Inspection on 12/05/05 for Francis Lodge

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Francis Lodge 30/03/10

Francis Lodge 02/12/08

Francis Lodge 06/12/07

Francis Lodge 19/02/07

Francis Lodge 03/05/06

Francis Lodge 27/09/05

Francis Lodge 21/10/04

Francis Lodge 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Francis Lodge 4 Belsize Road Harrow Weald Middlesex HA3 6JJ Lead Inspector Andreas Schwarz Unannounced 12 May 2005 9.00am 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 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. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Francis Lodge Address 4 Belsize Road Harrow Weald MIddlesex HA3 6JJ 020 8931 2108 020 8931 2108 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Monica Maxwell Ms Monica Maxwell Care Home 3 Category(ies) of OP 3 registration, with number of places Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 21st October 2004 Brief Description of the Service: Francis Lodge is a semi-detached house in a quiet residential street located in Harrow Weald. The home is a registered care home offering personal care for three older people, aged 65 years and over. There is space to park one car in the front drive of the home and unrestricted parking on the road. The home has a large garden, which can be accessed by steps though the kitchen. One service users room is located on the ground floor with en-suite facilities. Two bedrooms are on the first floor. There is a bathroom and toilet located on the first floor. The home is fairly close to community and leisure facilities within Harrow Weald and Stanmore. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two mornings in May 2005, 12th May 2005 over three hours and half hours and 18th May 2005 over three hours. The reason for having two inspection days was that the inspector was unable to assess standards on the first visit due to most documents not being available for inspection. The inspector called the proprietor Mrs Maxwell on 17th May 2005 asking her to make the missing documentation available for inspection. During the inspection the inspector spend time with the manager/proprietor explaining the difference between National Minimum Standards and Care Home Regulations 2001. The inspector was able to talk to all residents, one member of staff and the manager. Positive feedback was received from residents for example “I treat this home like my own” and “Staff treat me with a lot of respect”. The inspector would like to take the opportunity thanking residents, staff and manager for making him felt welcome during both inspection days. What the service does well: What has improved since the last inspection? The home implemented all requirements made by CSCI Pharmacy Inspector and did some work on requirements from the previous unannounced inspection. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 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 Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1; 3; 4 The homes Statement of Purpose (SoP) and Service User Guide (SUG) are not compliant with standards and residents are not able to make a full informed choice about where they want to live. Resident’s needs are assessed, but further work will be required to comply with National Minimum Standards. EVIDENCE: The inspector viewed the SoP and a brochure of the home. Both documents are not adequate and need to be reviewed to comply with National Minimum Standards. The inspector explained in detail what the two documents must entail and went through the NMS and Regulations with the manager/proprietor. These issues have been addressed in previous inspections and are still outstanding. The inspector viewed assessment forms of residents currently living in the home, however only one of the forms viewed have been filled out. It is required to needs assess all residents admitted to the home. The resident’s carer and or family member fills in the forms. The assessment form is detailed and assesses independence, mobility, dressing, washing, medication, behaviour, finance, death and dying, etc. The needs assessment of service Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 9 users must be done by someone other than carers or family members, unless suitably qualified to do needs assessments. The assessments seen form part of residents care plans and staff showed good understanding of residents needs. The home’s admission policy was not available for inspection and the home must make sure there are adequate policies for the admission of service users in place. The home currently meets the needs of residents living at Francis Lodge. The home does not provide services for people with dementia, sensory impairment, physical disabilities, learning disabilities, etc. and is not registered for providing these services. The home has improved their care plans and staff/manager were observed having a good understanding of residents needs. Residents informed the inspector they were happy at the home and considered the care received by staff as being adequate and satisfactory. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7; 8; 9; 10; 11 Progress has been made in improving care plans for residents and health care needs are identified and met. The home has improved their medication procedures and received a positive report after the most recent CSCI pharmacy inspection. Residents are treated with privacy and have the choice to meet people or being on their own. EVIDENCE: The inspector viewed all three care plans, which were made available for inspection. Care plans were found to include residents likes, dislikes, health needs, visits to health care professionals, activity charts, pressure sore management, risk assessments, etc. The manager reviews care plans monthly and residents have signed review minutes to show their participation. Not all care plans were found to be of the same standards and the manager is required to up date and bring all care plans to the same standards. The inspector has assessed resident’s health care records. The home records what assistance is given maintaining residents personal hygiene daily. Resident’s pressure sores have been monitored and treated by the GP and regular visits from the community nurse. The home provides equipment for Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 11 pressure relief such as mattresses and cushions. Psychological health needs are monitored within the care planning process but not all detail was recorded. The home monitors residents weight regularly and recording sheets have been viewed by the inspector. Residents are registered with a local GP and are visited by their doctor as and when needed. Records showed that residents receive regular visits from chiropodist, optician and other health care professionals. The home was visited by the CSCI Pharmacy Inspector on the 3rd November 2004 and had an additional visit on the 15th March 2005. The report of the most recent visit was positive and the Inspector stated that medication procedures have improved. Requirements made by the pharmacy inspector are documented in this report and are available on request. The inspector raised the following issues during this inspection. Medication for the next cycle were not locked away and found on a table near the cooker; it is required to store all medication in a locked cupboard. The homes medication procedure has no PRN guidelines, which is required. Staff informed the inspector that they had received medication training, but certificates were not available for inspection. The inspector observed staff treating residents with respect and dignity; residents the inspector has spoken to confirmed this. The home has a cordless phone and residents are able to use this in the privacy of their room. Mail was observed to be handed to the resident unopened. Staff informed the inspector that they would knock the door before entering residents rooms and address service users with their preferred name. Residents were observed wearing clean and well-maintained clothes. The home assesses residents’ wishes in regards death and dying in the initial assessment process, but policies and procedures were not available for inspection and the manager is required to provide these. Additionally resident wishes must be discussed with service users and appropriate arrangements must be put in place. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 14; 15 Standard 14 has not been fully assessed during this inspection, however previous requirements were still found to be outstanding. Residents receive a wholesome, varied diet and appealing diet. EVIDENCE: The inspector viewed the home’s menu and spoke to residents regarding the meals received at the home. Residents’ comments were overall very positive and the inspector observed lunch being served looking appetizing and smelling nice. The main meal of the day is served at lunch. Menus assessed showed that the home is providing a varied meal choice with cooked meal and dessert. Fruit and snacks were available during the inspection and residents can have snacks during the day if they wish to do so. It was not clear to the inspector how residents are involved in choosing their meal. Residents informed the inspector “I eat what they give to me”. The home does not record meal choices, which is required. One resident is diagnosed with diabetes and the inspector observed staff giving fruit in syrup to the resident, which is judged as not being appropriate. Some food in the home’s fridge was found to be out of date; it is required to provide food within the manufactures use by date. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16; 18 Complaints are not handled properly and necessary policies and procedures were found not to be in place. The lack of a vulnerable adults policy does not ensure that the people living in the home are protected from abuse. EVIDENCE: The home’s complaints procedure was not available for inspection and residents informed the inspector that they have never received a copy and were not aware whom to complain to when asked by the inspector. These issues have been addressed in previous inspections and were found to be still outstanding. The home has not recorded any complaints received since the last inspection. The lack of a vulnerable adults policy is concerning, additionally the home has no whistle blowing or Management of Aggression policy in place. Staff informed the inspector having received POVA training, but no records where made available to validate this. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19; 22; 25 Residents are living a nicely decorated, clean and safe environment; however further work will be required to achieve full compliance. Specialist equipment provided is well maintained and residents can safely use the stair lift available to them. Overall the home has been judged as being comfortable and safe, however previous requirements are still outstanding to be complied to. EVIDENCE: The inspector was shown around the home by a member of staff, all residents invited the inspector and showed him their room. The inspector found the light pull switch in the en-suite bathroom being faulty and required to have this repaired. The home was judged as being nicely decorated, clean and very homely. Furniture is of domestic character and pictures as well as photos and ornaments were on show throughout the home. Residents can access all areas in the home. The garden can be accessed through the kitchen and was in need for some attention as the grass was very high and the inspector felt this would hinder access for residents. The home has no fire risk assessment in place and is required to provide this for the following inspections. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 15 The home’s stair lift was found being in working order and good condition, recent maintenance certificates were available for inspection and of satisfactory standards. Documentation of safe working practices for the stair lift was made available for inspection, however the inspector observed staff not using the seatbelt when using the lift for one service user. The manager is required giving staff appropriate training in the safe use of the stair lift. The home is bright, airy and nicely ventilated. There is central heating around the home and radiators are guarded. Staff informed the inspector that they measure water temperature daily, but records were not available for inspection. The home has no Legionella risk assessment, which has been required in previous inspections. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29; 30 Staff employment history and documentation is not checked appropriately and residents are not protected appropriately by the home’s recruitment practice. Staff are not appropriately trained and is not clear if they are competent to do their job. EVIDENCE: The inspector viewed the home’s job descriptions, which defines the responsibilities of carers clearly. The blank contract shows that all staff have six months trial periods, but does not include the pay, how to be paid and the number of holidays, which the inspector recommends be added to the contract. The home has a disciplinary procedure, but it is not clearly defined within this procedure when staff are disciplined and/or dismissed. Four staffing records were made available for inspection, not all records included the required documents and the manager is required to include them for existing and new staff. Training records were not available for inspection. Staff, the inspector has spoken to say they have received one day induction training, but no further training since starting in March 05. However the member of staff informed the inspector having attended Medication training and First Aid training in her previous job. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33; 37; 38 The homes annual development plan was not made available; the inspector was not able to fully assess if the home is run in the best interest of residents. Service users’ records are not fully accessible for this inspection and it was not able to fully assess if the home safe guards service users rights. Health and safety records are in need of updating to comply with standards. EVIDENCE: The home has no annual development plan in place and there was no evidence that residents are consulted in the running of the home. The manager must forward an annual development plan to the Commission of Social Care Inspection once it has been developed. Feed back from residents and staff about the service was however positive. The Inspector could not assess policies and procedures, due to not being made available and/or not being in place. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 18 Numerous records were not made available for inspection and the manager is required to have these available for the inspector to view at any time. This has been required in previous inspections.The manager informed the inspector having records and documentation in her private home for updating. The inspector viewed Health and safety records made available to him. - Portable Equipment certificate expiring 22/11/04 - Stair lift service expiring 1/11/05 - Gas certificate expired 16/09/03 and must be renewed. Electrical Installation and fire equipment checks were not available for inspection. The home checks the fire alarm monthly and documents for this were found to be in order. The last recorded fire drill was on 14/08/02. A fire risk assessment has been put in place in form of a diagram and must be up dated to have a clearer understanding of the fire risk. Accident and incident book was assessed and no accident/incident has been recorded since 08/10/02. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 2 x x 2 x x 2 x STAFFING Standard No Score 27 x 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x x 1 x x x 1 1 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 20 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. Standard OP1 Regulation 4(1) c Schedule 1, 1-18 Requirement The required Statement of Purpose must include a statement of the facilities and services that are to be provided by the Registered Provider to service users and those items identified within Regulation 4 (1) (c), Schedule 1, 1 to 18. (Timescale of 17/10/03, 10/6/04, 10/8/04 & 11/01/05 not met) The required ‘Service Users Guide’ for the care home must contain a statement about the terms and conditions in respect of accommodation to be provided to service users, including as to the amount and method of payment of fees. This is in addition to other items identified within Regulation 5. (Timescale of 17/10/03, 10/6/04, 10/8/04 & 11/01/05 not met) When available, full copies of the Statement of Purpose and ‘Service Users Guide’ for Francis Lodge are required by the Commission for Social Care Inspection. (Timescale of 17/10/03, Timescale for action 11/01/05 2. OP1 5 11/01/05 3. OP1 4(2) & 5(2) 18/01/05 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 21 4. OP3 14(1)(a) 5. OP7 17(1)(a) Schedule 3 17(1)(a) Schedule3 (3)(k) 13(2) 6. 7. OP8 OP9 8. 9. 10. OP9 OP9 OP11 13(2) 13(2) 12(2) 11. OP14 12 12. OP15 17(2) Schedule4 (13) 13. OP15 17(2) 10/6/04, 17/8/04 & 18/01/05 not met) The home must not provide accomodation to service users unless their needs have been assessed by a suitably qualified person. All care plans must be up dated and include requirements stated in Schedule 3 of Care Homes Regulations 2001. The manager is required to record residents psychological health care needs. It is required that the requirements arising from the Commission for Social Care Inspection Pharmacy Inspectors unannounced visit to the care home are complied with, within the stated timescales. The manager must include PRN guidelines within the medication procedure. Medication must be kept locked away when not in use. The manager must provide a detailed policy on Death and Dying and residents wishes must be discussed with service users. Develop an ‘Access to Records Policy’ for the care home. (Timescale of 17/11/03, 20/9/04 & 21/01/05 not met) There must be a record of the foods actually provided for individual service users in order to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition and otherwise, and any special diets prepared for service users. Timescale of 10/5/04, 24/7/04 & 01/01/05 not met) It is required to provide low sugar or no sugar diet to residents being diagnosed with 30/06/05 31/07/05 30/06/05 30/06/05 30/06/05 31/05/05 30/06/05 21/01/05 01/01/05 31/05/05 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 22 high glucose levels. 14. 15. OP15 OP16 13(4)c 22 Food provided must be within manufacturers use by date. The ‘Complaints Procedure’ must be updated to include all aspects required by Regulation. (Timescale of 17/10/03, 27/7/04 & 21/01/05 not met) The ‘Complaints Procedure’ for Francis Lodge must also be included with the home’s Statement of Purpose and Service Users Guide. (Timescale of 10/8/04 & 11/01/05 not met) The ‘Complaints Procedure’ must be appropriate to the needs of the service user and each must be supplied with a copy, as does any person acting on the service users’ behalf that requests one. (Timescale of 10/8/04 & 11/01/05 not met) There must be a written adult protection procedure for this home (including ‘WhistleBlowing). It must be linked to the local authority protection of vulnerable adult procedures. (Timescale of 17/9/03 & 21/01/05 not met) There must be a written policy and procedure on the management of aggression and challenging behaviour. (Timescale of 17/9/03 & 21/01/05 not met) Staff must receive training in adult protection. (Timescale of 17/10/03 & 21/02/05 not met) It is required to provide an up to date fire risk assessment (Timescale of 21/01/05 not met) The light pull switch in the ensuite bathroom must be repaired The garden must be attended to 31/05/05 21/01/05 16. OP16 22 11/01/05 17. OP16 22 11/01/05 18. OP18 13(6) 21/01/05 19. OP18 13(6) 21/01/05 20. OP18 13(6) 21/02/05 21. 22. 23. OP19 OP19 OP19 22(2)(n) 23(2)(d) 21/01/05 30/06/05 30/06/05 Page 23 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 24. 25. OP22 OP25 13(4) 26. OP25 13(4) 27. OP29 18 28. OP29 19(1)(b) Schedule2 29. OP29 19(1) 30. OP29 19(5)c providing safe access for residents, staff and visitors. The manager is required to provide training in the safe use of the homes stair lift. Mechanisms must be in place to prevent the risk of Legionella in Francis Lodge. This includes the maintenance of the hot water temperatures at required levels in the tank and pipe work. (Timescale of 17/12/03, 20/8/04 & 21/01/05 not met) It must be ensured that the hot water runs at a temperature close to 43 °C in order to avoid a risk of scalding whilst also maintaining preventative measures to prevent the risk of Legionella.(Timescale of 21/01/05 not met) Policies need to be developed for staff grievances and disciplinary procedures. (Timescale of 17/11/03 & 21/02/05 not met) New staff, employed after April 2002, must have a cleared ‘Enhanced’ CRB check before starting work. (Timescale of 17/9/03 & 21/12/04 not met) Two references must be obtained in respect of applicants for employment in the care home, before the member of staff commences work, and are duly authenticated by the Registered Provider. (Timescale of 20/7/04 & 21/12/04 not met) The Registered Provider must ensure that applicants for jobs in Francis Lodge are physically and mentally fit for the purposes of the work that they are to perform. (Timescale of 20/7/04 & 21/12/04 not met) 15/06/05 21/01/05 21/01/05 21/02/05 21/12/04 21/12/04 21/12/04 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 24 31. OP29 19(1)(b)(i ) 32. OP30 18(1)c 33. OP30 18(1)c 34. OP32 24 35. OP33 10(1) & The Registered Provider must ensure that there is the required documentary evidence relating to proof of the applicant’s identity and the applicant’s right to work. (Timescale of 20/7/04 & 21/12/04 not met) The staff induction must be to NTO specification and available to new staff within 6 weeks of appointment to their posts. The induction must include training on the principles of care, safe working practices, the organisation and the worker role, the experiences and particular needs of the service user group. Details of staff’s training must be recorded and form part of their individual training and assessment profile. (Timescale of 17/11/03, 17/1/04, 20/9/04 & 21/02/05 not met) Foundation training to TOPSS specifications must be provided within 6 months of a new member of staff starting employment. A record of this training must be kept. (Timescale of 17/1/04 & 21/03/05 not met) An annual development plan must be developed for Francis Lodge as required. This review must include consultation with current service users, their representatives and other stakeholders about the quality of care provided in the care home. A copy of the report of the annual review must be forwarded to the National Care Standards Commission and service users. (Timescale of 17/12/03 & 21/02/05 not met) Ensure that the required Policies 21/12/04 21/02/05 21/03/05 21/02/05 21/02/05 Page 25 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 12(1) 36. OP37 17(1)(a), Schedule2 ,2 17(1)(2) Schedule (3)(4) 37. OP37 38. OP38 13(4) 39. OP38 13(3)(4) 40. OP38 24(4)(e) 41. OP38 13(3)(4) 42. OP38 13(4) and Procedures for the home are developed. (Timescale of 17/11/03 & 21/02/05 not met) Service user records must include a photograph of the individual. (Timescale of 17/11/03 & 21/12/04 not met) It is required that the required range of records and other records to be kept in a care home are established as required by Regulation 17 (2), Scheds. 3 & 4. (Timescale of 17/11/03, 10/6/04 & 21/01/05not met) The Registered Manager must ensure safe working practice in the care regarding moving and handling, fire safety, first aid, food hygiene and infection control. This includes staff training and written guidance. (Timescale of 20/9/04 & 21/02/05 not met) Ensure that the home has available risk assessments in respect of safe working practice topics and record of significant findings. (Timescale of 20/9/04 & 21/02/05 not met) It is required that fire drills and practices are carried out on a quarterly basis with a record maintained. (Timescale of 20/7/04 & 21/01/05 not met) A ‘Health & Safety’ policy for Francis Lodge, including compliance with all relevant legislation, is required. (Timescale of 20/8/04 & 21/01/05 not met) The following certificates must be forwarded to the inspector. Electrical Installation certificate, gas certificate by CORGI 21/12/04 21/01/05 21/02/05 21/02/05 21/01/05 21/01/05 30/06/05 Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 26 registered technician, Fire Equipement service certificate and up dated fire risk assessment 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 OP3 OP29 Good Practice Recommendations The inspector recomends having an up-to-date admission policy in place. The inspector recomends including rates of pay and leave entittlement in contracts given to staff. Francis Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Lodge G62-G11 S17571 Francis Lodge v212105 120505 Stage 4.doc Version 1.30 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!