the garden. The acting manager said one of the residents travels independently. From a conversation with a resident we understand that the home encourages and supports a resident to visit their family. The AQAA states that the home supports the residents to gain confidence by helping them attend education and training. The resident we talked to said they have the front door and their bedroom keys and they can go to or get up from bed at a time of their choice. They said they watch Care Homes for Adults (18-65 years) Page 12 of 22 Evidence: television in the lounge. We noticed that the sofas in the lounge were not comfortable to sit on and raised this with the owner of the home. Please see below for more of our conversation with the owner about this. The menu was available for inspection. The person in charge said each resident chooses what they want to eat on a daily basis and do not stick to the menu. The resident we spoke to confirmed this and said they are happy with the meals. They explained what they normally have for breakfast, lunch and supper. They said they are vegetarian and the home meets their needs. When we checked the kitchen there was not much food items or milk in the fridge. The person in charge explained the reason for this by saying that it was the day for the delivery of food items. The owner of the home confirmed this when he arrived. We raised this area as being of a concern in the past at the home but the owner said things have now improved and the acting manager liaises with him trough email and telephone if food items are running low. He said that he will open a separate bank account for petty cash so that the acting manager is able to withdraw and do food shopping as needed. Care Homes for Adults (18-65 years) Page 13 of 22 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents have benefited from improved systems of the storage and administration of medication. Evidence: At the last inspection we asked the owner of the home to make improvements around storage of medication, staff training, and administration and recording of medication. An examination of the staff files and conversation with the staff indicated that the staff who administer medication have had training. The owner has also provided locked cabinets for storage of medication on the ground and first floors. We checked the medication administration record sheets (MARS) and found that they were all in order. All the residents are registered with their own general practitioners. The person in charge confirmed that the residents have regular medical checks including, eye and dental checks. The AQAA confirms that the residents privacy and dignity are respected and each person who uses the service has a person centred care planning. The resident we talked to said the staff treat them well and they are satisfied with the service they receive. Care Homes for Adults (18-65 years) Page 14 of 22 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are confident that there is someone at the home to listen to their concerns and resolve for them. Evidence: The resident we talked to said they know how to make a complaint if they have a concern. They said the staff and the person in charge are approachable if they have any issues. The AQAA states that all complaints and incidents are recorded and the home tries to resolve them within 20 to 28 days. It also says that the home listens to the residents. We checked the complaints book but found out that no complaints have been recorded since the last inspection. There is a policy on complaints. There is also a policy on safeguarding. A copy of the local authoritys policy on the protection of adults from abuse was also available. The person in charge confirmed that the home takes all safeguarding issues seriously and reports them to the local authority. Care Homes for Adults (18-65 years) Page 15 of 22 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Even though the location and cleanliness of the home are good, the residents can be more satisfied when the old sofas are replaced with new ones. Evidence: We have mentioned above that the sofas were not comfortable and needed replacement. The owner said he was aware that they were worn out and needed replacing. He said he would involve the residents in the choice of the type of the sofas to be bought and ensure that this is done without a delay. Apart from the sofas all parts of the home were clean, tidy and free from bad smell. All the residents have keys for their bedrooms and the front door. Also we said above that the resident we spoke to liked the home. The home is located in a quite residential area within walking distance from Hendon Central underground and local shopping facilities. Care Homes for Adults (18-65 years) Page 16 of 22 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are confident that they are supported by staff who are properly vetted, experienced and trained to meet their needs. Evidence: The AQAA explains that new staff are employed only after a satisfactory criminal record bureau (CRB) certificates and two written references are obtained. It also says that full induction programme is available and there is a probationary period before staff become permanent. We were able to see evidence of application forms, terms and conditions of employment, CRB certificates and written references in three staff files we checked. The owner of the home said staff had recently attended training in handling and administration of medication, customer care and communication. Observations and discussions with a member of staff indicated that they are experienced and knowledgeable about their work. A resident we talked to said they are happy with the care and support they receive from the staff. Care Homes for Adults (18-65 years) Page 17 of 22 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed well; however, the residents remain concerned that there is no registered manager who they can be confident of to continue to improve quality of the services and facilities. Evidence: The previous acting manager had applied to the CQC for registration but had left before being registered as the manager of the home. A new acting manager has been recruited and is now managing the home. The acting manager had previously worked at the home and had completed a national vocational qualification (NVQ) level 3.She said she currently undertaking training to achieve a care management qualification and NVQ level 4. She is in the process of making an application to the CQC to be the registered manager of the home. At the last inspection we asked the owner to seek the views of the residents and other stakeholders about the quality of the service and facilities. The owner said he had prepared distributed questionnaires to the residents for their feedback. He said staff also ask the residents how they feel about the service on a regular basis. During the Care Homes for Adults (18-65 years) Page 18 of 22 Evidence: inspection we were not able to see written evidence of a quality assurance system. However, the owner of the home said he would forward to us a summary of the outcome of the homes quality assurance. A copy of this has not reached us. we recommend that the quality assurance is fully implemented and made available for inspection. The acting manager confirmed that fire alarms and emergency lights are tested and recorded weekly. Records showed this to be the case. The owner said the gas boiler was installed only five months ago and was not due for servicing. We said above that the home was clean and tidy with no bad smells. We also mentioned that the owner was about to replace the sofas in the lounge. Care Homes for Adults (18-65 years) Page 19 of 22 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 20 of 22 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 17 An easy and transparent system should be put in place in order to allow the home to make the necessary food items available at the home at all times. The sofas should be replaced. This will ensure the health and safety of the residents and make the home more comfortable to live in. The outcome of the quality assurance system should be shared with the residents and their relatives. It should also be used to improve the quality of the services. 2 24 3 39 Care Homes for Adults (18-65 years) Page 21 of 22 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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