Inspection on 20/09/05 for Acacia Lodge

This inspection was carried out on 20th 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

Acacia Lodge 28/08/07

Acacia Lodge 09/05/05

Acacia Lodge 27/10/04

Acacia Lodge 13/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acacia Lodge 37-39 Torrington Park Finchley London N12 9TB Lead Inspector Daniel Lim Unannounced Inspection 26th September 2005 10:30 X10015.doc Version 1.40 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 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 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 Older People. 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. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Address 37-39 Torrington Park Finchley London N12 9TB 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) 020 8445 1244 020 8343 7459 Mr Michael David Pringsheim Mrs Janet Wairimu Bethuel Mrs Marie Conely Care Home 32 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (4) of places Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: ]Date of last inspection 9th May 2005 Brief Description of the Service: Acacia Lodge is a care home registered to provide care for a maximum of thirty two older people. It is owned by Mr Michael David Pringsheim and Mrs Janet Wairimu Bethuel who opened the home in 1971. The home’s stated aim is to stimulate and help maximise each resident’s physical, emotional and social capacity, so that they remain mentally and physically as active as possible, subject to any personal limitations, which will always be respected. The home is a detached three storey house with fourteen single bedrooms and nine shared bedrooms located across the three floors of the building. On the ground floor, there is a kitchen, laundry room, toilets, bathrooms, large lounge, dining room and bedrooms. On the first floor there is an office, small lounge, toilets, bathrooms and bedrooms.On the second floor there are toilets, bathrooms and bedrooms. A shaft lift is available from the ground to the first floor and a stair lift is provided from the first floor to the second floor. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is located in a quiet residential area of North Finchley close to shops, restaurants and transport links located along the Finchley High Road. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 26 September 2005 and took a total of 3 hours to complete. The inspector found that most of the National Minimum Standards had been met and the overall quality of care provided was good. During this inspection, the inspector was accompanied by the manager of the home (Marie Conely). The inspector was able to interview four residents. The feedback received from them indicated that they were satisfied with the care provided. Statutory records including four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home were examined. The premises including bedrooms, bathrooms, laundry, kitchen, gardens and communal areas were inspected. Staff on duty were interviewed on a range of topics associated with their work and staff training and supervision records were examined. In addition, the minutes of residents’ and staff meetings were examined. What the service does well: The care documentation examined was structured and up to date. The premises were clean and homely. The gardens were attractive. Residents had been consulted and their preferences regarding activities organised had been responded to. Residents were satisfied with the quality of meals served. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 6 Staff and residents expressed confidence in the way the home was managed. The manager had responded promptly to requirements made. The home was provided with efficient clerical support and information required was readily made available by the administrator. Staff were knowledgeable regarding their roles and responsibilities. What has improved since the last inspection? What they could do better: The registered person must ensure that the temperature of the medication fridge is maintained between 2 - 8 C. One complaint made by a resident had not been fully investigated. The registered person must ensure that this complaint is fully investigated. To improve fire safety, the registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. Please contact the provider for advice of actions taken in response to this Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs were met. EVIDENCE: Four residents who were interviewed stated that they were well cared for and staff treated them with respect. Comments made by them included, “enough staff on duty”, “staff are well mannered”, “staff treat us well” and “staff are responsive”. A sample of four residents’ case records which was examined contained comprehensive plans of care and details of how residents needs had been met. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 10 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Residents had been treated with respect and arrangements were in place to ensure that the healthcare, personal, cultural and social needs of residents were attended to. Improvement is however, needed in the storage of medication. EVIDENCE: Feedback from the four residents interviewed, indicated that residents’ healthcare needs had been met. Comments made included, “can see the doctor when I want to” and “my medication had been given promptly by staff”. The sample of four case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were documented. A record of weekly GP visits had been maintained. Staff interviewed were knowledgeable regarding the care to be provided to residents. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 12 The temperature of the room where medication was stored had been recorded daily and was satisfactory. The temperature of the fridge was however, on occasions above 8C. This must be kept at between 2 – 8C according to guidance provided by the CSCI pharmaceutical advisor. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 The daily life and routines of residents were well organised and met the cultural and social preferences of residents. Residents indicated that they were generally happy with the meals served. EVIDENCE: Residents interviewed were of the opinion that the home had activities which were appropriate. The home had a programme of weekly activities provided for residents. The manager informed the inspector that more activities were planned for residents. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The inspector noted from the records that residents who were assessed as able to were allowed to go out freely. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 14 The home had been inspected by the local environmental health officer in the previous month and requirements made for improving the kitchen facilities. had been responded to. The menu examined was varied and balanced. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 There was evidence that the rights of residents were protected and they had been well treated by staff. A requirement has however, been made for a recent complaint made by a resident to be fully investigated. EVIDENCE: The complaints record was examined. There was documented evidence that complaints recorded in the complaints book had been promptly responded to. Residents who were interviewed stated that they had been well treated. Comments made about staff included, “ staff are responsive”, “we are well treated”. The inspector noted that a complaint made by a resident during a recent review of care had not been fully investigated. This was discussed with the manager. A requirement is made in this report for the complaint to be fully investigated in accordance with the home’s complaints procedures and a report forwarded to the inspector. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The home was well equipped, clean and well furnished, therefore providing a nice environment to live in. EVIDENCE: The premises were inspected and found to be clean and well furnished. The hot water in bedrooms was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive and colourful and seating had been provided. The required maintenance records and safety certificates had been seen by the inspector (during the announced inspection carried out in May of this year). Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 17 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The recruitment process in place ensured that residents’ needs were met by an appropriate group of staff. EVIDENCE: Three staff who were on duty were interviewed on a range of topics associated with their work (such as health and safety, adult protection, fire procedures, care of residents with diabetes). They were noted to be knowledgeable regarding their roles and responsibilities. Residents who were interviewed stated that staff were respectful and responsive towards them. The agreed staffing levels had been maintained and staff and residents interviewed were of the opinion that this was adequate. There was evidence that staff had been provided with essential training required. This included food hygiene, health and safety and the care of residents with dementia. The staff records examined indicated that the required recruitment procedures (including obtaining satisfactory CRB disclosures) had been followed. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 19 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33, 36,38 Systems were in place to ensure that the rights and interests of residents were safeguarded. However, improvements are needed in the area of health and safety. EVIDENCE: When interviewed on a range of topics associated with the care of residents and staff management, the manager was found to be knowledgeable. Residents and staff interviewed expressed confidence in the manager and were of the opinion that the home was well managed. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 21 The fire logbook examined indicated that fire drills and weekly checks of the fire alarm had been carried out. Fire training had been arranged for staff. When questioned, staff were knowledgeable regarding the fire procedures. Fire doors had been kept closed. The inspector however, noted that no fire drills had been organised after dark (dusk). This is required to ensure that staff are fully aware of the required procedure to follow. The home had a comprehensive record of weekly health and safety checks. Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 X 2 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 9 Regulation 13(2) Requirement The registered person must ensure that the temperature of the medication fridge is maintained between 2 - 8 C The registered person must ensure that complaints made are fully investigated. The registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. Timescale for action 30/10/05 2 3 16 38 22(3) 23(4) 13/11/05 01/12/05 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 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 24 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 Acacia Lodge DS0000010392.V249568.R01.S.doc Version 5.0 Page 25 - 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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