Inspection on 16/09/06 for Dr French Memorial Home Ltd

This inspection was carried out on 16th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dr French Memorial Home Ltd 03/11/05

Dr French Memorial Home Ltd 14/07/05

Dr French Memorial Home Ltd 14/12/04

Dr French Memorial Home Ltd 27/07/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dr French Memorial Home Ltd 13 Nether Street Finchley London N12 7NN Lead Inspector Mr Stephen Boyd Key Unannounced Inspection 16th September 2006 10:55 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 Dr French Memorial Home Ltd DS0000010424.V308916.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. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dr French Memorial Home Ltd Address 13 Nether Street Finchley London N12 7NN 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 8445 4353 020 8445 4353 Dr French Memorial Home Limited Florence Somers Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Dr. French Memorial Home is a care home which is registered to provide care for 30 older people, some of whom may have dementia. The home has charitable status and is run by a voluntary committee. The stated aim of the home is; To support residents to continue living as independently as possible by receiving care and support consistent with their incapacities and disabilities. The home consists of a large two-storey, detached building. There are 24 single bedrooms and 3 double bedrooms, located on the first and second floors. Fifteen single bedrooms have en-suite facilities, and there are eight toilets, three bathrooms and a shower. On the ground floor, there are two lounges, a dining room, a hairdressing salon, an activities room and two offices. There is a large, secluded, attractive garden at the rear of the premises and a car park at the front. The home is situated near the busy Tally Ho Corner in Finchley, North London and there are good public transport links. The fees charged at the home range between £450 and £506. A copy of this report can be requested directly from the home or accessed via the CSCI website (web address on page 2 of this report) Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in one day in September 2006.The Inspector was helped by assistant manager, Angela Fathers, throughout the inspection. During the Inspection five service users, four staff and three relatives were spoken with. A tour of the premises was undertaken and various records and policies were reviewed. 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. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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 Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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 and 6 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Prospective Service users can be assured that their needs are assessed prior to moving to the home and that these will be met. EVIDENCE: The file of a service user admitted to the home since the previous inspection was examined and showed that the home had carried out a pre admission assessment and had received an assessment from the placing authority. The service user was spoken with during the inspection and although she could not recall whether she had visited the home prior to admission, she said she was settling in well and being well cared for. The home was seen to have an appropriate policy and procedure for the admission of new service users. Other service users files seen indicated they too had assessments carried out prior to admission. The home does not offer an intermediate care service. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users have individual plans of care which are clearly written. Their health needs are given high priority including the administration of medicine in a timely fashion. Service users are treated with respect and dignity. EVIDENCE: Service users sampled were seen to have an individual plan of care which set out clear objectives and were based on holistic assessments. They were seen to have been reviewed regularly. Since the previous inspection, service users now had a copy of their plan in their rooms. Risk assessments had also been carried out covering a range of potential and actual risks. These were also reviewed periodically. Service users case files showed evidence of regular healthcare appointments for service users with practitioners such as dentists and opticians. Service users weight was recorded as an aid to monitoring their ongoing health. All service users seen during the inspection appeared well cared for. The home operates a bottle to mouth system of medicine administration. The medication was stored safely as were controlled drugs the home administer. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 9 Staff who administer medication have received training and a recommendation that their signatures and initials are recorded in the MAR sheet folder had been carried out. The assistant manager reported good relationships with the providing pharmacy. Service users spoken with during the inspection stated they were treated with dignity and that their privacy was upheld. No institutional practices were seen on the day of inspection. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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): 12,13,14 and 15 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users social, cultural religious and recreational preferences are met by the home. Service users retain contact with family and others as they wish. Choice and control over their lives is promoted. Meal quality, quantity and dining arrangements are good. EVIDENCE: Service users spoken with during the inspection said they liked living at the home. There is an activities programme available which service users confirmed and includes exercise, arts and crafts, Bingo, card games and creative writing and poetry. Music tapes, videos and books are also available. Service users can follow their own interests such as watching television. Occasional outings take place including a recent one to Southend. In house entertainment is also arranged from time to time. There is a monthly Church of England service for those interested and one service user is taken to church by a relative. Other faiths and beliefs would be and have been assisted in the past by the home. The majority of service users have contact with relatives, friends or significant others. Relatives spoken with during the inspection said they could visit at any time and were always made to feel welcome. All those spoken with praised the care given to their relatives at the home. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 11 Service users are involved in meetings every three months where they are able to give their views on the operation of the home. Those spoken with indicated they have choice and control in their lives. For example, who to sit beside, what clothes to wear and whether to join in planned activities. Menus seen at the home offered choice at all meals. Service users were positive about the quality and quantity of food on offer. Food stocks were seen to be good, reflecting the variety in the menus. The inspector felt an additional choice to melon and soup, as the lunchtime starter would further enhance variety for service users. Food seen was kept safely and fridge and freezer temperatures were recorded daily. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. The home has appropriate systems in place to address any complaints or concerns from service users, family and others. There are adequate policies and procedures to protect service users from abuse. EVIDENCE: The home has an appropriate complaints policy and procedure which is made available to service users and others. No complaints had been recorded since the previous inspection. One anonymous complaint had been made to the CSCI in August. This had stated service users were being got up at 4.30 a.m. The complaint was found to be unsubstantiated. A recommendation to record the preferred getting up and going to bed times of service users from the unannounced visit made to investigate the complaint, had been implemented. On the day of inspection, no service users or relatives spoken with raised any concerns. The home has policies and procedures in respect of protecting service users from abuse. These were seen and appeared appropriate. However it is recommended they are reviewed to ensure they meet best practice in relation to whistle blowing by staff. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to this service. Service users live in a wellmaintained and comfortable environment. There are potential risks relating to water temperatures from hot water outlets in bedrooms, bedroom doors that do not fully self-close and risk associated with leaving hazardous substances in unsafe areas. EVIDENCE: The home was found to be well maintained and in a good state of decoration. Work has been undertaken to further enhance the home’s environment since the previous inspection including redecoration and re-carpeting in various areas. Service users bedrooms seen during the inspection had clear evidence of personalisation including photographs, ornaments and pictures. The home has a pleasant rear garden area which is accessible to service users and provides a nice outlook from one of the lounges and dining area. On the day of the inspection, it was evident that some wash hand basins in bedrooms were producing hot water at around 47c which is above the requirement for water temperature to be controlled at no more than 43c. The Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 14 assistant manager said she would contact the firm who installed temperature regulators to address this situation, as it was clearly a potential safety hazard. The assistant manager advised that self-closing bedroom doors had not yet been fitted as required from the last inspection, though believed the job had been assessed by a firm with a view to carrying out work. During a look in the laundry area, a hazardous chemical detergent was seen lying on the floor. The assistant manager on the advice of the inspector locked this away. The home was found to be clean and tidy and there were no offensive odours. Service users commented favourably on the cleanliness of the home during the inspection. There is an infection control policy in place. Dr French Memorial Home Ltd DS0000010424.V308916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to this service. Service users benefit from a properly recruited staff team. Achievement of National Vocational Qualifications at level two or above by care staff is not yet at the required ratio of 50 . EVIDENCE: Staffing levels at the home allowed for at least four carers plus a senior carer on morning shifts and an additional carer on afternoon shifts. There are separate cooking and domestic staff. There is a handyperson employed and administrative staff. Staffing levels were in the view of service users able to meet their needs. Staff spoken with during the inspection felt the levels were generally adequate. Recruitment procedures at the home were found to support the safety of service users. Staff files showed that prospective staff filled in application forms, attended interviews and had references taken up if successful. Criminal Records Bureau checks were sought and photo- identity was seen to be available. Staff confirmed they were given contracts and received an induction period. Staff training that had taken place since the previous inspection included, first aid, fire training, medication training and protection of vulnerable adults. The assistant manager advised the inspector, that currently five out of nineteen care staff had achieved NVQ’s at level two or above. Others were starting to undertake the course in the near future. The home therefore needs to have more staff achieve these qualifications to meet or exceed the 50 ratio of Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 16 qualified to unqualified staff required by the National Minimum Standards for older people. Staff had individual training records in their files, however it is recommended that an “at a glance” record is kept showing what training has been achieved by all staff, which would aid the booking of needed first time training or refresher training. Dr French Memorial Home Ltd DS0000010424.V308916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. The home is run and managed professionally in the best interests of service users. The health, safety and welfare of service users and staff are generally well promoted and protected. EVIDENCE: At the time of the inspection the home’s manager, Florence Somers was on annual leave and therefore the inspector did not meet with her. The inspection process and the comments received from service users, visitors and staff indicated her management of the home was undertaken in a professional manner. Service users have the opportunity to be involved in the running of the home by way of periodic meetings. Their views are also sought in surveys as part of quality audits held from time to time. Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 18 Monies are held on behalf of a number of service users. These were sampled for two service users and the monies held balanced correctly with the individual records kept by the home. A recommendation is made that to facilitate easier auditing of these monies, numbered receipts are kept which can then relate directly to the entry on the record card which would have the same number against the relevant transaction. During the inspection, current certificates of safety were seen for Gas, Electrical installation, Fire appliances and Water safety. The homes lift had been regularly serviced. COSSH policies and assessments were available. As indicated in standard nineteen of this report, some issues in respect of safety hazards need to be addressed. Dr French Memorial Home Ltd DS0000010424.V308916.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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 13(4)(a) Requirement The registered person must ensure that all bedrooms have a supply of hot water at the appropriate temperature. The registered person must ensure that 50 of care staff employed at the home have achieved National vocational Qualifications at level 2 or above. The registered person must ensure that bedroom doors are enabled to self-close. This requirement is restated from the last inspection. The previous timescale was 31/3/06. The registered person must ensure any dangerous chemicals are kept locked up safely Timescale for action 31/10/06 2. OP28 18 (1) (a) 30/06/07 3. OP38 13(4)(a) 30/11/06 4. OP38 13(4) (a) 16/09/06 Dr French Memorial Home Ltd DS0000010424.V308916.R01.S.doc Version 5.2 Page 21 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. 2. 3. Refer to Standard OP18 OP30 OP35 Good Practice Recommendations It is recommended the home review it’s policy and procedure in respect of the protection of vulnerable adults. It is recommended that an “At a glance” training record is kept for staff. It is recommended that to make auditing of personal monies held on behalf of service users easier, that receipts for individual purchases are numbered. Dr French Memorial Home Ltd DS0000010424.V308916.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: 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 Dr French Memorial Home Ltd DS0000010424.V308916.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. 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