Inspection on 16/11/05 for Francis House

This inspection was carried out on 16th November 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Francis House 11/11/08

Francis House 22/01/07

Francis House 26/01/06

Francis House 11/03/05

Francis House 02/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Francis House Cofield Road Boldmere Sutton Coldfield West Midlands B73 5SD Lead Inspector Christy Wannop Unannounced Inspection 16th November 2005 09:30 Francis House DS0000016992.V255155.R01.S.doc Version 5.0 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 Francis House DS0000016992.V255155.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 Adults 18-65. 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. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Francis House Address Cofield Road Boldmere Sutton Coldfield West Midlands B73 5SD 0121 354 7772 0121 354 7772 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) Lisieux Trust Mrs Kathleen Beechey Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The establishment may provide personal care to residents under the age of 65 years. The home may provide care for 9 service users with learning disabilities. 11th March 2005 Date of last inspection Brief Description of the Service: Francis House is a purpose built modern property in the style of a large residential dwelling and is owned by the Lisieux Trust. The home is registered to provide accommodation for nine persons with learning disabilities. The Lisieux Trust is a voluntary organisation based upon a Christian ethos, however this does not preclude service users or staff from a non-Christian background to receive a service or obtain employment. The home is furnished and maintained to a high standard with service users involvement in choosing décor of both their individual rooms and communal areas. All bedrooms are single occupation, service users are supported to rise and retire when they prefer. Communal areas are situated on the ground floor with bedrooms on the first floor. There is no lift facility within the home and all service users are required to be fully mobile. To the rear of the home is a garden, which is well laid out and includes adequate seating facilities. There is sufficient off road parking for the home’s own vehicle and a further four vehicles. The home is situated in a side road and has easy access to local amenities including shops, cinema, banks and public houses. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on an autumn morning. Three members of staff were spoken with over the course of the inspection and three service users were at home. Others were at college or day services. The inspector observed care practice, read documentation relating to the maintenance of the home and service user care plans. One parent spoke with the inspector and three returned their views on written questionnaires sent out before the inspection. Five service users gave written comments on separate questionnaires. The manager has given information to CSCI about policies and procedures; service user needs, staffing arrangements in a “pre inspection questionnaire”. Francis House provides supportive, respectful care to nine service users. It promotes their independence in a group living setting with minimal staffing levels. What the service does well: What has improved since the last inspection? The manager has made changes to improve the safety of service users in the case of fire or suspected abuse. Information for service users about making complaints to CSCI has improved. Staff now receive professional supervision six times a year. The manager has carried out and made public the first quality assurance audit for the home, based on the views and service users, parents and interested others. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 6 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. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 There have been no new admissions since the last inspection and there are no current vacancies. Prospective residents are given easy to understand information about the home in a CD-Rom format and have the opportunity to visit prior to admission. This helps prospective residents to make informed decisions as to whether they wish to live in the home. Service user assessments and introductory processes help to ensure that admissions are positive and successful. EVIDENCE: The people living at Francis House are an established group. There have been no people moving in or out recently. A quality audit has been carried out. The views of service users have been incorporated into the Service User Guide as required at the last inspection. The Statement of Purpose should also refer to the availability of the accessible CDRom format for the Service user’s Guide. One service user reported that other service user’s do shout at her but staff were aware of this and had strategies for managing any minor conflict. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 Residents have individual care plans and accompanying risk assessments, most of which are reviewed regularly. The home offers opportunities for personal development and care plans promote independence. Service users are involved in deciding and reviewing their care. Resident’s individual records are accurate and securely stored when not in use. Staff demonstrated a good knowledge of individual needs and preferences. EVIDENCE: Generally care plans are well organised and recorded. Information about preferences for personal care and making choices is particularly good, as is the way that financial information is written to be understandable by the service user. One service user said they were helped to look after their money. People are actively supported to vote. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 10 Key workers have monthly update sessions with the service user and make a written summary of changes and plans. One service user had no record of formal review or these sessions since 4/1/04 and risk assessments had not been updated. This puts him at risk if new staff are unaware of his care needs. Service users have a range of physical and emotional needs that are generally well met. It is recommended that the manager investigate early mental health support from learning disability nursing services, both for individual service users and for training for staff. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 People are as involved as they are able and wish to be in the planning and preparation of meals. Meals are a social occasion and reflect the atmosphere of group living. Healthy eating is promoted. EVIDENCE: During the inspection several people helped themselves to what they wanted to eat for brunch. Food in accessible cupboards showed a wide range of good quality ingredients from which to make meals. Staff and service users’ described how menus were planned and food bought and prepared. Each resident takes responsibility for an evening meal in rotation. Menus showed a choice at breakfast and lunch but not dinner. Staff reported that an alternative is available if advance notice is given. The evening meal is the main meal of the day. Plenty of fresh fruit was freely available on the sideboard. There are no special diets needed and no-one needs assistance with eating. One service user said about shopping for food “ I don’t like it very much”. Another said they could “sometimes” choose what to eat. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents benefit from individual based care and support that is sensitively and discretely delivered by the staff. The home has appropriate systems in place for the safe management and storage of medication. EVIDENCE: A monitored dosage system is used. Staff are about to undertake formal training to administer medication, previously the manager had trained staff. There have been medication errors but these have been responded to appropriately. Storage and administration was inspected and found to be satisfactory. One service user self medicates and a risk assessment is in place. The manager’s quality assurance survey showed that one resident had wanted greater choice when choosing health professionals and staff did that this for them rather then individually. The manager was attempting to sort this out for the person. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service users are supported by policies, staff and people outside the organisation in having concerns raised and in being protected from harm. Staffs knowledge and understanding of adult protection issues supports a safe environment that can protect service users from harm. EVIDENCE: The Manager seeks and reports the views of service users in the Quality Assurance Audit. There are resident’s meetings, chaired by someone not directly involved in the home. Minutes are kept and service users spoke about these meetings as somewhere to bring up important things. The home has a complaints policy and procedure that has been improved since the last inspection and all service users have been given a “post card” to send off to CSCI if necessary. The system is working. One complaint has been received and resolved by the Commission. The manager should ensure that a stock of these cards is available anonymously in the home. One service user said they would tell the manager or their key worker if unhappy. One parent said, “ If I am unhappy, staff quickly move to resolve things” and reported only one such occasion in five years. Additionally there is also a Vulnerable Adults Procedure that has been improved following requirement made at the last inspection and staff receive Vulnerable Adult Awareness training. This reduces the risk of abuse, neglect or self-harm of the residents. There have been no reported incidents of alleged abuse. Staff demonstrated their awareness of reporting chains and responsibilities in the case of a suspicion of abuse. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The standard of the environment within this home is good, providing physically able service users with an attractive and homely place in which to live. EVIDENCE: The house is large, well maintained, attractively furnished and comfortable. One parent suggested that the service should actively plan for developing the building to meet the needs of current residents as they age and their mobility reduces. He suggests developing into the neighbouring property to provide ground floor bedroom and bathing facilities. This neighbouring property was once part of this house and is operated as an independent living flat by the Lisieux trust. He also requested a safer, larger vehicle for communal use, with better sized adult rear seats. There is a plan to provide a walk in shower for the first floor. All bedrooms and bathing facilities are on the first floor and there is no lift or stair lift at present. Two residents have mobility difficulties, which do not require specialist attention at the moment but are being kept under review. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34,36 Staff are appropriately trained and supported to meet the individual needs of service users and the aims and objectives of the home. However, whilst the existing staff showed themselves to be skilled and knowledgeable, the permanent staff team is far too small to be able to fully meet the needs of the people living at the home without dropping to minimum staffing levels thus reducing the individual care that can be given. Recruitment procedures are generally satisfactory, though the central recruitment office of the organisation has again failed to request information about applicants’ suitability for working with vulnerable people. This was a requirement made in March 05. This omission reduces the Manager’s ability to safe guard and protect residents when recruiting new staff. EVIDENCE: Staff were respectful, affectionate and caring about the service users at home during the inspection. Parents’ comments and service users’ replies bore this out. Training records evidenced a range of skills tailored to the needs of service users. 70 of staff have NVQ level 2 and professional 1:1 sessions with the manager and staff appraisal are established. Staff spoke with motivation and commitment. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 16 The rota showed that there were regular occasions when only one member of staff was on duty and the manager acknowledged that two staff were needed. The manager reported difficulties in recruitment of care staff, despite competitive pay scales. Parents commented in their questionnaires that two staff were needed, particularly at weekends and acknowledged the difficulties when staff left quickly. No agency staff are used and the small bank of relief staff is not able to supply replacements when needed. This puts service users at risk through low staff supervision and compromises the quality of individual attention they can expect to receive. An HR consultant is now working with the Trust to improve this situation. Staff said that they felt confident in the “on-call” system. A requirement made at the last inspection was not met, as demonstrated by the recruitment records of the newest member of staff. Two reference request letters did not seek confirmation of the applicant’s suitability to work with vulnerable adults. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,40,42,43 A well organised home and a committed, professional and well organised manager promote the comfort, safety and well being of the residents. The Manager ensures that individual service user views are taken into account in the running of the home. EVIDENCE: Action has been taken to meet requirements made at the last inspection for a fire safety risk assessment, removal of bolts and wedges from office door and to improve the evacuation risk assessment. There is a safe risk management system in place. Action has been taken to meet requirements made by the Fire service and Environmental Health. Service users are consulted and involved formally, through meetings, monthly update sessions and in the annual Quality Audit as well as in day to day choices they make. The manager undertook the first Quality Audit in September 2004 consulting with service users and their families and associated professionals. This audit has been made available and the next audit should be begun, improving and reporting on action taken. Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 X 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 2 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Francis House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 x 3 3 DS0000016992.V255155.R01.S.doc Version 5.0 Page 19 yes Are there any outstanding requirements from the last inspection? 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 2 Standard YA6 1YA33 Regulation 15 18 Requirement Care plans must be reviewed every six months and supporting documents must be updated. Ensure that sufficient staff are employed to work with the service users at the level of 2 staff to 9 residents, as deemed safe by the manager. The manager must ensure that Recruitment processes seek confirmation of the applicant’s ability and suitability to work with vulnerable adults in a residential setting. Timescale for action 01/01/06 01/01/06 3 YA34 7,9,19 01/01/06 Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The manager should investigate early mental health support from learning disability nursing services, both for individual service users and for training for staff. Supplies of complaints cards should be freely available in a discrete place along with other service user information 2 YA22 Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 46 – 46 Stephenson Street Birmingham B2 4UZ 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 Francis House DS0000016992.V255155.R01.S.doc Version 5.0 Page 22 - 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. 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