Inspection on 21/04/08 for Heathgrove Lodge Nursing Home

This inspection was carried out on 21st April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heathgrove Lodge Nursing Home 15/04/09

Heathgrove Lodge Nursing Home 07/06/07

Heathgrove Lodge Nursing Home 07/11/05

Heathgrove Lodge Nursing Home 23/06/05

Heathgrove Lodge Nursing Home 17/01/05

Heathgrove Lodge Nursing Home 06/09/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heathgrove Lodge Nursing Home 837 Finchley Road Golders Green London NW11 8NA Lead Inspector Ffion Simmons Key Unannounced Inspection 08:45 21st April 2008 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 Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 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. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathgrove Lodge Nursing Home Address 837 Finchley Road Golders Green London NW11 8NA 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 8458 3545 020 8209 1650 askewt@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd vacant post Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2007 Brief Description of the Service: Heathgrove Lodge is a purpose built home owned and operated by British United Provident Association (BUPA), which aims to provide care with nursing for up to thirty-six people aged over sixty-five years of age. Accommodation for service users is arranged over four floors. All bedrooms are provided with en-suite facilities. A passenger lift provides access to all floors. To the ground floor is a dining area and a lounge on each floor of the home. To the front of the home is off street parking for several vehicles. To the rear is a large wellkept garden with an attractive pond in the middle. The aim of the home, as stated in the statement of purpose, is to ensure that individual needs are carefully identified, regularly reviewed and handled with professionalism and dignity. The home provides care under the supervision of registered level one nursing staff, with a GP visiting once a week or when requested. Additional medical support such as psychiatric consultancy, physiotherapy and chiropody can be accessed via GP referral and services such as opticians and dentistry are provided as required. A hairdresser visits the home on a weekly basis. The home employs an activities co-ordinator who organises social activities to residents such as bingo, a musician, quizzes, flower arrangement and outdoor visits to the pub and theatre. The home is situated on the busy Finchley Road near to Golders Green underground station and Golders Green bus terminus. There are also local shops, pubs, restaurants and a park within a short walk of the home. The fees charged at the home range between £950and £1200. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The unannounced key inspection took place between 08:45 and 17:30 on the 21st April 2008. During the inspection, we spoke with residents and observed care practices. We tracked the care of three residents, and in doing so we checked their personal records. We met the home’s Manager and a Manager from another BUPA home and spent time with staff. A number of records and documentation was checked during the inspection, including medication administration records, staff files, health and safety documentation, the home’s complaint records and quality assurance documentation. Questionnaires were sent to residents, relatives/carers and advocates, professionals and staff to comment on the service. We had a 15 return rate, which consisted of two questionnaires from staff and residents and five questionnaires from relatives/carers and advocates. We have used the information within these questionnaires to contribute to the content of the report. The designated Manager took time to complete and return the Annual Quality Assurance Assessment (AQAA), and has been used as evidence to inform this report. What the service does well: Accurate and personalised assessments are undertaken prior to a resident moving into the home to make sure that the home understand the residents’ needs. Care plans are comprehensive, clearly outlining residents’ needs which makes sure staff are aware of how best to support the residents. People at the home benefit from social activity co-ordinators who organise many different activities. Residents are offered wholesome, varied and appealing meals, which meet their individual needs and preferences. The Manager and staff are welcoming and helpful. Residents commented positively on the support they receive from the staff team and one resident said “staff are fantastic, I am happy here and they look after me well”. Residents live in a clean and well-maintained home, which is homely, and comfortable which impacts positively on the well-being of the residents living in the home. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 7 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 Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Standard 6 is not applicable. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home ensures that accurate and personalised assessments are undertaken prior to a resident moving into the home. This ensures that the home understand the residents’ needs and are confident that they can meet their assessed needs. EVIDENCE: During the inspection we checked the files of three residents. Each resident had a full needs assessment on their file, which was comprehensive and person centred. This enables the home to build a picture of their needs including their cultural and personal beliefs. Where residents had been referred by the local authority, a full and comprehensive assessment of their needs and a care plan were available on their files. The home does not offer intermediate care. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place, clearly outlining residents’ needs and how staff can best support residents to meet their needs and support them to live the life they choose. These plans need to be kept updated to respond to resident’s changing healthcare needs. Risk assessments are used to identify risk and to promote the health and safety of residents. Improvements are needed in the management of medication in the home so that residents are fully protected in this area. EVIDENCE: During the inspection we viewed the personal care records of three residents. As previously discussed, residents’ needs are well assessed prior to their admission and also on admission to the home. Comprehensive care plans were in place, which were based on the needs identified during the needs assessment and risk assessments. The care plans are generally updated on a monthly basis or when there is a change in their needs. We noticed however that the plan of care for a recently admitted resident who had a pressure sore, had not been updated since admission, and that there was no documentation Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 10 to indicate that the wound had been assessed, although staff told us that the wound is healing. The home promotes the health and safety of residents through the use of risk assessments including manual handling risk assessments, falls risk assessments, Waterlow assessments (for assessing the risk of developing pressure sores) and a tool for assessing malnutrition. Information within the Annual Quality Assurance Assessment (AQAA) completed by the Manager informed us that, “every resident is registered with a General Practitioner of their choice (within the constraints of access to G.P.’s).” The homes’ management of medication was assessed during the inspection. We found that the medication was securely stored. Staff record the temperature of the store room and the fridges where medication is stored. We noticed that there were occasions where the temperature of the store room exceed 25 degrees Celsius. Staff must make sure that when this is noted, that remedial action is taken and documented to make sure that temperatures do not exceed 25 degrees. This is important as this can have an effect on the medication. The balance of the controlled drugs in use were checked and were correct. The home has a Controlled Drugs register, and staff told us that they check the balances at handover of shifts from night staff to day staff. It became evident during the inspection that staff were unaware of the new arrangements for the safe disposal of controlled drugs. The need to ensure that the correct arrangements are followed was discussed with a nurse and the Managers present during the inspection. The home’s medication policy was available, but we noticed that this was last reviewed in the year 2000. Steps must be taken to ensure that BUPA’s most up-to-date policy (which according to the AQAA has been recently updated) is available for staff reference. The medication administration records (MAR) were checked, generally these were well completed but we did note some gaps in recording. The recording must be improved. We noted that the drug Warfarin was being administered at the home. We noticed that the most recent blood result was available and placed with a copy of the MAR sheet. Guidance notes for staff in the safe administration of Warfarin was also available with the MAR chart. These are examples of good practice. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a range of activities, which are appropriate to their age and culture. They are able to keep in touch with their family and friends and the local community. Residents’ cultural and religious needs are met. Residents are offered wholesome, varied and appealing meals, which meet their individual needs and preferences. EVIDENCE: The home has a structured programme of activities, which was on display in various parts of the home. The activities on offer for the week included chair exercise, bingo, shopping, cards, dominos and jigsaw. There were plans in place for celebrating St George’s day during the week, with an invite extended to relatives and friends to join in the celebrations. The activity co-ordinator is in the process of involving residents in an audit of the activities on offer in the home. The aim of the audit is to gain feedback on the current programme of activities and to introduce new activities based on residents’ preferences. The home operates on open visiting policy. Residents spoken with confirmed that staff welcome their friends and relatives into the home and that they can visit any time. One of the residents told us that they are able to keep in touch with friends and family by using the telephone in their room. Each resident Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 12 has a record on their file illustrating a map of their life including life events and people who play a significant part in their lives. This provides staff with good background information and gives a good picture of the residents’ history. Religious and cultural needs of people living at the home are assessed prior to admission and form part of their care plans. We checked the menus during the inspection and saw that the home offers a good level of choice and variety of food. There are always two choices at main meals plus a range of alternatives should the choice of food on offer that day not appeal to people. The home caters for special diets including vegetarian, diabetic and pureed meals. People spoken with were complimentary about the food and the quantity they received and the following comments were received “the food is just the best for residents as they have the option to choose what they want to eat.” and “there is usually plenty of food for residents at mealtimes.” The Manager confirmed that they would be able to meet residents’ individual cultural needs. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, accessible to its residents. Complaints from individuals are not always fully recorded with action taken to investigate these not always clear. Policies and procedures for safeguarding people who use the service are in place but some staff are not familiar with the guidance. More training of staff needs to be carried out to ensure people living at the home benefit from a good level of protection. EVIDENCE: The home has a complaints policy, which was seen on display and available in a leaflet form for residents and their representatives to refer to. The leaflet explains the three stages and attaches a form to complete if they wish to make a complaint. The home’s policy outlines that they would aim to respond fully to the complaint within three weeks of receipt. Residents are encouraged to raise issues at the residents’ meetings. One of the residents commented “I am happy here, they look after me very well, if I didn’t like it here, I wouldn’t be here”. They confirmed they had no cause for concerns or to complain but would feel able to tell staff if they were not happy with the care provided. We saw that the home had copies of the local multi-agency policy for the protection of vulnerable adults. During the inspection whilst checking the complaints records, we came across an example where an allegation was made but the protection policies had not been followed. It was not possible through checking the complaint records and other records in the home, to establish what action had been taken to investigate the allegation. Further information Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 14 gained through investigation by the current home manager suggests that the incident was dealt with internally. The Commission and the local authority were not alerted to this allegation at the time of the incident, which is in breach of the agreed local multi-agency procedures for the protection of vulnerable adults. The training matrix also showed some gaps in the training given to staff in the Protection of vulnerable adults. Staff must receive further training to make sure that where allegations of abuse are made, that they follow the correct procedures to ensure residents receive a good level of protection. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and well-maintained home, which is homely, and comfortable. The home is accessible to wheelchair users, but the accessibility and availability of specialist equipment needs to be reviewed to ensure residents have a choice when attending to their personal care. EVIDENCE: Heathgrove Lodge is a purpose built home situated on the Finchley Road near to Golders Green underground station and Golders Green bus terminus. There are also local shops, pubs, restaurants and a park within a short walk of the home. We toured the building to find that the home is well maintained and in good decorative order. All parts of the home, including the outside spaces is accessible to wheelchair users. A passenger lift provides access to all floors. During the tour of the building we noticed that the home’s communal bathrooms are fitted with showers only. One room previously used as a Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 16 communal bathroom has an assisted bath in it, but this room is not available for residents as it is used as a staff changing area. We were told that only one of the residents has an assisted bath in their en-suite area. It is recommended that the Manager reviews the location of the staff changing room and considers giving residents access to this room so that they can be offered a bath instead of a shower if they so wish. A relative/visitor also suggested “given the amount of lifting in the home, residents and staff would benefit by there being more electric profiling beds”. Staff confirmed that vacant rooms are decorated prior to new residents moving in and that they are encouraged to bring their own personal possessions with them. The premises were clean and free from any offensive odours. Sluice facilities appear on each floor. The home’s laundry room is situated on the lower ground level. We noticed when we were touring the building that the fire door in the laundry was obstructed. Staff were asked to remove this obstruction to ensure that in the event of a fire, the door would close. Feedback was good about the level of cleanliness in the home and the following comment was made “the home is always kept clean and tidy”. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels are considered sufficient for meeting the basic needs of residents. There are identified gaps in staff training, which must be addressed so that residents’ individual needs are understood and fully met. Residents are generally protected by the home’s recruitment procedures. EVIDENCE: It was confirmed during the inspection that there is always a minimum of two nurses and five care staff on morning shifts. This reduces to four care staff on afternoon shifts. At night there is one nurse and three care staff on duty. There are separate kitchen, cleaning, activities and administrative staff employed. The staff were very helpful during the inspection and were able to tell us about residents’ individual needs. We checked the personal files of four members of staff. There was evidence that applicants are required to complete an application form and to attend a face-to-face interview. Two professional references had been obtained and there was evidence that an enhanced criminal records bureau (CRB) check and check against the protection of vulnerable adults list had been undertaken. Staff who provided feedback on the service also confirmed that the employer carried out checks such as CRB and references before they started work. The Manager must make sure that the relevant documentation is in place as evidence that staff have the right to work in the Country. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 18 Forty eight per cent of the staff team has the National Vocational Qualification (NVQ) level 2 in care, with a further fourteen percent of the staff team working towards this qualification. The home’s induction training booklet was shown to us during the day of the inspection. Staff who provided feedback felt that the induction covered mostly what they needed to know to do the job. There is a training matrix specific for the home and this was checked during the inspection. At the home’s last key inspection in June 2007, we identified training gaps for individual staff in core areas such as manual handling, protection of vulnerable adults and food hygiene and a requirement was made to address these gaps. We found similar issues during this inspection also, and so this requirement is repeated in this report. The home provides care to people with dementia and people who are not able to communicate verbally. A resident commented that its “sometimes difficult to communicate needs to staff”. In order to meet their individual needs, staff should attend training to support them to meet these needs. We discussed training needs with the Manager who was aware of the gaps in the training and has plans to address these gaps. The Manager also aims through supervision to look at staff personal development needs and specific interests and aims to facilitate training in these areas. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has good quality assurance systems in place, which include residents. Some staff need to undergo training in various areas of safe working practices to fully be able to promote and protect the health and safety of people have in the home. There have been gaps in the supervision of staff working in the home, which could be impacting negatively on the quality of care to residents. EVIDENCE: During the inspection we welcomed the opportunity to meet the home’s new Manager. He had been in post for only two weeks. The previous home Manager resigned in December 2007 resulting in a five month gap between the Home Manager leaving and new Manager being in post. During the inspection, a Manager from another BUPA home supported the Manager. Both Managers Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 20 were very helpful throughout the inspection and we had open and constructive dialogue about the standards of care in the home. The Manager showed us his induction programme, which was seen to be very comprehensive. The need for the Manager to apply to the Commission’s Regional Registration team to register as the Registered Manager was discussed. Since the last key inspection in June 2007, we have noticed improvements in the home’s systems for assuring the quality of the service. The Manager shared with us the results of the annual residents’ satisfaction survey that was conducted in 2007. During the inspection, a home Manager from another BUPA home was visiting the home to carry out a monthly audit of the service. This report was also shared with us, and we could see that a clear action plan had been set following this audit. The Manager told us that a full audit of the service is due to take place in May 2008 by the Quality and Compliance Team. Monthly pressure sore audits, medication audits and complaints audits are undertaken and the summary sent to the Quality and Compliance Team. Information within the Annual Quality Assurance Assessment (AQAA) completed by the Manager informed us that “meetings are held with residents and relatives on a regular basis. These meetings provide an open forum where problems can be discussed and resolved where possible.” The Manager also told us that he is proposing to increase the frequency of these meetings to monthly, offering an evening and weekend meeting every other month. The home has a policy for the management of residents’ money, valuable and financial affairs. We observed that residents had a lockable drawer in their rooms to keep their valuables. The AQAA indicated that residents may handle their own finances should they wish to. At our previous inspections, we made a requirement that the registered persons must make sure that all staff receive regular formal supervision at least six times a year and the information is recorded. The files of four members of staff were checked during the inspection. We could not see evidence that staff are receiving supervision. The Manager has identified the lack of staff supervision as an area for improvement and we were told that it will be given a high priority. This requirement is now repeated for the second time. The Manager confirmed and showed us records as evidence that regular health and safety meetings take place to discuss any issues. Health and safety records were checked during the inspection and were seen to be up-to-date. We noticed when we were touring the building that the fire door in the laundry was obstructed. Staff were asked to remove this obstruction. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 21 We saw that some of the staff had not received training in safe working practices, which must be arranged. Staff must also be briefed on the importance of using the appropriate protective clothing when handling food. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 1 X 2 Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 14 (2) Timescale for action Steps must be taken to ensure 01/06/08 that care plans are kept updated to respond to resident’s changing healthcare needs. Staff must make sure that when 01/06/08 the temperature of the medication store room exceed 25 degrees Celsius in temperature that this is noted, and remedial action is taken and documented to make sure that temperatures do not exceed 25 degrees. This is important as this can have an effect on the medication. An up-to-date medication policy 01/06/08 must be available for staff reference to ensure that they are up-to-date with their practices in the administration of medication. Individually prescribed 01/06/08 Controlled drugs must be disposed of in a denaturing kit. Medication must be administered 01/06/08 as prescribed and recorded accordingly. If not given, the correct endorsement must be used so it is known why it has not been given. The complaint records must be 01/07/08 DS0000010433.V361349.R01.S.doc Version 5.2 Page 24 Requirement 2. OP9 13 (2) 3. OP9 13 (2) 4. 5. OP9 OP9 13 (2) 13 (2) 6. OP16 22 Heathgrove Lodge Nursing Home 7. OP18 18 (1) c (1) 8. OP18 18 (1) c (1) 37 9. OP18 10. OP29 17 11. OP30 & OP38 18 (1) improved to make sure that actions taken to investigate complaints are clear and well documented. Staff must receive training in relation to protecting vulnerable adults from abuse. Original timescales of 31/08/07 not met, this is a repeat requirement. The multi-agency policy for the protection of vulnerable adults must be followed to ensure the protection of residents. The Commission must be given notice without delay of any event in the home, which adversely affects the well-being or safety of residents. Relevant documentation must be in place as evidence that staff have the right to work in the Country. All care staff must receive training that enables them to fully meet their roles and responsibilities. Original timescales of 30/09/07 not met, this is a repeat requirement. 31/07/08 01/06/08 01/06/08 01/06/08 31/07/08 12. OP31 9. 13. OP36 18(2) The home’s new Manager must 01/08/08 lodge an application with the Commission’s Regional Registration Team to become the Registered Manager of the home. All staff must receive regular 01/07/08 formal supervision at least six times a year and the information is recorded. Previous timescale of 6/1/06 and 30/09/07 not met. This requirement is repeated for the second time. Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP22 Good Practice Recommendations Consideration should be given to reviewing the location of the staff changing room and consider giving residents access to this room so that they can be offered a bath instead of a shower if they so wish. Consideration should be given to provide more electric profiling beds. 2. OP22 Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Heathgrove Lodge Nursing Home DS0000010433.V361349.R01.S.doc Version 5.2 Page 27 - 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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