Inspection on 07/06/07 for Heathgrove Lodge Nursing Home

This inspection was carried out on 7th June 2007.

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 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 21/04/08

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 Stephen Boyd Key Unannounced Inspection 09:30 7th June 2007 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.V336672.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.V336672.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 www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Doreen Marjorie Bourne 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.V336672.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 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 £600 and £1000. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in one day in June. The inspector was pleased to meet with the manager, Doreen Bourne. Three people living at the home were spoken with in private and others in general. Three staff were spoken with in private and others during the course of their duties. Various records, policies and procedures were viewed. A comprehensive tour of the building was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: An area still outstanding from the previous inspection is to ensure that all staff receive formal supervision at least six times per year and that this is recorded. This inspection highlights a further three requirements to enhance the care operation at the home. Some staff had not received training in protection of vulnerable adults and this need to be pursued. An examination of training undertaken by staff showed that gaps in essential training such as moving and handling, food hygiene and fire safety existed for some staff and this needs to be put right. On the day of the inspection, the inspector was not able to see any documentation in relation to the home having quality assurance measures Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 6 in place such as internal audits, surveys of people living at the home and action plans based on results from these methods. 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.V336672.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.V336672.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into the home have their needs assessed to ensure and are assured these will be met. Those people who come to the home for intermediate care are helped to regain skills needed for more independent living. EVIDENCE: Sampled files of people living at the home showed that pre-admission and on admission assessments had taken place. These were seen to be holistic assessments covering all areas of need. There was an admissions policy and procedure with people being encouraged to spend time in the home prior to admission if possible. The home does offer intermediate care to people. At the time of the inspection no –one was receiving this service. The manager or senior staff carry out Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 9 assessments for this care arrangement and understand that the focus of such care is to enable people to increase their independence skills with a view to returning home. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person at the home has their own individual care plan. Health care needs are at the forefront of the home’s thinking for people living there. The medication system used in the home is appropriately managed. People living at the home are treated with respect and care values such as privacy are promoted. EVIDENCE: People living at the home were seen to have individual care plans. Plans identified problems and needs, what the hoped for outcome was and what action needed to be in place to attain the outcome. Plans took account of psychological, social and health needs and were seen to have been regularly reviewed. Daily progress reports are linked to the care plans and a named nurse system helps to create an individualised care service. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 11 Health care needs of people living at the home were clearly given a good level of priority. Care plans indicated health issues and how these were to be addressed. People spoken with during the inspection indicated they could see a range of health professionals and files seen gave details of appointments people had with for example opticians, G.P’s and chiropodists. The home operates a monitored dosage system of medication administration. This was checked for one floor of the home and found to be working well. At the last inspection a requirement had been made to ensure all medication record sheets were filled out with correct codes for any non-administration. No issues regarding this were seen at this inspection. People spoken to said they received their medication at appropriate times. The medication was seen to be stored in a safe and secure manner. People living at the home spoken with during the inspection were very complimentary about the manner in which staff treat them. Staff were witnessed showing great respect and following care values such as privacy by knocking on people’s bedroom doors and awaiting a response before entering Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have a good range of social activities. Cultural and religious needs are met. People are able to maintain important relationships. Choice is promoted for all people living at the home. The provision of food at the home is good in terms of quantity and quality. EVIDENCE: Heathgrove lodge employs two activity co-ordinators. There is an weekly programme of activities which includes things such as Bingo, Reminiscing, relaxing to music, painting and drawing, chair exercise, trips out and entertainers coming to the home. Each person has as part of their assessment an activities profile so that activities can be tailored for individuals. People spoken to said they enjoyed the range of activities on offer. One person said, “ They have very good social occasions” Recently, there had been a 100th birthday party for a resident which everyone enjoyed. Religious and cultural needs of people living at the home are assessed and incorporated into people’s plans of care. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 13 The manager advised that all people currently living at the home have contact to varying degrees with family and friends. People spoken with said they could receive visitors and that they were always treated well. A good rapport between staff and some visitors at the home during the inspection was witnessed. Meetings where people living at the home can air their views on home life take place. People also confirmed that they could choose what to do in their daily lives. For example, what to wear, whether to eat alone or in company, when to go to bed and whether to take part in activities. Menus seen during the inspection indicated 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. People spoken with were complimentary about the food and the quantity they received. People are consulted over menus and there is availability of snacks outside main meal times. Meals seen on the day of inspection looked appealing and were well presented. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home know that their concerns and complaints will be dealt with in a professional manner. 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 was seen to have a complaints policy and procedure. Since the previous inspection, there had been three complaints received and these had been dealt with appropriately. People spoken to on the day of the inspection indicated they knew about the complaints policy and procedure and said they felt confident that if they had to raise a complaint or concern, it would be properly addressed. The manager advised that the home had no current issues in respect of the protection of vulnerable adults. The home had policies and procedures for dealing with protecting vulnerable adults from abuse and had a copy of the local London boroughs procedures. In discussion with staff and on examination of training records, it was clear that a number of staff still need training in the protection of vulnerable adults. A requirement to this effect is made in the report. Heathgrove Lodge Nursing Home DS0000010433.V336672.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Heathgrove lodge provides a safe and well-maintained environment for people. The home is clean and hygienic. EVIDENCE: Heathgrove lodge was found to be a pleasant environment. Bedrooms and communal areas were seen to be well decorated and maintained. There was ample evidence of people having personalised their rooms with pictures, photographs, ornaments and their own furniture. Issues raised at the last inspection regarding discarded items at the front of the home and problems with cleanliness in the kitchen had been addressed. People spoken with during the inspection said the home was kept clean, as were their own rooms. The home employs a full time maintenance person and the garden area to the rear of the home was a pleasant place to sit. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 16 There were no problems noticed during the inspection with odour control. All areas of the home presented as tidy. One potential hazard was removed from the laundry area during the inspection. Staff had suitable equipment to maintain hygiene and cut the risk of infection such as gloves and aprons. Policies on infection control were available. Heathgrove Lodge Nursing Home DS0000010433.V336672.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a consistent staff team in good numbers to meet people’s needs. The recruitment practices of the home are good. Some staff need to undergo training in various areas to fully be able to meet the range of needs people have in the home. EVIDENCE: The home was found to have adequate numbers of staff to meet the needs of people living in the home. 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. The manager’s post is supernumery to the above figures. Separate kitchen, cleaning, activities and administrative staff are employed. Staff presented well and had a good knowledge of peoples needs. The recruitment processes at the home were seen to protect people living at the home. Staff files indicated that applications were filled out, interviews undertaken, references taken up, criminal records bureau checks made and identity and health checks pursued. Staff spoken to confirmed that they had undergone these processes and were also subject to an induction period. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 18 Approximately sixty percent of care staff had achieved national vocational qualifications in care at level two or above. The manager advised that four more staff were due to start nvq’s this year. Staff training records indicated that staff had pursued and were to pursue a range of individual training in areas relevant to the care of older people. Training included manual handling, fire safety, first aid, drug administration, care planning and dementia. Training gaps for individual staff in core areas such as manual handling, protection of vulnerable adults and food hygiene must be addressed and a requirement is given to this effect in the report. Heathgrove Lodge Nursing Home DS0000010433.V336672.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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by a competent manager. A quality assurance system needs to be in place at the home. Financial interests of people at the home are safeguarded. The health, safety and welfare of people and staff are given good priority. EVIDENCE: The registered manager, Doreen Bourne is a registered general nurse and also has achieved the registered managers award. She has been manager at the home for approximately eighteen months. Staff spoke well of her abilities and supportiveness towards them. People living at the home also spoke well of her and it was clear she had a good rapport with them. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 20 People living at the home have meetings, which they can attend to discuss issues of importance to them regarding the running of the home. However at the time of the inspection there was no evidence that a formal quality assurance process is utilised. The manager was not able to produce any surveys conducted on people living at the home. There were no staff surveys seen or any relating to significant others such as relatives. There was no written audit or action plan based on a quality assurance cycle. A requirement to address these issues is made in the report. Records seen on the day of inspection relating to finances of people living at the home were satisfactory. Good accounting procedures were in place including receipts being available for items purchased for people. Certificates of soundness and safety were seen to be available for electrical installation, gas safety, hoists, lift, and water and fire equipment. Regular fire checks such as alarm and lighting tests are carried out. Health and safety and COSSH assessments have been carried out for the home. Accidents are recorded and relevant bodies such as the CSCI notified where appropriate. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 21 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 22 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 OP18 Regulation 18 (1) c (1) 24 Requirement The registered provider must ensure all staff have received training in relation to protecting vulnerable adults from abuse. The registered provider must ensure a system of quality assurance is in place and available for inspection. The system should include regular monitoring, review and action planning and have people’s views at the heart of the system. The registered provider must ensure all care staff receive training that enables them to fully meet their roles and responsibilities (see standard 30 for detail) The registered persons must ensure that that all staff receive regular formal supervision at least six times a year and the information is recorded. This is a repeat requirement. Previous timescale of 6/1/06 not met. Timescale for action 31/08/07 2. OP33 30/09/07 3. OP30 18 (1) 30/09/07 4. OP36 18(2) 30/09/07 Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 23 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 OP32 Good Practice Recommendations It is recommended that care staff meetings are held bi monthly and that minutes of these meetings are maintained. Heathgrove Lodge Nursing Home DS0000010433.V336672.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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.V336672.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!