CARE HOMES FOR OLDER PEOPLE
Spring Grove 214 Finchley Road London NW3 6DH Lead Inspector
Ms Franki Solomon Unannounced Inspection 6th December 2005 10:00 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 Spring Grove DS0000010336.V271277.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. Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Spring Grove Address 214 Finchley Road London NW3 6DH 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 7794 4455 Springdene Nursing & Care Homes Limited Mrs Martha Ohene Acquah Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Spring Grove is a private care home which provides support to vulnerable frail older people aged 65 and over. The home is registered to provide personal care to forty-six service users the majority of whom are privately funded. The home is furnished to a high standard and is one of three care homes owned by proprietors Springdene Care Homes Ltd. The building is purpose built over three floors with a smart hotel style front entrance and reception area. All floors can be accessed via 2 lifts. The home has forty single and three double ensuite bedrooms. The double rooms are set aside for couples. Residents also have access to communal toilet and bathroom facilities. Each floor has a small self-service kitchen. The homes main kitchen is on the ground floor adjacent to the dining room. A spacious communal lounge, art room and atrium is also on the ground floor. A library is on the 1st floor which leads out to the upper landscaped garden. The serviced laundry room, parking area and maintenance workshop is on the lower ground floor. The home provides 24-hour personal care. There is a staff team of forty seven including the registered manager, two deputy managers, team leaders, a fulltime housekeeper, activities co-ordinator, qualified chef, kitchen staff and maintenance operative all of whom are accountable to the Operations Manager Mrs Diane Surtees. Springdene Nursing and Care Homes Ltd as the providers are responsible for the management and maintenance of Spring Grove. The home is situated on Finchley Road NW3 halfway between Swiss Cottage and Golders Green, near to shopping and community facilities. Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory inspection of the year April 2005 – March 2006. The inspection was unannounced over one day lasting 5 hours. The inspection was to check requirements made at the last inspection, to inspect those key standards not previously inspected, and to meet with residents and staff. The registered manager was on study leave on the day and the inspector met with the Person-in-Charge, the operations manager who was available throughout the inspection. The inspector would like to thank the management, residents and all staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection?
Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 6 The home has been responsive in undertaking some requirements made at the last inspection in July 2005 and is progressing those remaining. The format of Care Plans are being revised so that assessed need and necessary action to be taken can be identified easily so that residents’ may feel secure that staff know how to provide the appropriate support for residents’ needs. Staff have a robust protocol now for calling out the G.P. and have had appropriate training so that the management of residents’ support needs will be clearly recorded and appropriately acted upon. Recording of medication and administration charts are recorded appropriately for the safety and well being of residents. The registered manager has provided in-house training to staff to undertake correct note taking and recording on medication and initial assessments, and the proper filing of records so that residents’ support needs may be professionally, safely and quickly acted upon. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spring Grove DS0000010336.V271277.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 Spring Grove DS0000010336.V271277.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): 3. The appropriate filing in service users’ care plans still need to be completed. EVIDENCE: A requirement made at the last inspection 0n 7th July 2005 for residents’ individual assessment of needs to be filed appropriately, has not been completed. The Person-in-Charge stated senior management were reviewing the present care plan system, but this means that some of the existing records were still not readily accessible. On one file the Person-in-Charge had difficulty in finding the necessary records requested by the inspector. The requirement has been re-stated. Spring Grove DS0000010336.V271277.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): 7, 8 & 9. The filing of residents’ care plans is poor, information is not readily to hand, so that staff are not able to access relevant information easily for the support of residents. This includes evidence that each plan of action is being reviewed regularly. A robust protocol is in place for when to call out the G.P. and the medication policy and procedures are properly adhered to ensure the well being and safety of residents. EVIDENCE: A requirement was made at the last inspection on 7th July 2005 to be undertaken by the 7th October 2005. During this inspection both the inspector and the Person-in-Charge were unable to access readily the relevant records in one file. The requirement has been re-stated. The Person-in-Charge produced a new care planning documentation which is being introduced and which should ensure that residents’ needs are individually identified; for staff to know what action to undertake; to record the action undertaken; and when the care plan should be reviewed.
Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 10 Following a requirement made at the last inspection, the home has produced a robust protocol for when to call out the G.P. Medication Administration Charts and medication, including that for homely remedies are now properly and professionally managed and recorded. Spring Grove DS0000010336.V271277.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): 12 & 13. The home excels in meeting residents’ expectations regarding their preferences and social life. Residents’ can expect a varied and delicious diet in very pleasant surroundings. EVIDENCE: When going round the home and talking with residents, not only did residents compliment the home on its various activities offered which they looked forward to and enjoyed, but it was evident that staffing ratios enabled staff to spend time talking to residents and assisting in group activities for residents. One resident did not want to join a group and a staff member played dominoes with them. Residents’ wishes are well catered for. The activities programme was full and innovative. The home has a number of schools participating in a competition to perform for residents. The home encourages residents’ involvement. Several residents’ had relatives visiting. Care Plans are being revised to record individual social activities.
Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 12 The menu is varied and nutritious with choices on the day. Residents said the food was appetising. Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Complaints are dealt with appropriately and according to regulations. EVIDENCE: Arrangements are in place to deal with and manage any complaints appropriately. The Person-in-Charge informed there were no complaints since the last inspection and produced the complaints file which confirmed no complaints had been received since the last inspection. Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 14 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): These standards were not inspected on this occasion. EVIDENCE: Spring Grove DS0000010336.V271277.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): 30. The home’s manager has provided to staff, various training to ensure staff’s relevant competencies for the professional skills they require for the safety and welfare of residents. EVIDENCE: Following a requirement at the last inspection of the 7th July 2005, the registered manager who is a recognised trainer has been providing in-house training to staff. The training is now complete, such as Care Plans format, note taking and recording of medication; appropriate filing of records in terms of initial assessment of needs, and records having to be in sequence. The training is complete and now the tasks such as appropriate filing of records in terms of initial assessment of needs and records to be placed in sequence have to be completed. The relevant requirement has been re-stated under standards 3 & 7. Spring Grove DS0000010336.V271277.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): 37. The home’s Regulations 37 reports are inadequate. The home’s Regulation 26 monthly visit reports summarise the weekly management meetings which detail quality assurance issues for residents, and maintenance issues of the home and building. EVIDENCE: The home’s reporting under Regulation 37 to the Commission has been inadequate, lacking relevant and appropriate information. The inspector took along 3 recent reports (One dated 14th November and two dated 18th November 2005) and discussed the deficiencies of the reports with the Personin-Charge. The Person-in-Charge agreed they were unacceptable and that she
Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 17 would inform the manager to have this deficiency remedied immediately. A requirement has been made. The home’s reports on Regulation 26 Visits received by the Commission have been sparse. This was discussed with the Person-in-Charge, who produced the home’s weekly management meeting log. It was demonstrated that the management have a weekly meeting where the home’s business is fully discussed and minuted in a log book for appropriate action. So that residents may be assured that the home looks into various aspect of the running of the home, and the support provided to residents, to ensure their safety and well being. The log is available to an inspector at any inspection Spring Grove DS0000010336.V271277.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 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 X Spring Grove DS0000010336.V271277.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 OP3 Regulation 14(1) Requirement Timescale for action 31/01/06 2 OP7 12(1)(a) 3 OP37 37(1)(a)(g)37(2) The registered person must make sure the individual’s assessment of needs are filed appropriately, accessible and available. This requirement has been re-stated. The Registered Person must 31/01/06 ensure service users’ Care Plans set out in detail the action which needs to be taken by care staff. This should include Social Activities. The care plan must be reviewed by care staff in the home at least once a month, more often if required and a date set for the following review. The Registered Person must 15/01/06 ensure Regulation 37 reports are completed appropriately with all relevant details. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 20 No. Refer to Standard Good Practice Recommendations Spring Grove DS0000010336.V271277.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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