Inspection on 22/01/07 for Francis House

This inspection was carried out on 22nd January 2007.

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 no outstanding requirements from the previous inspection report, but made 5 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 26/01/06

Francis House 16/11/05

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 Gerard Hammond Unannounced Inspection 22nd January 2007 12:10 Francis House DS0000016992.V320650.R01.S.doc Version 5.2 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.V320650.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 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.V320650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Francis House Address Cofield Road Boldmere Sutton Coldfield West Midlands B73 5SD 0121 354 7772 F/P 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.V320650.R01.S.doc Version 5.2 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. 26th January 2006 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, a local voluntary organisation. The home is registered to provide accommodation and support for nine people with learning disabilities. All nine single bedrooms are situated on the first floor of the house, as is the Manager’s office. The home is furnished and maintained to a high standard and residents have helped in choosing how both their individual rooms and shared areas have been decorated. Downstairs is a comfortable lounge, with an additional room next to it that is used for a range of activities. The kitchen is roomy and open plan, and includes the main dining area. There is no lift facility within the home, so it would not be suitable for people with significant mobility problems. There is an attractive private and enclosed garden to the rear of the property, with a patio and seating area. The house is situated close to Boldmere village, and offers easy access to local amenities including shops, pubs, restaurants, and Sutton town centre is a short drive away. The area is well served by public transport. There is sufficient off road parking at the front of the house for five cars, including the service’s own vehicle. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered from a range of sources prior to the visit being made to this service. These included previous inspection reports, service history and the pre-inspection questionnaire and incident reports completed by the Manager, and reports submitted on behalf of the Registered Provider. Direct observation and sampling of records (including personal files, care plans, safety records and other documents) were also used for the purposes of compiling this report. The Inspector was able to meet with all of the residents during the course of the visit. The Manager was formally interviewed and the Inspector was able to meet with two other members of staff. A tour of the building was also completed. Following the inspection visit, the Inspector was able to speak with relatives of three of the residents by telephone. Thanks are due to the residents and staff team for their hospitality and support during the inspection visit. What the service does well: Service users enjoy living in a comfortable house that is homely and welcoming. The care team is well established and well motivated, and members show a good understanding of people’s support needs. Staff support people to get involved in things they value and like to do. They are able to be part of their local community, and to get involved in things around the house, according to their individual abilities and wishes. They are supported to keep in touch with their families and friends. The service provides people with a good standard of basic personal care and they are assisted to keep medical appointments and to access primary and specialist healthcare support, according to their needs. They are encouraged to eat healthily and enjoy their food. The home is generally well run. Feedback from relatives says that the Manager and care team are approachable and that any issues raised with them are listened to and dealt with promptly. Clear efforts are made to find out what people think about the service, and to act on it. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 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.V320650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is available to help people make a decision about whether or not to use this service. People are able to try it out, to help them make an informed choice about whether or not the home is right for them. Residents’ support needs are properly assessed, so that their care can be planned appropriately. EVIDENCE: There have been no new admissions since the time of the last inspection. Previous reports indicate that information required to support prospective residents in making a choice about whether or not to use the service (Statement of Purpose and Service User Guide) is readily available. This is supplemented by a DVD presentation about the work of the Lisieux Trust and the homes it runs, including Francis House. Reports also show that systems are in place to ensure that people would have opportunities to check out what the service has to offer, before making any decisions about moving in. Residents’ personal files were sample checked. It was noted that individual assessments were up to date and had been reviewed. The format currently in use also provided evidence of the use of person centred approaches, and this should be commended. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to help staff support residents according to their wishes. They are asked about how things are on a regular basis. Developing agreed goals and including more detail in individual care plans could improve good practice further. EVIDENCE: Sample checking of individuals’ records showed that care plans are in place and these provided further evidence of the use of person-centred approaches. Plans examined had been appropriately reviewed. In addition to required reviews, a system is in place where individuals’ key workers complete a monthly review sheet. These cover all their support needs and seek to ensure that issues are monitored frequently and regularly, so as to keep plans current and up to date. Again, this represents good practice and should be Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 10 commended. It was noted however, that in some instances these had not been completed every month. Some work is required to develop individual plans. Detail should be expanded so that it is clear how support should be given. For example, one person’s plan said “needs help with ironing”. The plan should give guidance as to what the person can currently do, say if perhaps some training might improve skills, and show exactly what the person supporting the service user needs to do. Another plan, about a resident’s shopping skills showed a need for “support to purchase items”. This could be expanded to say what the person’s understanding of the value of money is, how they might be supported to make choices about what to buy, and so on. It is important that the knowledge that members of the care team have gained over (in some cases) several years of working closely with service users is included in people’s plans. It was also noted that there is dedicated space within the current care plan format for identifying individuals’ goals. It is good to see that efforts have been made to set goals, but in some cases these are somewhat limited. It may be that this is an area for staff development, and this should be viewed as a work in progress. Goals need to be agreed with service users, and to have outcomes that can be measured. These should be evaluated when the plans are reviewed, and judgements made about what is working and what might need to be changed. Detailed risk assessments were in place on individuals’ files, but it is not always easy to correlate these with the care plans to which they relate. It is suggested that simple numbering and indexing of plans and risk assessments will facilitate this. Plans and risk assessments can then be cross-referenced to each other (e.g. “see risk assessments 2 & 5” etc.). However, conversation with the Manager showed that risk assessment is viewed positively and seen as providing opportunities for learning and personal growth. In addition to individual monthly meetings with key workers, residents have regular service user meetings, where the full range of issues of interest to them are discussed. These meetings are supported by an independent advocate. While reporting on matters that might be developed further or could be improved, it should be acknowledged that the systems currently in place (to support service users and help them make choices about their lives) are generally working very well. It is clear that the Staff team works very conscientiously to support the people in their care. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a good range of valued activities of their choosing and are very much a part of their local community. They are able to keep in touch with friends and family, and enjoy living at Francis House. Residents say that they like the food they get, and enjoy their mealtimes. EVIDENCE: Residents generally attend local centres and colleges for structured activities on weekdays. Sampled records showed a wide range of social and leisure activities are also enjoyed on a regular basis. These included meals out, going to the cinema, to the pub, going for walks, bowling, a trip to the illuminations, attending “Weight Watchers”, shopping, and going to a friend’s birthday party. Staff also try to support service users in meeting their spiritual needs. A number attend a local prayer group, and others are supported to go to places of worship of their choosing. The Home is well situated for access to local Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 12 amenities, and residents enjoy a real presence in their local community. Apart from their individual rooms, residents have access to a comfortable lounge and another separate room for “in house” games and activities, or just for relaxing in, when they are at home. Service users said that they enjoy living at Francis House. One resident’s father said his daughter had made a positive choice about going to Francis House “and never regretted it”. He said she has a very busy and active life, and had “developed a terrific amount” since moving there. The Manager advised that most residents’ relatives have well-established links with the home, and the majority regularly spend time visiting their families and staying for weekends. Relatives confirmed that they were able to keep in touch through visits, over the phone and on the Internet. The Inspector was able to sit with the residents while they had their evening meal. They said that in the mornings they are supported to get their own breakfasts. If they are at home for lunch during the week, then they are assisted to make sandwiches or an appropriate light meal. Staff said that each resident is encouraged to do whatever they can for themselves, so as to promote their independence. The main meal of the day is usually in the evening, and this is generally taken together, around the large dining table in the kitchen. This was directly observed and seen to be very convivial, having the feel of a large family gathering. Service users help to plan the menus, and those that want to are also directly involved in doing the shopping. Residents take turns to assist in preparing the meal, and everyone also gets involved in the household chores, in rotation. The record of meals taken showed that residents have access to a diet that is sufficiently balanced, varied and nutritious. Food stocks were plentiful and included fresh produce. As reported above, service users are also encouraged to eat healthily, and some attend “Weight Watchers” to help them achieve this. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from good quality personal care, and they are well supported to try and maintain a healthy lifestyle. They are generally well protected by the home’s practices relating to the storage, handling and administration of medication. EVIDENCE: It was noted that interactions between residents and staff were warm and friendly, and that both are clearly at ease in each other’s company. It is quite clear that service users have a good rapport with staff and are comfortable approaching them with any issues, and this was directly observed throughout the inspection visit. Staff were also seen to be appropriately respectful. Residents’ personal grooming and attire provided further evidence that service users receive a good standard of basic personal care. Records show that residents are assisted to access primary and specialist healthcare support (including GP, dentist, optician, chiropodist), in accordance Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 14 with their needs. As indicated earlier in this report, residents are encouraged to eat healthily and to monitor their weight, which is checked regularly. It was recommended at the time of the last inspection that Health Action Plans be developed for each individual. The intention here is to promote a more proactive “mindset” to personal health (rather than one that reacts when problems arise) and to build on existing good practice. As with general care planning, this should include setting some clear goals to actively promote each person’s healthcare. It might be helpful to do this in conjunction with the local community nurse for people with learning disabilities. This recommendation does not seek to imply that practice is not up to standard, rather to seek ways of developing it further. The Medication Administration Record (MAR) was examined, and had been completed appropriately. Medicines were stored securely, the store was clean and tidy, and creams / lotions were appropriately labelled with the date of opening. Written protocols were in place for PRN (“as required”) medication. It was noted that some of the protocols were generic in nature. These should be reviewed, to ensure that guidance given is specific and details precisely the circumstances in which medication should be administered. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their concerns are listened to, taken seriously, and acted upon. General practice in the service ensures that people are appropriately protected from abuse, neglect and self-harm. EVIDENCE: As indicated earlier in this report, residents are clearly comfortable in approaching the Manager or other members of staff with any concerns. During the inspection visit, they were directly observed doing this, and were happy to come to the office to seek out the Manager, demonstrating the stated “open door” policy in action. Residents’ meetings are held regularly and there are further opportunities to raise concerns when individuals meet with their key workers each month. Service users now also have postcards that they can send directly to the Commission for Social Care Inspection should they so wish. No complaints have been received in respect of this service since the last inspection. An appropriate Adult Protection Policy is in place. Information provided by the Manager with the response to the pre-inspection questionnaire shows that most of the staff team has completed training in the protection of vulnerable adults from abuse, or are scheduled to do so shortly. Sample checks of staff files showed that appropriate checks had been completed with the CRB (Criminal Records Bureau) prior to the commencement of employment. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27,28, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a house that is well maintained, comfortable and homely. They enjoy their home and the facilities it offers them meets their needs. Staff ensure that the house is kept clean and tidy. EVIDENCE: A tour of the premises was completed. All nine residents’ bedrooms are situated on the first floor. It was noted that rooms are very individual in style, with personal effects and possessions much in evidence. One of the bathrooms has now been converted to accommodate a “walk-in” shower: this is to ensure that residents’ future care needs can be met, as the new shower facilitates assisted bathing. A small repair to the tiles in this room is required to complete the job. The home’s other shower has also been refurbished, and there is an additional bath with shower over. Toilet and bathing facilities in the home are sufficient to meet service users assessed care needs: as previously reported Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 17 these are pleasant amenities, and allow service users the privacy to carry out personal care needs. In the evenings the large open plan kitchen-dining room is the hub of the home. This has been improved since the last inspection with new work surfaces and tiling. Residents can also enjoy relaxing in the comfortable main lounge, or make use of the adjacent additional room for activities, alternative TV watching, games, and so on. To the rear of the house is an enclosed private garden, with patio, seating area and garden furniture. Staff say that this is well used when the weather permits. The garden is attractively laid out, and can be accessed through two separate patio doors. There is a separate laundry room at the back of the house, and a new washing machine and tumble drier have been installed since the last inspection took place. Fixtures and fittings in the house are of a high standard. The home is comfortably furnished and provides residents with a welcoming, homely living environment. Staff work hard to keep the place clean and tidy for the benefit of the service users, and a good standard of hygiene is maintained throughout. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by a well-trained and qualified team of staff, who are positive about their work and the people they care for. Residents are protected by the organisations’ recruitment policies and practice, and benefit from staff that are well supported and motivated. EVIDENCE: Information provided with the response to the pre-inspection questionnaire shows that over 60 of the current staff team hold qualifications at NVQ Level 2 or above. Previously vacant posts are now filled, and a regular member of “bank” staff covers an average of two shifts per week. Staff say that their colleagues are very supportive, and observations confirm that the team has a very cohesive feel about it. Staff spoke positively about the job they do and the people they support. Service users’ relatives said that staff are “very caring” and “always want to do better”. Another said that staff are “kind and helpful” and also “they communicate well, are approachable and keep us informed”. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 19 The organisation runs a rolling programme of training for staff across all of its services. A training and development plan is in place for the staff team, and shows that statutory training has generally been delivered as required. Two staff files were sample checked. Both contained completed application forms, two written references, evidence of CRB (Criminal Records Bureau) checks, appropriate induction and also of regular staff supervision. Staff team meetings are also held at regular and frequent intervals. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy living in a home that is generally well run for their benefit. Action is taken to find out what they think, and to make use of this information positively. Residents’ health, safety and welfare are generally safeguarded, but some improvement is required to one or two practices so as to ensure continuing protection. EVIDENCE: The Manager is qualified to NVQ level 4 and has now been in post for a number of years. Her management style is open and inclusive. Staff report that she is approachable, and, as reported above, it is clear that residents are Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 21 comfortable about coming to her with any concerns. This was directly observed. This view was reinforced by feedback from relatives who said, “her door is always open” and “you can always speak to the Manager”. They also said “things get sorted out straight away”. As indicated earlier in this report, the views of people using the service are actively sought through a number of different ways (e.g. residents’ meetings, key worker reviews etc.) on a regular basis. The home produces an annual quality assurance report, and a copy of this was provided during the inspection visit. Relatives also said that they received a copy. It was noted that, although visits and reports required under Regulation 26 (Care Homes Regulations 2001) have been done during the year, that the frequency of these is not currently up to the required standard (i.e. monthly). The Registered Provider should ensure that such visits take place as appropriate, and reports duly completed. Safety records were sample checked. The fire alarm system has been serviced, and the Manager reported that work required on fire doors in the home has now been done. Fire safety training has been delivered, and it was reported that building evacuations are performed on each occasion that the alarm is tested. It was decided that this is potentially less confusing for service users. It was noted that although testing of the fire alarm system is generally carried out as required, that there were significant gaps in the record. The Manager must ensure that tests are carried out each week, and a written record fully maintained. Records for other safety checks (water temperatures, portable appliance testing of electrical equipment, gas safety) were all in order and complete. It was noted that the home’s hard wiring certificate is in date, but requires renewal in three months time. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 2 x Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Expand detail in individual plans so that preferences are clear, and precise guidance about how support should be given is shown Review protocols for PRN (“as required” medication, to ensure that guidance about the circumstances in which medication should be given is clear. Repair / replace tiles in first floor shower room The Registered Provider must ensure that visits required under this regulation (Care Homes Regulations 2001) are carried out each month, and reports duly completed Ensure that the fire alarm is tested each week, and a complete record maintained. Timescale for action 30/04/07 2. YA20 13 (2) 31/03/07 3. 4. YA27 YA39 23 (2b) 26 31/03/07 31/03/07 5. YA42 13 (4c) 23 (4c) 31/03/07 Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 24 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. Refer to Standard YA9 YA19 Good Practice Recommendations Number and index care plans and risk assessments, so that one can be cross-referred to the other, and vice versa. The service users should be supported to have individual health action Plans. Francis House DS0000016992.V320650.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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