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DS0000010433.V375316.R01.S.doc

Version 5.2

Key inspection report

CARE HOMES FOR OLDER PEOPLE

Heathgrove Lodge Nursing Home

837 Finchley Road Golders Green London NW11 8NA

Lead Inspector Duncan Paterson

Key Unannounced Inspection15th April 2009 9:20

DS0000010433.V375316.R01.S.doc Version 5.2

This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:

• Be safe • Have the right outcomes, including clinical outcomes • Be a good experience for the people that use it • Help prevent illness, and promote healthy, independent living • Be available to those who need it when they need it.

We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by:

• Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice

• Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983

• Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.

• Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money.


Reader Information Document Purpose Inspection Report Author Care Quality Commission Audience General Public Further copies from 0870 240 7535 (telephone order line) Copyright Copyright © (2009) Care Quality Commission

(CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

Internet address www.cqc.org.uk


SERVICE INFORMATION

Name of service

Heathgrove Lodge Nursing Home

Address

837 Finchley Road Golders Green London NW11 8NA

Telephone number

020 8458 3545

Fax number

020 8209 1650

Email address

[email protected]

Provider Web address

www.bupa.co.uk

Name of registered provider(s)/company (if applicable)

BUPA Care Homes (CFC Homes) Ltd

Name of registered manager (if applicable)

Type of registration

Care Home

No. of places registered (if applicable)

36

Category(ies) of registration, with number of places

Dementia - over 65 years of age (36), Old age, not falling within any other category (36)


SERVICE INFORMATION

Conditions of registration:

Date of last inspection 21st April 2008

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 residents is arranged over four floors. All bedrooms are provided with en-suite facilities. A passenger lift provides access to all floors. On the ground floor is a dining area and a lounge. 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 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 two activities co-ordinators (working on a job share basis) who organise social activities to residents such as bingo, a musician, quizzes, flower arrangement and outdoor visits to the pub and theatre. The home is situated on the busy Finchley Road near to Golders Green underground station and Golders Green bus terminus. There are also local shops, pubs, restaurants and a park within a short walk of the home. The fees charged at the home range between £750 £1472.69 per week.


SUMMARY

This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This mean the people who use this service experience good quality outcomes. This unannounced key inspection took place on 15 April 2009. The inspection involved time at the home talking with residents, staff, relatives and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to us by the manager. This was taken into consideration. A sample of residents’ case files were inspected as well as a sample of the home’s records, procedures and forms. Observation of care practice was also completed. What the service does well: The manager and staff have created a very pleasant, friendly home. Many positive comments were made by residents and visiting relatives. One resident, for example, described the home as, “very comfortable” and the staff as, “great”. There is a calm, relaxed atmosphere with staff and the manager finding time to chat and speak with residents. The activities provided are good. There are enthusiastic and energetic activities staff who have worked hard to provide a range of activities that include all residents. Time is also found to assist people to go out of the home if they wish. The lunch arrangements are well organised with staff working together well to assist residents to eat. Many residents eat in their bedrooms and need help. Many of the staff have worked at the home for a number of years and this helps with consistency and expertise. Staff know residents well. Staff are helpful and there are good relations between staff and residents. The building is kept clean and tidy and is well presented. The entrance hallway, for example, is nicely arranged and makes a welcoming first impression of the home. There is effective use of monitoring and quality assurance tools such as a monthly monitoring assessment of the home and satisfaction surveys of residents. There is also an openness to the complaints procedure with evidence that complaints are treated seriously and investigated thoroughly.


What has improved since the last inspection? There have been lots of improvements since the last key inspection of 21 April 2008. The manager started in post around the time of the last inspection and has been able to work on improvements arising from the requirements given at that inspection. The manager is well organised and committed to improving the service. He has brought a thoroughness and good organisation skills to the home. For example, he has improved staff morale and is well liked and respected by the staff. Information about the home available for residents and relatives has improved with the introduction of a newsletter, careful design of notice boards and an attractive booklet about the home. Communication with us has improved and the manager has been able to discuss arising issues with us during the past year. Where there are matters that must be reported to us the manager makes sure that we are informed. There have been improvements to staff training, recruitment and supervision. The manager has been able to review all the staff training records which will assist with planning future training. The recruitment process is clear and considerable effort has been put into making sure that staff receive regular supervision. What they could do better: The manager must apply to us for registration as the manager of this service. There had been a delay but the required information has now been obtained clearing the way for the application. Attention needs to be given to drawing up a revised statement of purpose. This is a key document and it is important that the service gets this right in setting out the aims and objectives and services that it provides. Some of the fire door closing mechanisms were not working and this must be attended to in order to provide effective safety for residents. This problem had already been identified by the service and there are plans to replace the fire doors later this year. In the meantime the defective door closing devices must be repaired. Other improvements needed are relatively minor in nature. Not all residents had completed end of life care sections in their care plans. Establishing all residents wishes in this regard is good practice. Should that not be possible the care plan can be detailed as such. The home’s records about the servicing of equipment and retaining servicing certificates could be improved with a new streamlined layout. And more details about staff training will be useful to demonstrate compliance in this area.


Over the past year the occupancy level has been beneath full capacity. The home is registered for 36 people but there were only 22 residents on the day of the inspection. Moving up to full capacity will be a challenge to the service and there will need to be an increased staff team. The service has been seeking to appoint a Head of Care for a number of months. This will be a key appointment over the coming months, particularly if there is also a rise in resident numbers. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4.

The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from [email protected] or by telephoning our order line – 0870 240 7535.


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


Choice of Home

The intended outcomes for Standards 1 – 6 are:

1. Prospective service users have the information they need to make an informed choice about where to live.

2. Each service user has a written contract/ statement of terms and conditions with the home.

3. No service user moves into the home without having had his/her needs assessed and been assured that these will be met.

4. Service users and their representatives know that the home they enter will meet their needs.

5. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home.

6. 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 & 4 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a range of good quality information about the service available for residents and relatives. Revising the statement of purpose will be an important addition to this. The current arrangements to assess and plan to meet people’s needs are good. EVIDENCE: There is a range of information available to residents, relatives and others. There is a brochure and an attractive colour booklet that contains good quality photographs and clear information about the service. There is also a newsletter which is a new initiative. In addition, there are weekly information sheets providing information about the week’s activities. However, the statement of purpose needs development and updating as it does not contain all the required information. This is an important document


as it allows the service to set out clearly the aims and objectives of the service and details of any specific services provided. The manager was clear about his understanding of the service and what it does well so developing the statement of purpose will be a straightforward task. However, a requirement is given to ensure that the work is carried out to a set timescale. The manager felt that what the service does well is to provide a personalised service for residents where everyone knows the residents well. This was endorsed by this inspection. There was a calm, relaxed air to the service, staff were assured in their work and positive feedback was received from many of the residents and relatives spoken with. For example, one resident referred to staff as being, “very helpful and kind”, and another resident said she, “liked the home very much”. A visiting relative said, “the care is very good”, and that her relative, “had improved since moving to the home”. There were times throughout the day when residents sat companionably together in the main lounge either taking part in an activity or having afternoon tea together. The manager and some staff joined the residents and chatted. Seven residents individual case records were inspected to assess this standard as well as the health and personal care standards. A standard format is used to provide assessment information and then care plans. Each person had had their needs assessed and there was detailed information available for staff about each person’s needs. The lead nurse was spoken with and she was able to explain the range of needs at the home as well as how care was provided. Specific needs, such as pressure area care were looked at and this is covered in the next section. Consideration had been given to arranging care to meet people’s needs.


Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. The service user’s health, personal and social care needs are set out in

an individual plan of care. 8. Service users’ health care needs are fully met. 9. Service users, where appropriate, are responsible for their own

medication, and are protected by the home’s policies and procedures for dealing with medicines.

10. Service users feel they are treated with respect and their right to privacy is upheld.

11. 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 & 11 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are detailed care plans in place for each person with additional information added where needed. Specific objectives exist for matters such as pressure area care and pain relief. Medication arrangements have improved with clear procedures now in place. Staff know residents well and are able to support residents’ choices. EVIDENCE: As described above, seven resident’s individual care plans were inspected to assess this standard. The sample was selected to make sure that a cross section of need was taken into consideration. Standard BUPA care planning documentation is used. Each person had a care plan and these were detailed. For example, care plans provided details about the specific hoist and sling that was required for manual handling. And a pressure area care plan objective was accompanied by charts, pictures, records and a referral to the Tissue Viability Nurse. The risk assessments to accompany the care plans, such as


manual handling assessments, were being regularly reviewed and there were additional sections such as a pain management objective for one resident. One disadvantage noted about the care plans was the fact that the style of the standard care planning documentation means that there is a lot of detail and paperwork provided about each person. This means that any new worker coming to the care plans would need to read through a great deal before being clear about the specific needs and interventions required. Staff in this home had provided additional written guidance on care plans which was useful and would assist any new staff. There is one GP for the home who visits each week. There are also links with specialist health care professionals such as the Speech and Language specialist and the manager reported that there are links with the North London Hospice for training purposes. Medication arrangements were inspected. The matters raised at the last key inspection of 21 April 2008 have been complied with. These related to having an up-to-date medication policy and the disposal of controlled drugs. The disposal arrangements are clear and paperwork relating to this was seen. A recent external audit of the medication arrangements was seen. Records of receipt of medication into the home were seen and a sample of records for individual residents were checked. No gaps in medication recordings were seen. Feedback from residents and relatives, as already described, was positive. Staff were observed to be working with residents in a kind, sensitive manner. Staff clearly knew residents well. A number of residents spend most of their time in their bedrooms. A number of such residents were spoken with. Each confirmed that they were treated well and encouraged to make their own choices. For example, one resident had personalised her room with lots of personal possessions and had regular visitors. Generally, thought and consideration has been made about residents’ choices regarding end of life care. Care plans have sections about end of life care and the majority of these seen had been completed with input from relatives where needed. There were also references to support organisations, such as Macmillan Nurses, where required. Two of the care plans seen were blank at the end of life section and a recommendation is given that residents wishes are established in this area. If wishes are not identified the care plans should be marked as such.


Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 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.

13. Service users maintain contact with family/ friends/ representatives and the local community as they wish.

14. Service users are helped to exercise choice and control over their lives. 15. 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with a range of activities from energetic activities staff. Staff work well together and provide a pleasant, welcoming atmosphere for residents and relatives alike. Food served is good with staff flexible in helping residents eat and respecting their choices. EVIDENCE: There is a good standard achieved in this area. On the day of the inspection one of the job share activities co-ordinators was present. She was working throughout the day from 9.30am to 6.30pm. She was very active throughout, involved in running group sessions, taking individual residents out of the home shopping, planning future activities and decorating the home with fresh flowers. This particular worker had a great deal of energy and enthusiasm for her role and was observed to be working well with the manager and other staff. For example, activities were put on in the lounge for residents and the activities co-ordinator and staff involved the residents.


The activities co-ordinator said that she worked two days per week and her job share partner an additional two days. She said that the remaining three days were often filled with visiting entertainers and musicians. There was evidence that a number of events had been put on at the home including a planned St George’s Day event and previous events for Easter. Religious services are also held at the home. Relatives visited throughout the day of the inspection and a number were spoken with. Positive feedback was received and a pleasant, welcoming atmosphere was present. The entrance hallway at the home is welcoming and sets the tone. The hall is neat and tidy with a range of information available. Staff were happy to assist with questions. The activities co-ordinator had completed a survey of residents views of the activities provided. These were viewed. They provided support for the work that was being provided as well as some suggestions for future events. The serving of lunch was observed. There is a dining room but only eight residents were eating in the dining room. The remainder of the residents ate in their rooms either through choice or because of health needs. This means that staff must be organised and work together well so as to be able to assist residents in the dining room and then to serve meals in bedrooms and help residents where needed. Smooth team work was observed although clearly this is a key period of the day that staff need to get right. The menu and food preparation arrangements were discussed with the chef manager. He said that he had worked at the home for three years and felt that he had been able to improve the standards. He felt free to work and that the budget given to him was suitable. The menus seen suggest that traditional style British food is provided. The chef manager felt that this was what residents wanted as there had been a 90% satisfaction rating in the most recent BUPA assessment. In addition, the 2008 Barnet Council kitchen inspection had awarded the home 5 stars, which is the maximum possible.


Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. Service users and their relatives and friends are confident that their

complaints will be listened to, taken seriously and acted upon. 17. Service users’ legal rights are protected. 18. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The safeguarding arrangements have improved. There is now much more openness about the service with safeguarding matters and complaints responded to promptly and thoroughly. EVIDENCE: The safeguarding arrangements at this service had been identified as needing improvement at the last key inspection of 21 April 2008. Not all safeguarding matters had been reported to us as is required. The new manager has been able to address this matter during the course of the last year and there are now good safeguarding arrangements in place. There are also now good communication links between this service and us as well as good links with other relevant agencies such as the local authority. For example, there was a recent safeguarding matter which was reported to us quickly and properly. There is a relevant safeguarding policy and procedure at the home and staff were able to demonstrate their knowledge of safeguarding matters and how they should respond. Staff spoken to, for example, were aware of the local authority safeguarding policy. Staff training needs in general have been assessed by the manager and the service is now in a position to provide such training to those members of staff who may not have received it to date.


The complaints records were inspected. These were well organised and easy to follow. Since the last key inspection there have been 9 complaints. Some of these complaints were about safeguarding matters. A great deal of detail was including for each complaint and it was clear to see that the matters had been responded to appropriately.


Environment The intended outcomes for Standards 19 – 26 are: 19. Service users live in a safe, well-maintained environment. 20. Service users have access to safe and comfortable indoor and outdoor

communal facilities. 21. Service users have sufficient and suitable lavatories and washing

facilities. 22. Service users have the specialist equipment they require to maximise

their independence. 23. Service users’ own rooms suit their needs. 24. Service users live in safe, comfortable bedrooms with their own

possessions around them. 25. Service users live in safe, comfortable surroundings. 26. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A pleasant, attractive, welcoming home has been created. Staff have made the best of the facilities providing benefits for residents. Attention must be given to the fire doors which were not all working. EVIDENCE: During the course of the inspection each part of the building was visited including the kitchen and laundry. A number of residents bedrooms were also visited in order to meet and talk with residents. The home was purpose built but that was now a number of years ago and the building does not have the modern facilities that other more contemporary purpose built nursing homes may have. The design, for example, has a lounge and dining area which is accessed via stairs and corridors and there is limited storage space.


Having said that, the manager and staff have created a welcoming, clean and comfortable care home and used the existing facilities to advantage. The rear patio and garden area, for example, is an attractive area with a large patio area for sitting out and a pleasant garden below. The lounge area is also relatively large and is a focal point for activities and a comfortable place for residents to sit. All parts of the home are accessible as there is a passenger lift serving all floors. The equipment in use at the home was discussed with the manager and staff. Staff said that they considered the equipment to be adequate. The manager said that he had bought new hoists and slings. He had not, after consideration, bought new profiling beds on the grounds that there were already some profiling beds as well as hospital beds and the local PCT could provide profiling beds if required. This situation will need to be reviewed periodically taking into consideration the needs of residents. Overall, the home was clean, tidy and well presented. There is a team of housekeeping staff and those on duty were spoken with. These staff said they were happy working at the home and felt that teamwork was an important factor in their work. As described above, the entrance hallway to the home was well presented. The rest of the home was also clean but attention may need to be given to the rear lounge windows, which needed cleaning, and the garden chairs which will need to be cleaned before use this spring and summer. The laundry was visited. It is a relatively large size and is equipped with two washing machines and two dryers. The laundry worker present was working between 8am and 3pm and was confident that this adequate to carry out the laundry duties. Some doors in use, although fitted with doorguard devices (which shut doors automatically at the sound of the fire alarm) were being held open. One with a chair and another with a dustbin. This was discussed with the manager who advised that this was a problem that had been identified and there was a plan to fit new fire doors later in 2009. However, in the meantime it is required that all doorguard devices are checked and repaired.


Staffing The intended outcomes for Standards 27 – 30 are: 27. Service users’ needs are met by the numbers and skill mix of staff. 28. Service users are in safe hands at all times. 29. Service users are supported and protected by the home’s recruitment

policy and practices. 30. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well lead and managed staff team who are happy in their work. The new manager has raised staff morale and made improvements in staff training and recruitment. EVIDENCE: The staffing numbers were discussed with the manager and nursing staff and the staffing rotas were inspected. The service aims to provide two nurses on duty throughout the day with, in addition, five care staff in the morning and four in the afternoon. On the day of the inspection there were two nurses on duty as well as four care staff in the morning and three in the afternoon. The staffing rota stated that there had been other recent occasions when there were only three care staff in the afternoon. Currently, such a staffing level is adequate for the numbers of residents. There were 22 people resident on the day of the inspection. However, the staffing level will need to be regularly reviewed and adjusted if needed taking into consideration the needs of residents. Even with 22 people resident there is still a need to provide more intensive support for some residents. For example, a number of residents required additional support for moving and handling and personal care as well as help required with feeding. This home is


registered for 36 people and therefore should occupancy increase the numbers of staff on duty should rise accordingly. Many of the staff spoken with had worked at the home for a number of years and each said they liked working at the home. Many praised the new manager and said that the home had improved since he had been there. Staff were observed to work well together and there was a supportive, friendly atmosphere. The manager reported that there is a key vacancy at the home, that of a Head of Care. He said that they have been trying to recruit to this post for some months. When a person is appointed it will greatly assist the development of the service as the appointed person can take the lead for care and nursing provision. Currently, the manager is doing that as well as managing all other aspects of the home. A sample of three recently appointed staff recruitment records were inspected. Each person had records to confirm that they had been recruited properly with references available as well as evidence that Criminal Record Bureau (CRB) checks had been obtained. There was evidence that each person’s right to work in the UK (if relevant) had been explored. Training was discussed with the manager and records seen. The manager explained that after his appointment he had reviewed all staff training records. He had drawn up a record of each staff member and the training they had received and used that to set out a training plan for 2009. The service is now in a good position to have accurate records about staff training needs and to plan accordingly. It was not possible at this inspection to go through all the staff training records. The BUPA computer system was used, however, to demonstrate that staff had completed manual handling training. 15 staff had completed this training. It is recommended that the manager keeps records available for inspection of the overall staff contingent and what training they have had. This is useful for proving evidence about the quality of services. The manager reported other training initiatives that were in place. These included the BUPA initiative of staff completing self-directed learning in topics such as health and safety and dementia. The first wave of this training was in progress with a deadline for staff to hand work in later in 2009. The manager said that resources were made available to staff as well as the manager’s time to help staff to do the work.


Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 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.

32. Service users benefit from the ethos, leadership and management approach of the home.

33. The home is run in the best interests of service users. 34. Service users are safeguarded by the accounting and financial

procedures of the home. 35. Service users’ financial interests are safeguarded. 36. Staff are appropriately supervised. 37. Service users’ rights and best interests are safeguarded by the home’s

record keeping, policies and procedures. 38. 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 & 38 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management monitoring and quality assurance systems in place mean that there is good information available for the manager in planning and improving the service. Similarly, there are now effective staff supervision arrangements in place. The manager must apply for registration to clarify his role at the home. EVIDENCE: The manager was appointed one year ago and in that time has been busy developing the service. As has been detailed throughout the report, he has been able to improve morale, boost staff teamwork and he has developed the home’s responsiveness to complaints and to staff training. Many people


spoken with said that the manager had made improvements at the home. And good relations were evident between the manager and staff. However, the manager is not yet registered with us and this must be addressed. This was discussed during the inspection. There have been a number of delays but the manager had the required information and will be able to formally apply for registration. On a positive note, the manager is currently studying for the new Leadership and Management in Care qualification. There are a range of quality assurance initiatives in use which provide a useful means for assessing the service as well as providing the manager with information on a regular basis. These include a monthly audit that is carried out assessing a sample of the home’s records. These include care plans. The March 2009 score for the home was 94%. In addition, BUPA complete regular Residents’ Customer Satisfaction Surveys. One had been completed in 2008 and this was viewed. Also viewed was a BUPA initiative which sought views from staff about the service, BUPA itself and the manager. There was a great deal of resident satisfaction found as well as positive views expressed by staff about the manager. In addition to these formal quality assurance initiatives there are regular team meetings. Records were seen of monthly meetings. Staff supervision records were also seen. The need to provide regular staff supervision was identified at the last key inspection and a requirement given. The manager has worked hard over the past year to develop staff supervision arrangements. The manager supervises the senior staff including nursing staff and the nursing staff in turn supervise the care staff. This was confirmed by the nursing staff spoken with. The supervision records seen confirmed that staff had received supervision twice in 2009 and that supervision had been provided in 2008 after a slow start. There is a need to increase frequency but the manager has put in place a sound system which can now be developed. The safekeeping of residents’ money was discussed with the home’s administrator. Money was being looked after for 11 of the residents in the home’s pocket money account. Mainly this account is for small amounts of money provided by relatives to cover out of pocket expenses. There is some involvement with local authorities or people with power of attorney who take the lead role. Computer records were seen of a sample of the transactions. Health and safety records were seen including the range of certificates obtained in respect to the servicing of the home’s equipment and fixtures such as the fire alarm system and mobile hoists. The file used to store this information needs some re-organisation as it was hard to follow. A recommendation is given about this. During the view of these records it was noted that remedial action was required in respect of a recent fire risk


assessment. This involves the plan to replace fire doors. There was also some action required by a Thames Water inspection. New taps had been installed.


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 (Commendable) 3 Standard Met (No Shortfalls) 2 Standard Almost Met (Minor Shortfalls) 1 Standard Not Met (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 ENVIRONMENT

Standard No Score Standard No Score

1 3 19 3 2 X 20 3 3 3 21 3 4 3 22 3 5 X 23 3 6 N/A 24 3 25 3

HEALTH AND PERSONAL CARE 26 3 Standard No Score

7 3 STAFFING 8 3 Standard No Score 9 3 27 3

10 3 28 3 11 3 29 3

30 3 DAILY LIFE AND SOCIAL

ACTIVITIES

Standard No Score 12 3

MANAGEMENT AND ADMINISTRATION

13 3 Standard No Score 14 3 31 3 15 3 32 3

33 3 COMPLAINTS AND PROTECTION 34 X Standard No Score 35 3

16 3 36 3 17 X 37 X 18 3 38 3


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. Standard Regulation Requirement Timescale for action

1. OP1 4 The statement of purpose must be revised so that all the information required by Schedule 1 of The Care Homes Regulations 2001 is included. .

01/08/09

2. OP31 8 The manager must apply to the Care Quality Commission for registration.

01/06/09

3. OP19 23(4) All fire door doorguard devices must be checked and repaired as required.

01/06/09


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

1. OP11 Where resident’s end of life care wishes have not been obtained such wishes should be discussed and recorded on care plans. If such a discussion is not possible that should be recorded.

2. OP30 It is recommended that the manager keeps records available for inspection of the overall staff contingent and what training they have had.

3. OP38 The records held relating to the servicing of equipment and the related certificates should be reordered to make them easier to follow.


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