Inspection on 04/11/05 for Springdene

This inspection was carried out on 4th November 2005.

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 16/01/07

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 Unannounced Inspection 4th November 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 Springdene DS0000010512.V261262.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. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 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 Mrs Myrlin Prenilla Amrill (Marilyn) ChristoBelgrave 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.V261262.R01.S.doc Version 5.0 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. 3rd May 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 two other care homes in North 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 coordinators. 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. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Friday 4th November 2005 and lasted four 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 deputy manager and registered manager who were open and helpful throughout the inspection. 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: 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. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 6 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.V261262.R01.S.doc Version 5.0 Page 7 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 (6 not applicable) The registered 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 registered 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.V261262.R01.S.doc Version 5.0 Page 8 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 and 10 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. These risk assessments included pressure care, manual handling, falls and risks associated with dementia. A recommendation was issued at the last inspection that care plans should be more “person centred”. Most care plans examined did give detailed information regarding the individual care needs of Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 9 service users. A small number of care plans did not contain information regarding the emotional needs of service users. A requirement has been issued relating to this in the relevant section of this report. There was evidence from service users’ files that they had good access to health care professionals. The registered 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 registered 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. 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.V261262.R01.S.doc Version 5.0 Page 10 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 and 15 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. 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 an exercise session. Service users that the inspector spoke with were very positive about the range of activities on offer at the home. 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. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 11 A number of service users are Jewish, the kitchen is not Kosher however the deputy 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 were not being routinely recorded. A requirement has been made relating to this issue in the relevant section of this report. Apart from this the kitchen was clean and well maintained. Springdene DS0000010512.V261262.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): 16 and 18 All complaints are taken seriously and dealt with in an open manner within set timescales. Service users are protected from abuse by clear procedures and by a well informed staff team. EVIDENCE: The complaints records were inspected. The registered 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 registered 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”. The inspector saw records of staff training with regard to the prevention of abuse. The home has dealt with adult protection issues. These were dealt with according to written procedures in an open and professional manner. Springdene DS0000010512.V261262.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 and 26 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 laundry was inspected and was appropriately equipped and in good working order. The home has good policies in connection with infection control. Service users praised the work of the domestic staff at the home. A new system of odour control is currently being tried out at the home. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 14 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): 27 and 30 The service users benefit from a positive, well trained and competent staff team. The registered manager ensures that staff receive the training they need to carry out their work in a professional manner. EVIDENCE: The staffing levels at the home have not changed since the last inspection and are in line with the Department of Health’s “No regression” policy. 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, “We get very well cared for” and “The staff work very hard”. 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. Staff interviewed were positive regarding the training they had undertaken at the home. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 15 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): 31, 33 and 38 The service users and staff benefit from an excellent 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. Overall the home has good systems in place to monitor health and safety compliance but domestic staff must ensure cleaning cupboards are kept locked. EVIDENCE: It was clear from discussion with the registered 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 registered manager informed the inspector that she has completed the NVQ level 4 management qualification. There was evidence from regulation 26 reports, residents meetings and customer satisfaction surveys that service users’ views are sort and used to Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 16 monitor the quality of the care provided by the home. Residents committees play an active role at the home. The fire logs were inspected. Weekly fire alarm checks and regular fire drills are recorded as taking place. However not all night staff are undertaking fire drills on a three monthly basis. A requirement has been issued relating to this. The Fire officer visited the home in June 05 and discussed evacuation procedures with the manager. Satisfactory certificates were seen in relation to electrical installation and gas safety. A sample of staff training records were inspected. All the staff had received fire training. Adequate numbers of staff have received first aid training to provide a member of staff on duty at all times with first aid training. During a tour of the building the inspector found that cleaning cupboards were unlocked on the second floor and ground floor. As these cupboards contain potentially dangerous chemicals this could be a risk for service users. A requirement has been made that all cleaning cupboards must remain locked at all times. The deputy manager attended to this issue immediately. Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 17 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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x x x x 2 Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15(1) Requirement The registered manager must ensure that the emotional needs of all service users are assessed and reviewed. The registered manager must ensure that fridge and freezer temperatures are regularly monitored and recorded. The registered manager must ensure that night staff undertake fire drills at least every three months. The registered manager must ensure that all cleaning cupboards are kept locked at all times. Timescale for action 01/01/06 2 OP15 23(2) 01/12/05 3 OP38 23(4)(e) 01/12/05 4 OP38 13(4) 01/12/05 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 Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 19 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 Springdene DS0000010512.V261262.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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