Inspection on 23/06/05 for Heathgrove Lodge Nursing Home

This inspection was carried out on 23rd June 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

Heathgrove Lodge Nursing Home 15/04/09

Heathgrove Lodge Nursing Home 21/04/08

Heathgrove Lodge Nursing Home 07/06/07

Heathgrove Lodge Nursing Home 07/11/05

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 Anthony Lewis Announced 23 June 2005 at 08.30am rd 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. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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 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 Robin Comerford of BUPA Care Homes Ltd Ben Domah N Care Home with Nursing 36 Category(ies) of OP Old Age registration, with number of places HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17 January 2005 Brief Description of the Service: Heathgrove Lodge is a purpose built home owned and operated by BUPA, which aims to provide care with nursing for up to thrity-six people aged over sixtyfive 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 well kept 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 denistry 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 arragement 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. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on Thursday 23rd June 2005 at 8.30am and was completed at 4.50pm. The registered manager was available throughout the inspection and was very accommodating. Evidence for the inspection was gathered from a variety of sources. The preinspection questionnaire provided information regarding residents and staff. Twenty comment cards were received from residents and three from relatives/visitors. Five residents were spoken to formally and three informally. The home’s cook, administrator, maintenance person, activities co-ordinator, two nurses and two support workers were spoken to in private. There was also a tour of the home with the registered manager. What the service does well: What has improved since the last inspection? What they could do better: All residents must have a contract/terms of conditions between them and the home to ensure that the home is meeting their obligations. In order to ensure HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 6 that resident’s health and safety is not put at risk due to the lack of space in the dining room and the lack of ventilation, a review of the dining room locality and its lack of proper ventilation must be undertaken. To protect people in the home in the event of a fire breaking out, doors must not be wedged open and instead all doors in the home must be fitted with a device that enables them to close automatically in the event of the fire alarm sounding. Residents’ wishes must be recorded and signed by the resident or their next of kin, or significant others to ensure that residents wishes are met in the event of them becoming terminally ill and dying. In order to ensure the authenticity of all staff and safeguard residents and other staff working in the home, all staff must have a recent photograph of themselves in their file. All staffs and residents files need to be reviewed with a view to compiling them into a standard and consistent format in order that information required is easier to find. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4. The admissions procedure is thorough and ensures that a full assessment of prospective residents to the home is carried out. Prospective residents to the home are provided with comprehensive information about the home in order to make an informed choice. EVIDENCE: The home has a good service user guide, statement of purpose and a brochure containing information about BUPA. All provide potential residents with information to make an informed choice as to whether to live at the home or not. The statement of purpose shows that it was updated on 17th January 2005. All residents are required to sign for a service user guide on moving into the home. Resident’s bedrooms seen, all contained a folder with a copy of the statement of purpose and service user guide inside. Although five resident’s files were viewed and each contained a copy of their contract /terms and conditions signed by the resident or their next of kin or power of attorney, the home’s administrator stated that four residents have been awaiting their contracts from their local authority for some time now. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 9 A requirement is made that the registered providers ensure that all residents have a copy of their contract/terms and conditions of residency. The home has a fully qualified nurse on each shift . Two nurses were spoken to and both had a good understanding of the residents’ needs and their associated health issues. The registered manager stated that about fifty percent of the residents are from the Jewish community. Meals are prepared according to the needs and customs of the Jewish residents. Staff spoken to had a good understanding of the needs and customs of the Jewish residents. One Afro-Caribbean resident was spoken to. She stated that she was happy with the home and the way in which it meets her needs. She went on to say, “Why they didn’t send me here in the first place, I don’t know”? The home has an admissions policy and procedure file, which was seen to contains extensive information on the admissions and assessment process. The registered manager stated that either he or the nurses would carry out the assessment of prospective residents. The home does not provide intermediate care. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 10 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, 8, 10 and 11. The staff ensure that the health care needs of the residents are being met and specialist support is provided when required and that when dealing with personal care, residents are treated with dignity and respect at all times. EVIDENCE: Five resident’s files were viewed, all contained information regarding the care that they receive from the staff. Files viewed showed nursing care plans outlining the short and long term care to residents. It indicates problems/needs and expected outcomes/goals with the appropriate actions required by the nurses. File indicate that `care plans were reviewed on 2nd June 2005. All residents seen were clean and tidy. Residents spoken to said that the care staff look after them well and are very supportive and sensitive with their personal care. The registered manager said that the home has one resident with pressure sores, which is being taken care of by the home’s nurses and the tissue viability nurse. On speaking to the resident, she said that she is in no pain or discomfort from the pressure sore and that the nurses look after her well. She went on to say that having the bandage on her leg makes it itch now and again. She concluded by asserting, “I am very happy”! She had a large smile on her face. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 11 At the previous inspection, a requirement was made that written guidelines regarding appropriate settings for pressure relieving equipment is available for staff. This was in relation to the pressure relieving mattresses. The registered manager stated that all residents’ mattresses were replaced in February 2005 with self adjusting overlay systems. On viewing a number of resident’s’ bedrooms, the new equipment was seen to be functioning appropriately. One resident said that his bed was very comfortable. At the previous inspection, a requirement was made that all residents receive immediate support with their personal care. It transpires that one resident was not been washed properly. A letter followed the inspection stating that the resident was washed properly but had just finished breakfast at the time the inspector saw her and she had food on her hands and clothes. Whilst touring the home, all residents seen were clean and tidy. The statement of purpose has information on treating residents with respect and ensuring that their dignity and privacy are upheld. This was observed when staff were supporting residents with their lunch and whilst they relaxed in the lounge or their bedroom. The home has a laundry room where residents’ clothes are washed. To ensure that resident’s clothes do not get mixed up, their name is written in with a permanent pen. The home’s administrator stated that any mail belonging to a resident is taken to them unopened by her and support in opening and reading the contents are according to the resident’s wishes or needs. The registered manager stated that the death of any resident is treated as sympathetically as possible. He went on to say that BUPA has a quality department where staff could find support in the form of bereavement counselling if they so wished. The registered manager went on to say that staff support each other and other residents in the event of a resident dying. On looking through five residents’ files, all had a section regarding funeral arrangements in the event of the resident dying. However, one resident did not have their last wishes written in the appropriate section. In another resident’s files, the last wish section was signed but the details of their wishes were not written in. A requirement is made that the registered persons must ensure that all residents’ wishes are recorded and signed by the resident or their next of kin, or significant others. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 12 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, 13 and 15. Residents are provided with a variety of daily social activities designed by taking into account their cultural, individual and collective needs. Staff ensure that residents are able to make their own choices as much as possible. EVIDENCE: Two residents were spoken to about autonomy regarding going to bed and getting up. One resident’s stated that she was able to go to bed whenever she wished but does not like staying up late and is usually in bed by 10pm. The other resident stated that she usually stays up until the night staff come in and then they help her to wash and go to bed. She went on to say that she is usually up by about 7am. The home has recently employed an activities co-ordinator who ensures that residents receive information regarding events inside and outside the home. When spoken to, she stated that the majority of the residents prefer to stay in the home and not go out. She went on to say that she ensures that she knows all of the resident’s hobbies and interests by speaking to them. She said that she compiles a weekly planner, taking into account what residents like to do and this is taken to the residents in order for them to know what activities are on in the home every week. The planner was seen and contained a variety of activities. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 13 On the day of the inspection, one resident’s son came to visit her. One resident was spoken to and stated that her daughter visits every week. She went on to say that staff are very kind and her daughter can visit whenever she wishes. According to the registered manager residents are able to see visitors in private in their bedroom. All other areas in the home are shared spaces and there is no guarantee that there would be privacy in these areas. One relative/visitor to the home wrote on the comment card, “The staff are all very helpful and do a very good job. Everyone of them are welcoming and give you a smile when they see you”. Another relative/visitor to the home wrote. “I currently work as a distance learner tutor, with students. I am always made to feel welcome by the manager and staff and treated in a professional way. I am able to visit the home anytime to carry out my work. It is a pleasure to work at this home”. On a tour of the kitchen, the cook was spoken to at length about food preparation and food storage. Food was seen to be stored correctly and in large quantities. The kitchen was clean and tidy. There were appropriate colour coded food preparation boards stacked in a divider to prevent cross contamination. The home has a four weekly cyclical menu, which the cook stated that she compiles by meeting with residents and including some of their choices. There was a chart containing information of residents with special dietary needs such as those who are diabetic. The menu contained a variety of wholesome meals that where in accordance with the cultural mix of the residents. At lunch, staff were observed supporting some residents to eat. This was seen to be carried out in a supportive, patient and dignified manner. Residents were given the choice of what they wished to eat and drink. Lunch was flexible and unrushed. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 14 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 and 18. Residents are confident that any complaints that they may make will be taken seriously and investigated fully and that they are protected by the homes policy and procedure on adult abuse. EVIDENCE: The homes policy and procedure file was seen to contain all the relevant information for making a complaint. The statement of purpose and service users guide also contains information on complaints and contains the Commission’s details. There is also information on the wall in the entrance hall regarding making a complaint. The complaints file showed that there has been one complaint on 18th April 2005 since the previous inspection. The registered manager investigated the complaint on 21st April 2005 and, according to the registered manager, a satisfactory outcome was achieved. All staff working in the home has received Protection of Vulnerable Adults POVA training. The registered manager stated that he has an ENB998 – Teacher and Assessing in clinical practice certificate, enabling him to train staff, which is mainly carried out “in house”. He stated that he also is a Registered Mental Health RMN nurse and has a D32 and D33 – NVQ assessor certificate. The training file shows that POVA training was carried out on four separate occasions for the staff team on, 7th and 9th December 2004, 23rd December 2004 and on 31st January 2005. There has been no staff included on the POVA register. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Although the majority of the home is well maintained, comfortable, clean and free of offensive odours and has adequate space, residents and anyone else in the home are being put at risk if a fire breaks out due to doors being wedged open. BUPA is not taking seriously the dining room provisions. Residents are at risk whilst in the dining room due to there not being acceptable space, ventilation and natural lighting. EVIDENCE: The home has a dedicated maintenance person, who ensures that all minor maintenance issues are dealt with immediately. Major maintenance issues are forwarded to the organisations maintenance department. The homes maintenance book was seen and all maintenance issues have been recorded accordingly. The maintenance person also ensures that the grounds are kept tidy and safe. The back garden is particularly well kept. The lawn is even, without any patches and there is an attractive water fountain in the middle of the garden containing fishes. A requirement at the previous inspection for the working environment in the kitchen to be assessed has been met. There is now an air conditioning system in the kitchen and a “Dorgard” device has been HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 16 fitted to the main door. All resident’s bedrooms are fitted with Dorgards. However, it was noticed that the office door and some other doors in the home were wedged open and therefore not able to close automatically in the event of the fire alarm sounding. A requirement is made that the registered persons ensure that all doors in the home are able to close automatically in the event of the fire alarm sounding. At lunch, it was noticed how small and cramped the dining room is. Although, according to the registered manager, only about half of the residents living in the home are able to participate in meals in the dining room, the space is still small, especially when staff are supporting residents and moving backwards and forth with meals, which can be a risk to residents. There is also the added burden of there not being any natural sunlight or ventilation in the dining room due to it being in the lower level/basement of the home with no window. On the day of the inspection, it was a particularly hot day and the high temperature was noticeable in the dining room. A requirement is made that the registered providers ensure that a full review of the locality of the dining room and the provision for adequate ventilation and natural lighting is undertaken and a report forwarded to the Commission. The home has bathrooms and toilets on all levels in the home, which provide washing facilities. All bathrooms were seen to be clean and tidy. All bathroom and toilet facilities are wheelchair accessible. All resident’s bedrooms have ensuite facilities, which are also wheelchair accessible. The home also has a sluice room, separate from other rooms in the home. An assessment of the premises was carried out on 1st February 2005 by an Occupational Therapist, as was a requirement from the previous two inspections. The Occupational Therapist stated in her report that nothing can be done to increase the amount of space in the home and went on to state that the space provided was within requirements. There are a number of adaptations and disability equipment throughout the home to meet the needs of the residents such as handrails, a passenger lift and hoists. All rooms meet the space requirements of the National Minimum Standards. A married couple share one room. The registered manager said that the room was previously single occupancy for the wife but the husband requested to move in to be with his wife. When spoken to briefly, the husband said that the room was, “ok”. On touring the home, a number of rooms were viewed. All rooms have en-suite facilities, an armchair, lockable chest of drawers and other homely comforts. Most rooms also have pictures of family and friends. All rooms have call systems fitted. These were tested and found to be working correctly and staff responded appropriately and immediately. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 17 All areas of the home were found to be safe and, according to residents spoken to, comfortable. All areas of the home had window restrictors and were able to open to an acceptable distance to allow for adequate ventilation. All rooms had centrally heated radiators with radiator guards fitted. At the previous inspection, a requirement was made that due to an offensive odour detected, bedrooms are thoroughly cleaned and carpets shampooed. The registered manager stated that the offensive odour might have been due to a resident who had just used the toilet. At this inspection, all areas of the home were inspected and a number of residents bedrooms inspected, including the bedroom in question, no offensive odours were noticed. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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, 28 and 29. Residents are confident that there is skilled and experienced staff on duty twenty-four hours a day in sufficient numbers to meet all of their needs. The registered persons are not ensuring that staff files contain all of the required information, to ensure the safety of all residents. EVIDENCE: The home’s weekly duty rota for part of May and June was viewed. At night, there is four staff on duty one nurse and three care assistants. On the early and late shifts, there is usually a senior nurse; a nurse and six/seven care assistants, including a senior care assistant. In addition to care staff, the home also employs domestic staff, of which there are usually about seven on duty from the morning to early or late afternoon. The registered manager said that four staff have completed the National Vocational Qualification NVQ 2 and one member of staff has completed the NVQ3. He also said that one member of staff is at present undertaking the NVQ3 and eight are undertaking the NVQ2. Staff files were seen to be generally in good order. Five staff files were viewed, all contained two references, an application form, terms and conditions and job description. However, none of the files viewed had a recent photograph of the member of staff. There was one or two files with an unrecognisable black and white passport photograph. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 19 A requirement is made that all staff working in the home have a recent photograph in their file for inspection. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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, 32, 35, 36, 37 and 38. The registered managers approach and experience ensures that resident care needs are of paramount importance. The homes record keeping and certificates of safety ensure the safety of residents, staff and visitors to the home. EVIDENCE: The registered manager said that he is a registered mental health nurse. According of the statement of purpose and information provided from the registered manager, he also has a certificate in management studies, ENB 941 – care of the elderly, ENB 998 teaching and assessing clinical practice and D32, D33 – NVQ assessor. He has also worked as a manager and deputy manager in private health care since 1994. While talking to the registered manager throughout the inspection and observing the way in which he interacted with the residents and staff team, it HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 21 became apparent that he has a good understanding of the needs of the residents and staff. His approach was open and professional at all times. The home’s administrator was spoken to at length. She stated that she is responsible for residents’ payments and the banking of their money. She stated that twelve residents’ finances are subject to power of attorney and the others are taken care of by their family. She also stated that all of the home’s money and receipts are retained and recorded. The registered manager has a separate file for staff supervision, which is kept locked away in his office. The registered manager or a senior staff member conducts all staff supervision. Records show that staff are receiving formal supervision on a regular basis. Confidential information regarding residents, staff and finances are kept in either of the home’s two offices under lock and key. The home has an access to residents file policy and procedure if residents wish to see their file. While looking through resident’s and staff’s files, information required was difficult to locate due to the disorder of the contents of the files. A recommendation is made that the registered persons ensure that all staffs and residents files are reviewed with a view to compiling them into a standard and consistent format. Documents and certificates for the safety and welfare of residents were viewed and were up to date. All Dorgards are tested weekly by the maintenance person and recorded. The last test was seen to have taken place on 20th June 2005. The home has a fire manual, which includes the fire safety policy and procedures in the event of a fire. The homes fire fighting equipment was last tested on 21st April 2005. The maintenance person tests fire alarms weekly and records the details. The last test was 20th June 2005. The last London Fire and Emergency Planning Authority LFEPA visit was carried out on 27th February 2004. The findings was that the home complying with the regulations. Fire drills are carried out regularly. The last fire drill was on 16th May 2005. The lift certificate of inspection was seen. The lift was inspected on 2nd March 2005. The portable appliances test was carried out in November 2004. The home’s water supply was inspected on 3rd June 2005 and the boiler on the 2nd June 2005. Records viewed show that the yearly legionella test was carried out 14th September 2004. The home’s emergency lighting was tested on 22nd April 2005. According to the maintenance person, the emergency lighting is also tested weekly. A record of the tests was seen. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 22 HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 23 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 2 x 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 1 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 3 3 3 HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 24 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 OP2 Regulation Schedule 4, 8. Requirement The registered persons must ensure that all residents are provided with a contract/statement of terms and conditions. The registered persons must ensure that doors are not wedged upen and that instead a device is fitted to them in order that they may close automatically in the event of the fire alarm sounding. The registered persons must ensure that a full review of the locality of the dining room and the provision for adequate ventilation is undertaken and a report forwarded to the Commission. The registered persons must ensure that there is a recent photograph of all staff in their file. The registered persons must ensure that all residents’ wishes are recorded and signed by the resident or their next of kin, or significant others. Timescale for action 01/08/05 2. OP19 13 (4), (a), (c). 23 (4) (a). 01/07/05 3. OP20 13 (4) (a), (c), 23 (g), (p). 22/07/05 4. OP29 5. OP11 17 (3 (a) and (b) and Schedule 2 (1). 12 (3) 22/07/05 22/07/05 6. 7. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 25 8. 9. 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 OP37 Good Practice Recommendations The registered persons should ensure that all staffs and residents files are reviewed with a view to compiling them into a standard and consistent format. HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 Page 26 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 HEATHGROVE LODGE NURSING HOME G59 S10433 Heathgrove Lodge V221624 23.06.05 Stage 4.doc Version 1.20 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. 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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