Inspection on 07/11/05 for Heathgrove Lodge Nursing Home

This inspection was carried out on 7th November 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 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 Anthony Lewis Unannounced Inspection 7th November 2005 10:05 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.V259198.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 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 BUPA Care Homes Limited Mr A.R. (Ben) Domah Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 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 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 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. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 7th November 2005 at 10.05am and was completed at 3pm. The registered manager was available periodically throughout the inspection process. The present registered manager stated that he would be leaving the home on 3rd January 2005. The new manager, Doreen Bourne, who was also at the home being inducted on the day of the inspection, supported the registered manager with the inspection. Evidence was gathered for this inspection by viewing various files and documents. Seven residents were spoken to. Two resident’s relatives and one resident’s friend and previous next door neighbour were spoken to in private. The chef and one staff member were spoken to informally. An extensive internal and external tour of the home was conducted with the incoming manager. What the service does well: What has improved since the last inspection? What they could do better: Four requirements were made at this inspection. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 6 Staff must ensure that medication administered is signed for on the Medication Administration Record (MAR). There must be a review of the kitchen cleaning and the metal kitchen work table must either be repaired or replaced and the extractor filters must be cleaned or replaced to prevent infection in the home and to ensure the health and safety of the residents, staff and visitors to the home. Items discarded in the front garden/car park must be removed to ensure that the good appearance of the home is maintained. To ensure that staff’s personal development is being monitored and to ensure that they are being supported, supervision must occur more regularly. 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. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 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.V259198.R01.S.doc Version 5.0 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 the following standard(s): 2, 5 and 6. The registered manager is ensuring that prospective residents to the home and their family and representatives are aware of the admissions policy and procedure and the terms of residency. EVIDENCE: Terms and conditions of residency were viewed in five resident’s files, which was a requirement at the previous inspection. The home has an admissions policy and procedure, which contains information regarding admission into the home. The home’s brochure also contains information on the facilities and visits to the home for prospective residents. The admissions policy and procedure also contains information on emergency admissions. The registered manager stated that the home does accept residents for intermediate care, which is assessed by the registered manager or a senior member of staff. The registered manger went on to say that residents on intermediate care are integrated with other residents in the home and that they are supported by staff to improve their independent living. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 and 10. Although residents are confident that their wishes and physical needs will be met, they are not confident that staff are following the correct procedures when administering medication, which may eventually result in residents not receiving their medication. EVIDENCE: One resident who has pressure sores was visited and spoken to. He stated that the nurses are taking good care of the pressure sores daily and that he is comfortable. The registered manager stated that one resident administers her own medication. The deputy manager who is a registered nurse has carried out an assessment on the resident. On looking through the Medication Administration Record (MAR) sheets, there were many gaps where staff have administered the medication, but had forgotten to sign the (MAR) sheets. Gaps were found on various residents (MAR) sheets and at various times of the day. A requirement is made that the registered manager ensure that all medication is signed for once administered. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 10 Five resident’s files were viewed, each contained information regarding their wishes in the event of them becoming terminally ill and dying, which was a requirement at the previous inspection. A letter was received from a relative thanking the staff for the care that they gave to her mother in the last few weeks of her life. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents are confident that they will be able to express their choices and that the staff will abide by their choices and ensure that residents are supported to have as much control over their lives as possible. EVIDENCE: The registered manager stated that residents handle their own finances if they so wish, otherwise, relatives or their representative deal with their finances. The registered manager also stated that resident’s choices are discussed at resident’s and relative’s meetings. A resident’s and relative’s meeting was scheduled for the same day of the inspection at 3.30pm. The agenda was seen and listed issues for discussions such as housekeeping, catering, care issues, maintenance, complaints, the new manager and health and safety. There was also a meeting on 19th September 2005 at which a variety of issues were discussed. In addition, the chef ensures that residents are consulted about the quality of meals and their comments and choices are recorded in a book, which is kept in the kitchen. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. Residents, their family and their representatives are confident that the staff team will protect their legal rights. EVIDENCE: The registered manager said that all residents are supported to vote, if they so wish and that some residents had postal votes at the most recent general election. One resident’s previous next door neighbour was spoken to with the resident present. She said that she visits her friend regularly and acts as her advocate when required. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 and 26. Residents, staff and visitors are being put at risk of contracting infection due to the staff not ensuring that the kitchen is kept clean, tidy and safe. The registered manager is also not ensuring that the front exterior of the home is clean and tidy. EVIDENCE: A tour of the home was conducted with the new manager. Although the home is generally well maintained, the front garden/car park had a discarded bed and mattress propped up to the side. There was also a large accumulation of empty oil and dishwasher cartons spilling out of a bunker. A requirement is made that the registered persons ensure that the items left in the front garden/car park are removed. A tour of the kitchen was also conducted with the new manager. The store cupboard where provisions are kept was untidy and dirty. The outer layer of onions and small potatoes were lying about on the floor and under boxes and units. The food delivery room was dirty and a wall socket was loose, and the walls were dirty. Also in the kitchen, a metal work table was very wobbly and Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 14 the cooker extractor filters were heavily blocked with dust. A requirement is made that the registered persons ensure that there is a review of the kitchen cleaning and the work table is either repaired or replaced and the extractor filters are cleaned or replaced. On the tour of the home, all communal areas were clean, tidy and safe. Two residents were spoken to about the facilities in the home, both said that the facilities are comfortable. The home has been decorated to a good standard and colours are warm and appropriate, with adequate lighting available. Two residents and a resident’s sister said that the home was very comfortable and safe. All parts of the home are provided with emergency lighting and accommodation lighting is adequate for residents. The home has a dedicated laundry room on the ground floor. The washing machine has a sluicing programme and there is a sluice room on each floor, which is kept locked when not in use. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. Residents are confident that the home is following the correct recruitment procedures and that the staff employed in the home have the necessary training to meet the needs of the residents. EVIDENCE: Six staff’s files were viewed, including the two most recent staff to the home. All had a Criminal Records Bureau (CRB) check and two references. All staff files have a current photograph inside their file, which was a requirement at the previous inspection. Whilst looking through staff files, various training certificates were seen. Staff have been receiving Protection of Vulnerable Adults (POVA) training and letters of congratulations was seen for four staff who have completed their National Vocational Qualification (NVQ) training. The registered manager had badges, developed by BUPA, to present to staff who have successfully completed their NVQ. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 36. Residents are confident that the home is financially viable and that they will be consulted and able to air their views regarding the running of the home but residents are not confident that staff are being supported by the registered manager. EVIDENCE: The staff team ensure that residents are consulted about issues in the home. The registered manager stated that regular resident’s and relative’s meetings are held and residents are encouraged to air their views. Requirements are met within the agreed timescale given at inspections. The home’s administrator, who handles the home’s finances, was spoken to regarding financial affairs. She had a good understanding of safe accounting practices. Petty cash is kept locked in the home’s safe. Money from the petty cash tin was counted against the petty cash receipts and was correct and up to date. BUPA provides the home with a monthly financial summary. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 17 The staff’s supervision file was viewed and although staff are receiving supervision, it is not consistent. Some staff have not received supervision for more than three months and throughout the year some staff had long gaps of up to four months without supervision. A requirement is made that the registered persons ensure that all staff receive at least six formal supervisions a year and that the information is recorded. Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 18 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 3 X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x 1 3 X X X X 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X 2 X x Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered persons must ensure that the administration of all medication is signed for on the (MAR) sheet and any nonadministration coded as to the reason why the medication was not administered. The registered manager must monitor the administration charts daily and bring any omissions in the completion of the administration charts to the relevant member of staff’s attention immediately. The registered persons must ensure that the items discarded in the front garden/car park are removed. The registered persons must ensure that there is a review of the kitchen cleaning and the metal kitchen work table is either repaired or replaced and the extractor filters are cleaned or replaced. The registered persons must ensure that that all staff receive regular formal supervision at least six times a year and the information is recorded. DS0000010433.V259198.R01.S.doc Timescale for action 02/12/05 2 OP19 13(4)(a) 23(d) 13(3) 16 (g,h)23(c, d) 02/12/05 3 OP19 02/12/05 4 OP36 18(2) 06/01/06 Heathgrove Lodge Nursing Home Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heathgrove Lodge Nursing Home DS0000010433.V259198.R01.S.doc Version 5.0 Page 22 - 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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