Inspection on 09/05/05 for Acacia Lodge

This inspection was carried out on 9th May 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 20/09/05

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 North Finchley London N12 9TB Lead Inspector Daniel Lim Announced 9 May 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Address 37-39 Torrington Park, North Finchley, London N12 9TB 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 8445 1244 020 8343 7459 Michael Pringsheim & Janet Bethuel Marie Conely PC Care Home 32 Category(ies) of OP registration, with number of places ACACIA LODGE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27 October 2004 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 in a quiet residential area of North Finchley close to shops, restaurants and transport links located along the Finchley Road. ACACIA LODGE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 9 May 2005 and took seven hours to complete. The inspector found that most of the National Minimum Standards had been met and the overall quality of care provided was satisfactory. During this inspection, the inspector was accompanied by the manager of the home (Marie Conely). The inspector was able to interview five residents. The feedback received from them was positive. A sample of six residents’ case records was examined and a community nurse was interviewed regarding the healthcare needs of residents. The premises including the bedrooms and gardens were inspected and maintenance records were examined. Staff on duty were interviewed on a range of topics associated with their work and a sample of four staff records were examined. In addition, the minutes of staff meetings and residents / relatives meeting were examined. What the service does well: The home was clean and well furnished. It was well maintained. The required records were available for inspection. These were up to date. Staff had been provided with essential training. This was confirmed in training records examined. Staff interviewed were knowledgeable regarding their responsibilities. There was evidence that they were closely supervised. This was confirmed in staff records examined. Arrangements were in place to ensure that the healthcare needs of service users are attended to. Records were kept of visits made by the GP and other healthcare professionals. Residents’ pressure area care had been attended to. Residents were satisfied with the food provided and said they liked the meals served. ACACIA LODGE Version 1.10 Page 6 Administrative and clerical support was provided for the manager and this was of a high standard. Staff reported that the manager was supportive and expressed confidence in her. What has improved since the last inspection? What they could do better: Risk assessment for those with diabetes must include instruction to staff on what to do in the event of a diabetic or insulin coma. The preferences and arrangements in the event of the death of a resident had not been documented. This is required to ensure that staff are fully informed. The plans of care of residents had not been signed by residents or their representatives. This is required as evidence that residents (or their representatives) have been consulted regarding plans of care. Please contact the provider for advice of actions taken in response to this ACACIA LODGE Version 1.10 Page 7 inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. ACACIA LODGE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection ACACIA LODGE Version 1.10 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 standard(s) 1-5 The standards examined were all met. The new manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs are met. Five residents who were interviewed spoke highly of staff and indicated that their care needs had been met. EVIDENCE: Five residents who were interviewed stated that their care needs had been met at the home and they were satisfied with the services provided. Completed questionnaires received from twelve residents and six relatives indicated that the respondents were satisfied with the care provided at the home and the needs of residents had been met. ACACIA LODGE Version 1.10 Page 10 A sample of six residents’ case records which were 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 Version 1.10 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 standard(s) 7-11 Residents interviewed informed that inspector that their healthcare needs had been attended to and they had been well treated. One of the standards (no. 7) was not fully met as some improvements are needed in care documentation (related to residents with diabetes) and there is a need to ensure that residents or their representatives are fully consulted and agree to the plans of care prepared for residents EVIDENCE: Feedback received from residents and relatives indicated that residents had been treated with respect and dignity. The sample of six case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were documented. Staff interviewed were knowledgeable regarding the care to be provided to residents. The plans of care of residents with diabetes did not contain instruction / guidance to staff on action to take when residents concerned had complications ACACIA LODGE Version 1.10 Page 12 (eg. Hypoglycaemia or hyperglycaemia). This is required to ensure that staff are aware of action to be taken. Some plans of care which were examined, had not been signed by residents or their representatives. This is required as evidence that they have been consulted. The medication administration charts examined had been appropriately signed. The temperature of the treatment room and medication fridge had been monitored daily and found to be satisfactory. Residents interviewed stated that they had been given their medication. The preferences and arrangements in the event of death had not been documented in the case records examined. This is required to ensure that staff are fully informed. ACACIA LODGE Version 1.10 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 standard(s) 12-15 The standards examined were all fully met. The daily life and routines of residents were on the whole, well organised and residents social and cultural needs had been met. The feedback received from residents indicated that they were satisfied with the activities provided and the meals served. EVIDENCE: The inspector saw the home’s programme of weekly social and therapeutic activities. Residents interviewed were generally happy with these activities. The kitchen and arrangements for the provision of meals were examined and found to be satisfactory. Service users who were interviewed stated that they were satisfied with the meals provided. Daily records of fridge and freezer temperatures had been documented. These were satisfactory. ACACIA LODGE Version 1.10 Page 14 Residents said they had been visited by their families. Residents had been encouraged to exercise choice in their lives and there was evidence that residents’ meetings had been held. The minutes of these meetings were available for inspection. ACACIA LODGE Version 1.10 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 standard(s) 16 - 18 The standards examined had been fully met. There was evidence that the rights of residents are protected and complaints are taken seriously. Systems were in place to ensure that residents are protected from abuse and ill treatment EVIDENCE: The staff records were examined. These contained evidence that staff had been provided with adult protection training. Staff who were interviewed knew how to respond to allegations of abuse made. The complaints book was examined and it was noted that complaints made had been promptly responded to. Residents interviewed stated that they were well treated by staff and no complaints were received from them. ACACIA LODGE Version 1.10 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 standard(s) 19 - 26 The standards examined had been fully met. The home was clean and well maintained. The washing and toilet facilities were adequate. Residents interviewed stated that they were happy with the accommodation provided. Bedrooms were comfortable and well furnished. EVIDENCE: The premises were inspected and found to be clean and hygienic. The required maintenance and safety certificates were seen by the inspector. These included safety inspection certificates for the portable appliances, electrical installations, lift, hoists and gas installations. ACACIA LODGE Version 1.10 Page 17 The hot water was tested and found to be within the required safe temperature range. Residents’ bedrooms were inspected and found to be well furnished. Residents interviewed stated that they were happy with the accommodation provided. The gardens were attractive and seating had been provided. ACACIA LODGE Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 The standards examined were fully met. Staff were recruited with care and the required recruitment procedures had been followed. Residents interviewed indicated that they were well treated by staff. Staff had been provided with essential training and were knowledgeable regarding their roles and responsibilities. EVIDENCE: The staff rota was examined. This confirmed that the agreed staffing levels had been maintained. The sample of four staff records examined contained the required documentation such as two references, satisfactory CRB disclosures, contracts and evidence of identity. Staff who were interviewed on a range of topics such as fire procedures, adult protection and response to accidents were knowledgeable regarding their roles and responsibilities. Training records examined indicated that the required training had been provided. ACACIA LODGE Version 1.10 Page 19 ACACIA LODGE Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-38 The standards examined had been fully met. Staff and all five residents interviewed were of the opinion that the home was well managed. Arrangements were in place to ensure the safety and welfare of residents and staff in the home. EVIDENCE: Maintenance records and safety inspection certificates were examined. These included safety certificates for the portable appliances, gas and electrical installations, hoists, lift and water tank maintenance). They were satisfactory. Fire records examined contained fire risk assessments, details of fire drills and weekly fire alarm checks carried out. ACACIA LODGE Version 1.10 Page 21 Staff records examined contained details of supervision sessions provided. The certificate of insurance was seen. This indicated that the home was appropriately insured. The minutes of monthly residents consultation meetings held were available for inspection and two residents were able to confirm that suggestions made by them had been listened to. The home had quality monitoring systems and the completed residents’ questionnaires were available for inspection. ACACIA LODGE Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 ACACIA LODGE Version 1.10 Page 23 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 7 Regulation 15(2) Requirement The registered person must provide evidence that residents (or their representatives) have been consulted regarding their plans of care. The registered person must consult with residents or their representatives regarding arrangements for residents in the event of death and this must be documented in the case records. The registered person must ensure that care staff are provided with guidance in the event of residents experiencing complications (such as hypoglycaemia or hyperglycaemia) as a result of their diabetes. Timescale for action 9/8/05 2. 11 12(1)(2) 15(1) 9/8/05 3. 7 12(1) 9/6/05 4. 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 Version 1.10 Page 24 1. ACACIA LODGE Version 1.10 Page 25 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 ACACIA LODGE Version 1.10 Page 26 - 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. 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