Inspection on 16/01/07 for Springdene

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Springdene 01/06/09

Springdene 27/03/09

Springdene 04/11/05

Springdene 03/05/05

Springdene 14/12/04

Springdene 20/04/04

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 Springdene 55 Oakleigh Park North Whetstone London N20 9AT Lead Inspector Mr David Hastings Key Unannounced Inspection 16th January 2007 09:30 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 Springdene DS0000010512.V322972.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. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Springdene Address 55 Oakleigh Park North Whetstone London N20 9AT 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 8446 2117 020 8446 2110 Springdene Nursing & Care Homes Limited ** Post Vacant *** Care Home 56 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 56 adults over 65 years of age (OP) some of whom may have dementia (DE(E)). One named person may be under 65 years of age. This condition will apply until the named person leaves the home or attains the age of 65 years, whichever is the sooner. 4th November 2005 Date of last inspection Brief Description of the Service: Springdene is a purpose built care home registered to provide care for 55 elderly people, some of whom may also have dementia. The stated aim of the home is to provide a service that is safe, sociable, comfortable and healthy to live in. The home is owned by a company called Springdene Nursing and Care Homes Ltd. The company also has three other care homes in London. The company is lead by a board of directors. The home is built on four levels and there are two shaft lifts. On the lower floor there is the kitchen and laundry as well as some bedrooms overlooking the garden. On the ground floor there is the main lounge area and bedrooms. The first floor has a small lounge and the main dining area. The second floor provides a designated service to people who have a higher range of needs and includes a lounge and dining area for these service users. The top floor provides a large activity room and hairdressing room. There are 55 single bedrooms and these all have en suite shower rooms. There are also four assisted bathrooms. The staff team consists of a manager, two deputy managers, senior carers and a team of carers. There are also two activity co-ordinators. There is a large team of ancillary staff including catering staff, laundry assistant, cleaning staff a handyman and reception staff. There are a minimum of seven care staff working on morning and evening shifts and at night there are three waking night staff. There is building work taking place on the ground floor at present as the home is planning to open a rehabilitation unit in the near future. This is not causing any major disruption to current service users. The current scale of charges are £630-£750 per week. A copy of this report is available on the CSCI website or/and from the home. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 16th January 2007 and lasted six hours. Five staff and eight residents were spoken to. A partial tour of the premises took place and care records were inspected. The inspector was assisted by the manager and service manager who were open and helpful throughout the inspection. Prior to the inspection 14 feedback forms from relatives, 8 forms from residents and 4 forms from health care professionals were received by the CSCI. These were overwhelmingly positive about the standard of care provided by the management and staff at the home. One relative commented, “Great home, mum is looked after so very well”. Residents that the inspector spoke with were very positive about the care and support they received. What the service does well: What has improved since the last inspection? What they could do better: One new requirement has been issued at this inspection to provide adult protection awareness training for all staff. Three good practice recommendations have been made relating to medication and staff training. The inspector is confident that all these matters will be attended to within the given timescales. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 6 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. Springdene DS0000010512.V322972.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 Springdene DS0000010512.V322972.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 (6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager makes sure that all service users have an initial assessment so that they know the home can meet their needs before they move in. EVIDENCE: The inspector examined three assessments carried out for the three most recently admitted service users to the home. One of these assessments was from a local authority and the other two were carried out by the home for two privately funded service users. All assessments covered the requirements of Standard 3 of the National Minimum Standards for Older People. The manager informed the inspector that herself or a deputy manager would always visit the potential service user before they were admitted on a trial basis. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff know the service users well and provide an excellent standard of care and support which maintains service users’ privacy and dignity. Service users health, personal and social care needs are well documented in their plan of care. Service users receive the correct medication that has been prescribed for them, at the right times and they are only given medication by those staff who have been trained to do so. EVIDENCE: The inspector examined ten care plans during the inspection. These plans gave detailed information for staff on how to meet the assessed needs of service users. Staff that the inspector spoke with had a good understanding of the care needs of service users and how the care plan enables all staff to provide a consistent approach to the care provided. There was evidence that plans are being reviewed regularly and appropriate risk assessments were seen. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 10 These risk assessments included pressure care, manual handling, falls and risks associated with dementia. Care plans have being recently revised and staff were positive regarding the new format. These revised plans included information about how the staff are to met the service user’s emotional needs. This was a requirement from the last inspection that has now been complied with. The manager also explained to the inspector how she can access CPNs if the staff feel that service users require further and more formal emotional support. There was evidence from service users’ files that they had good access to health care professionals. The manager praised the local doctor and the health team. The doctor was visiting service users during the inspection and it was clear service users were able to access this service when required. The home has good systems, policies and procedures in connection with the receipt, recording, storage, handling administration and disposal of medicines. The manager informed the inspector that all staff dealing with medication have undertaken medication training and certificates were seen. The inspector examined satisfactory records in relation to medication. Two good practice recommendations have been issued as a result of this inspection. Where service users are prescribed PRN pain control a detailed description of possible pain indicators may be of benefit and information regarding what effect medication has and any possible contra indications should be detailed on every individual MAR chart. Throughout the inspection it was observed that the staff were supporting service users to receive personal care with privacy. This is facilitated by each service user having their own en suite showers. The service users were also observed to be well groomed and to be receiving a high standard of personal care. Service users that the inspector met said they were treated with dignity and respect. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can choose from an excellent and varied range of activities provided by the home. Many of these activities are designed to have a positive therapeutic effect for service users with dementia. The home provides a varied, wholesome and appealing menu, which is regularly discussed and reviewed at residents’ meetings. Service users are able to exercise choice and control over their lives. Visitors to the home are encouraged and made welcome. EVIDENCE: The home has two activity co-ordinators. The activity programme for the month was inspected. This included exercise sessions, quizzes, games, videos and reminiscence sessions. The activities take place on the different floors and include sessions for service users with high care needs. On the day of the inspection the service users were observed enjoying playing cards and taking part in discussion groups. Service users that the inspector spoke with were very positive about the range of activities on offer at the home. One service user said that there was plenty to do. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 12 There was evidence from the visitor’s book that service users can have visitors at any reasonable time. Service users told the inspector that visitors were made welcome by staff. It was clear from discussion with staff and service users that service users are encouraged to be a part of the local community if they so wish. One visitor commented, “The staff are excellent, polite, kind and respectful to the residents and visitors”. Service users that the inspector spoke with said the food was very good at the home. There was evidence that service users can choose the menu the day before. A number of service users are Jewish, the kitchen is not Kosher however the manager informed the inspector that all service users are made aware of this before they move in. There was evidence that service users regularly discussed the menu plan at service users’ meetings. Snacks are available throughout the day. Service users were observed enjoying their lunch in relaxed and pleasant surroundings. Staff were giving discreet assistance were needed. One service user commented to the inspector that the food was very fresh. The inspector visited the kitchen during the inspection. It was found that fridge temperatures are now being routinely recorded. This was a requirement from the previous inspection that has now been complied with. The kitchen was clean and well maintained and there was plenty of fresh fruit and vegetables available. Care plans gave good examples of how choice is offered to service users in relation to activities, food, clothes and personal care. Service users told the inspector that they felt they had choice and control over their lives. Records of residents’ meetings also provided evidence that service users could have a say in the running of the home. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All complaints are taken seriously and dealt with in an open manner within set timescales. Service users are protected from abuse by clear policies and procedures. Further training is required in adult protection matters so all staff are aware of the risks older people face. EVIDENCE: The complaints records were inspected. The manager records all complaints and concerns, however minor. These records were recorded in a comprehensive manner and there was evidence that they had all been investigated. It was clear from discussion with the manager that complaints are taken seriously and dealt with in an open and professional manner. Service users were aware of the complaints policy. The home has a satisfactory adult protection policy and procedure, which is in line with the Department of Health’s guidance “No Secrets”. Not all staff have attended adult protection training recently and some staff were not aware about the types of abuse older people can be at risk from, although all staff knew they should report any suspicions of abuse to the appropriate authorities. A requirement has been issued that all staff must attend adult protection training. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, safe and decorated and furnished to a high standard. The domestic staff work hard to ensure the home is always clean and free from offensive odours. EVIDENCE: The inspector toured the premises. The home is purpose built and was clean, tidy and comfortable. The home is well maintained. There are a number of communal areas in the home. On the lower floor there is a games room and library. On the ground floor is a large lounge. On the first and second floor is a lounge and dining area. All communal areas are decorated and furnished to a high standard. The garden provides a paved area with seating. The home has been designed for service users who have a physical disability. The home was clean and free of offensive odours. The home has good policies in connection with infection control. Service users praised the work of the domestic staff at the home. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users benefit from a positive, well trained and competent staff team. The manager ensures that staff receive the training they need to carry out their work in a professional manner. Service users are supported and protected by the home’s recruitment policies and procedures. EVIDENCE: On the day of the inspection there were thirty-four service users residing at the home. There are a number of vacancies and no new service users are being admitted at present while building work takes place on the lower ground floor. The lower ground floor of the home will become a rehabilitation unit and the home has applied to the CSCI to be registered for nursing care. Some staff and service users have moved to a new home owned by the organisation. Although staffing levels have reduced, appropriate numbers of staff are deployed to meet the dependency levels of current service users. The rota was examined and matched the names of staff on duty that day. Feedback received by service users was positive regarding the staffing levels at the home and the quality of care provided. One service user said, “The staff work very hard”. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 16 Records seen indicated that about 70 of care staff have NVQ level 2 or equivalent. This exceeds the requirements of Standard 28 of the National Minimum Standards for Older People. The inspector examined a satisfactory training programme and there were copies of relevant certificates on file. Training covered mandatory training as well as training in dementia and diversity. A recommendation has been issued that the manager develop a staff training overview to ensure that all staff have completed the required mandatory training and the need for refresher courses can be clearly highlighted. Staff interviewed were positive regarding the training they had undertaken at the home and the training opportunities available to them. Four files of recently employed staff at the home were examined. These all contained the information required by Standard 29 of the National Minimum Standards including proof of identity, written references and CRB disclosures. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. The service users and staff benefit from a manager who takes her responsibilities seriously and makes sure the home is well run. Service users are able to have their say in the way the home is run and their input is used by the management to improve the quality of the service. Service users financial interests are safeguarded by clear policies and procedures. The home has good systems in place to monitor health and safety compliance. EVIDENCE: Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 18 It was clear from discussion with the manager that she has the competences and skills required to run the home effectively. Staff and service users were very positive regarding the manager’s abilities. The manager is currently applying to be registered with the CSCI. There was evidence from regulation 26 reports, residents meetings and six monthly customer satisfaction surveys that service users’ views are sort and used to monitor the quality of the care provided by the home. Residents committees play an active role at the home. Small amounts of money are held by the home on behalf of service users. This money is used to buy various items for individuals such as toiletries and to pay for hairdressing and outings. A sample of these accounts were examined and found to be accurate with clear audit trails. The fire logs were inspected. Weekly fire alarm checks and regular fire drills are recorded as taking place. Records indicated that night staff have undertaken fire drills every three months. This was a requirement from the last inspection that has now been complied with. During the inspection all cleaning cupboards were locked. This was another requirement from the last inspection that has now been complied with. All other records seen in relation to health and safety were satisfactory and up to date. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X X 3 Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 20 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 OP18 Regulation 18(1)(a) Requirement The registered provider must ensure that all staff undertake training in adult protection so they are aware about the types of abuse older people can be at risk from. Timescale for action 01/04/07 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 OP9 Good Practice Recommendations The registered provider should ensure that where service users are prescribed PRN pain control a detailed description of possible pain indicators are detailed on their individual MAR chart. The registered provider should ensure that information regarding what effect medication has and any possible contra indications should be detailed on every individual MAR chart. The registered provider should ensure that a staff training overview is developed to ensure that all staff have DS0000010512.V322972.R01.S.doc Version 5.2 Page 21 2. OP9 3. OP30 Springdene completed the required mandatory training and the need for refresher courses can be clearly highlighted. Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 22 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 Springdene DS0000010512.V322972.R01.S.doc Version 5.2 Page 23 - 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!