CARE HOMES FOR OLDER PEOPLE
Francis Lodge 4 Belsize Road Harrow Weald Middlesex HA3 6JJ Lead Inspector
Robert Bond Key Unannounced Inspection 19th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000017571.V325203.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000017571.V325203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Francis Lodge Address 4 Belsize Road Harrow Weald Middlesex HA3 6JJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8931 2108 020 8931 2108 Ms Monica Maxwell Ms Monica Maxwell Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places DS0000017571.V325203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd May 2006 Brief Description of the Service: Francis Lodge is a semi-detached house that is located in a quiet residential street in Harrow Weald. Francis Lodge is registered as a care home to provide personal care only to 3 adults, aged 65 years and over. It does not offer a specialist service. The home has a garden that can be accessed by steps through the rear of the house. One bedroom (with an en-suite) is located on the ground floor and the other 2 bedrooms are on the first floor. There is a bathroom and toilet on the first floor of the building. The home has a stairlift. The Proprietor maintains a private room on the first floor. The care home is fairly close to community and leisure facilities within Harrow Weald and Stanmore. The care home has off road parking on its driveway in addition to unrestricted street parking. Mrs Maxwell is the Registered Provider and Manager. The fees are £450 per week. DS0000017571.V325203.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report is of an unannounced inspection that took place over one day. The inspection was a ‘key inspection’ that considered mainly the key National Minimum Standards (NMS) for care homes for older people, as created by the Department of Health. The Inspector toured the premises, interviewed the Registered Manager who is also the Proprietor, interviewed the Senior Care Worker, met all three service users, observed care practices, and examined a range of records and files. The Inspector assessed the home’s performance against the anticipated outcomes for 24 of the Standards, and found that 13 were fully met, whereas 11 were only partly met. This led to the Inspector making 22 requirements and 1 recommendation. The previous CSCI inspection had resulted in 46 requirements being made. Of these 32 have been complied with, whilst 14 remain outstanding and hence have been restated within the 22 requirements made this time. The Statutory Requirement Notice issued on 25th October 2006 has been complied with. The Proprietor reported that she is intending to cease to be the Registered Manager as she is going to request the CSCI to register the current Senior Care Worker as the new Registered Manager. The overall standard of the home has improved significantly What the service does well: What has improved since the last inspection?
DS0000017571.V325203.R01.S.doc Version 5.2 Page 6 Care plans have been extended to include further aspects of health, personal care and social care needs. The recording of pressure area care, and oral care needs are examples of this. A new and improved care plan format is being introduced. An improved risk assessment process is being introduced. The keeping of daily records has improved. Staff have been provided with some additional instruction and training in aspects such as catheter care. The keeping of the records of service users’ weight has improved. Medication records have been improved. Key policies are made available to service users by being kept in the dining room. The home’s complaints policy and procedure has been improved. The home’s staff have been externally trained in Adult Protection. A new front porch has been built. New carpets have been laid. The bathroom ceiling paper has been stuck back. Staff have been trained internally concerning the safe operation of the stairlift. Staff have been trained in manual handling techniques. Staff recruitment procedures and induction training have been improved. Training records have improved. Consultation with service users is now more formalised. The risk assessment records of aspects of the premises have improved. Certificates of safety for electricity and gas installations within the care home have been produced. DS0000017571.V325203.R01.S.doc Version 5.2 Page 7 What they could do better:
The home must produce a Statement of Purpose and a Service Users’ Guide that comply with the Care Standards Act requirements, and supply these documents to the CSCI and to service users. Each service user and where appropriate their next of kin must be issued with a contract or statement of the terms and conditions of their residency in the care home, and a signed copy of the document must be kept on file for inspection. Care plans must indicate how all assessed needs are to be met, including toileting and bathing. Where a service user is unable to sign their agreement to a care plan, a representative must sign on their behalf. A photograph must be kept of each service user. Risk assessments must be reviewed on a more regular basis. Staff must receive external training in medication procedures. The home must have a Disclosure or Whistle-blowing policy. The home’s leaflet on the Protection of Vulnerable Adults (also known as Safeguarding Adults) must refer to ‘whistle-blowing’ and acknowledge the role of the CSCI in adult protection investigations. The rear steps to the garage area must be levelled to avoid a trip hazard for service users. The hot water temperature must be reduced to around 42 degrees Centigrade. A Legionella safety certificate must be obtained. The rear garden must be cleared of rubbish such as a broken tumble drier and a felled tree. The rickety occasional table in the lounge must be mended or replaced. It is recommended that internal written references are put on file when a former employee is re-engaged. The target of 50 of the care staff having NVQ level 2 or 3 awards has not yet been achieved.
DS0000017571.V325203.R01.S.doc Version 5.2 Page 8 The home is required to have a Grievance Procedure for staff to use. The CSCI require to be sent a copy of a current insurance certificate. Fire drills must be at least quarterly, and their dates and outcomes recorded. Regular health and safety checks of the premises must take place. Hot water temperatures must be taken and recorded weekly at all points where service users have access to the hot water supply. 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. DS0000017571.V325203.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000017571.V325203.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective and actual service users do not have sufficient information they require to make a fully informed choice as the Statement of Purpose and Service Users’ Guide do not completely meet the NMS. Service users’ care files do not contain a copy of the written contract or statement of terms and conditions concerning their residency. No service users have moved into the care home since before the previous CSCI inspection, hence no initial assessments have been undertaken on which to make a judgement. The home does not offer intermediate care. EVIDENCE: The Inspector examined the home’s Statement of Purpose and Service Users’ Guide. Although the Registered Manager has updated these documents and has made the documents available to existing service users and the CSCI, the documents still do not meet the requirements of the Regulations. This is because the Registered Manager, who is also the Proprietor, did not have available a copy of the NMS. The Inspector allowed her to photocopy the
DS0000017571.V325203.R01.S.doc Version 5.2 Page 11 relevant sections of his NMS, and provided advice on how to obtain a full set of the Standards. Requirements 1, 2 and 3 are restated. The Inspector examined all three service users’ files. None contained initial assessments by the referring agency or by the home itself, but in one case a full assessment had been subsequently undertaken on 04/02/07. It was noted that the Manager Designate (Senior Care Worker) was reorganising and extending the care planning system. None of the files contained a copy of the contract or terms and conditions of residency within the care home. Each service user and/or their relative must be issued with this document, and a signed copy must be retained on file within the care home. Requirement 4. DS0000017571.V325203.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are set out in individual plans of care, but not always in sufficient detail. Service users’ health needs are fully met. Service users are sufficiently protected by the home’s medication procedures but external training must be provided. Service users are treated with dignity and their privacy is upheld. EVIDENCE: The Inspector examined the care plans of all three service users. The Manager Designate is in the process of introducing an extended and improved care planning system, and is in the process of transferring information from the old system to the new one. It was noted that personal care needs, health care needs and social needs have been assessed, and recorded better than before. There is still some way to go, as for example a bed-bound service user’s toileting and bathing needs,
DS0000017571.V325203.R01.S.doc Version 5.2 Page 13 and how to meet them, were not recorded. Hence Requirement 5 is restated. Spiritual needs were recorded. Oral care needs were recorded. It was noted that a service user’s file contained a ‘consent to care plan content’ form but it had not been signed by the service user (who was too ill to do so), nor by any relative, or the service user’s key worker. See Requirement 6. Another service user had however signed her care plan. None of the care files contained a photograph of the service user. See Requirement 7. Care plan files contained a record of outings. Daily record notes have been improved as from 06/02/07. On one file, the latest risk assessment was dated 03/07/06. The Registered Manager believed it had been reviewed since and agreed to fax a copy of the updated risk assessment to the CSCI. In the meantime Requirement 8 is restated. The care plan had been reviewed on 03/01/07. The Inspector noted monthly weight charts, nutritional assessments, food and fluid intake notes, and details of medical appointments. The Manager Designate reported that District Nurses visit twice a week to advise on any pressure area treatment necessary and to deal with catheter care. The nurses maintain their own notes. The Inspector examined the homes storage arrangements for medication, and the records of its administration. No issues were noted. The Registered Manager reported that the pharmacist has not yet provided training for the home’s staff in medication issues hence Requirement 9 is restated. The Inspector observed that service users were treated with respect and that their dignity was maintained. Cash boxes are provided for service users to keep their valuables or private possessions in. DS0000017571.V325203.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle within the care home meets their needs for a quiet life but with activities offered. Sufficient links are maintained with family and community. Service users are given choices and are consulted. Service users received a sufficiently wholesome diet in pleasant surroundings and served at appropriate times. EVIDENCE: The Inspector noted that care files contain a record of activities undertaken. The Inspector saw an activity timetable that included church attendance, music and movement, watching named television programmes, doing crosswords and playing dominoes. On the day of the inspection, one service user was bed bound but was being visited by another service user. The third service user was watching television. The home has a visitors’ book that indicates visits do take place. The care plans indicate some involvement by relatives.
DS0000017571.V325203.R01.S.doc Version 5.2 Page 15 The Inspector observed details of service users’ meetings where food and activity choices are discussed. The Inspector examined the home’s food menu, which was satisfactory. He observed service users eating their lunch, which was sausage casserole, mashed potato, and cabbage, followed by rice pudding. One service user told the Inspector he was satisfied with the food served in the home. DS0000017571.V325203.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has in place a satisfactory complaints procedure. The home’s adult protection procedure and leaflet are not adequate as they do not refer to the role of the CSCI, or the role that staff might play in ‘whistleblowing’. EVIDENCE: The Inspector examined the home’s complaints policy and procedure, which were satisfactory. The Inspector was unable to examine the home’s complaints record as the Manager Designate did not have access to it. The two service users who the Inspector spoke to said they did not have any complaints to make about the care they received. The Inspector examined a recently produced leaflet concerning the Protection of Vulnerable Adults (POVA). The leaflet is not adequate as it refers to the Local Authority Inspection Unit instead of the CSCI, and does not indicate to staff their duty to report any potential abuse they observe in line with the home’s yet to be written Disclosure (Whistle-blowing) policy. Requirement 10 is restated, and see Requirement 11. The Registered Manager reported that staff had been externally trained in POVA. The Inspector noted training certificates for two staff members. DS0000017571.V325203.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is not sufficiently safe or well maintained in the sense that potential avoidable hazards remain. The hot water system is not sufficiently safe in terms of temperature and potentially Legionella. The home is clean, pleasant and hygienic. EVIDENCE: The Inspector toured the premises including the back garden. He found the home to be reasonably spacious, well decorated, clean and hygienic, and generally adequately furnished and equipped. No unpleasant smells were noted. The following however require attention. DS0000017571.V325203.R01.S.doc Version 5.2 Page 18 The Registered Manager reported that the rear side steps to the garage area had not yet been levelled to avoid a trip hazard for service users. Requirement 12 is therefore restated. The hot water temperature was found by the Inspector to be excessive and it must be reduced to around 42 degrees Centigrade. The Registered Manager reported that a Legionella safety certificate had not yet been obtained. Requirements 13 and 14 are therefore restated. The rear garden was seen to contain a broken tumble drier, and a tree that had blown over. These must be removed to make the area safe and attractive for service users to use Requirement 15. The rickety occasional table in use in the lounge must be repaired or replaced as it is used to hold hot drinks that could scald a service user in the event of the table collapsing. See Requirement 16. The Inspector was pleased to note that new carpets had been laid, much redecoration had been achieved, and a new front porch installed. The home has a stair-lift to the first floor. The Registered Manager/Proprietor reported that she has plans to have a conservatory built at the rear of the home. The Registered Manager/Proprietor maintains a locked room on the first floor. The Inspector was not allowed access to it, and was provided with conflicting information as to whether or not this room was used by the member of staff who sleeps in the home overnight on a rota basis. DS0000017571.V325203.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed and deployed. Service users are in safe hands. Service users are protected by adequate recruitment policy and practices, except that the home has no Grievance Procedure. Staff are being trained but insufficient are qualified at present. EVIDENCE: The Inspector examined the home’s staffing rota, which was satisfactory. Sufficient staff were on duty on the day of the inspection. The Registered Manager reported that two staff members were undertaking NVQ level 2 awards, and the Manager Designate was also undertaking the NVQ 4 management qualification. The 50 qualification target has not yet been reached so Requirement 17 is restated. The Inspector noted that two staff members had recently received POVA training. In house training had been provided on catheter care. The Inspector noted the home’s training plan for the year ahead. The Inspector examined the recruitment papers for a recently recruited employee. Appropriate recruitment checks had been undertaken except that only one reference had been forthcoming. As the employee had previously
DS0000017571.V325203.R01.S.doc Version 5.2 Page 20 worked at Francis Lodge, an internal reference could be provided by the Proprietor. See Recommendation 1. The Registered Manager reported that a Grievance Procedure has not yet been written, hence Requirement 18 is restated. DS0000017571.V325203.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in home which is run and managed satisfactorily. The home is run in the best interests of service users. Evidence of adequate insurance cover is required. The CSCI is unable to judge whether service users’ financial interests are adequately safeguarded. The health, safety and welfare of service users are not sufficiently promoted and protected. EVIDENCE: The Registered Manager/Proprietor reported that she is intending to stand down from the Registered Manager position, and intends to put forward the Senior Care Worker in her place. This employee is already said to be undertaking the Registered Manager’s Award. The present Registered Manager
DS0000017571.V325203.R01.S.doc Version 5.2 Page 22 has been successful in complying with many of the requirements of the previous CSCI inspection although a substantial number remain. The Registered Manager pointed out that the insurance certificate displayed in the home ran out on 07/12/06, but she maintained that the premium had been paid for the current year. The CSCI requires that a current insurance certificate be sent to them. Requirement 19. The Inspector saw evidence of service users being consulted at residents’ meetings. The Inspector was unable to check the records of any service user’s money being administered by the home as the Manager Designate did not know whether this service was provided by the Registered Manager. The Inspector checked the record of fridge and freezer temperatures. He saw the home’s gas and electricity safety certificates. The Inspector noted that fire alarms were tested monthly. The last recorded fire drill however was in October 2006. They must be at least quarterly hence Requirement 20 is restated. Several of the requirements made in the Environment section of this report have health and safety implications. The Inspector enquired whether regular safety checks are undertaken throughout the premises to look for hazards. He was told such checks are not done. Hence Requirement 21 is restated. The temperature of the hot water must be taken and recorded on a weekly basis at all points throughout the building where service users have access to the hot water. Requirement 22. DS0000017571.V325203.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 x x x x X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 2 x x x 2 DS0000017571.V325203.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement Timescale for action 01/05/07 2. OP1 5 3. OP1 4&5 The required ‘Statement Of Purpose’ must include a statement concerning those items identified within Regulation 4 (1) (c) Schedule 1, 1 to 18. (Previous timescales of 17/10/03, 10/06/04, 10/8/04, 11/01/05, 29/01/06 & 03/09/06 not met). 01/05/07 The required ‘Service Users Guide’ 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 addition to the other items identified within Regulation 5. (Previous timescales of 17/10/03, 10/06/04, 10/08/04, 11/01/05, 29/01/06 & 03/09/06 not met). When available, full copies of the 01/05/07 Statement Of Purpose and Service Users Guide for Francis Lodge are required by the Commission for Social Care Inspection.
DS0000017571.V325203.R01.S.doc Version 5.2 Page 25 4. OP2 5(1)© 5. OP7 15(1) 6. OP7 15(2)© 7. 8. OP7 OP7 17(1)(a) Sch3(2) 13 9. OP9 13(2) (Previous timescales of 17/10/03, 10/06/04, 17/08/04, 18/01/05, 05/02/06 & 03/09/06 not met). Each service user must be issued with a contract or statement of terms and conditions of the their residency, with a signed copy kept on their file. Ensure that care plans include those actions that need to be taken by care staff to ensure that all aspects of health, personal and social care needs of service users are met. (Previous timescales of 29/12/05 & 03/09/06 not met). Evidence is required that service users, or their representatives have been consulted on and agreed to their care plan contents. The care home must keep a photograph of each service user on file. The risk assessments require some expansion to incorporate the required actions by staff etc to minimise any risks to residents and in addition must be reviewed as part of the care planning processes in the care home. (Previous timescales of 29/12/05 & 03/09/06 not met). It must be ensured that accredited medication training is undertaken by those staff employed in the care home that administer medication to residents with a record maintained of those attending. (Previous timescale of 29/12/05 & 03/09/06 not met).
DS0000017571.V325203.R01.S.doc 01/05/07 01/05/07 01/05/07 01/05/07 01/05/07 01/05/07 Version 5.2 Page 26 10. OP18 13(6) 11. OP18 13(6) 12. OP19 13(4)(a) 13. OP25 13(4)© 14. OP25 13(4)© 15. OP19 13(4)(a) 16. OP19 13(4)© 17. OP28 18(1)(a) 18. OP29 19 A ‘whistle-blowing’ procedure must be developed to ensure the safety and protection of residents. (Previous timescales of 29/01/06 & 03/09/06 not met). The home’s POVA leaflet must mention whistle-blowing, and the role of the CSCI in Adult Protection. Arrange for the rear side steps to the garage area to be resurfaced and levelled to avoid a trip hazard for residents. (Previous timescale of 03/09/06 not met). 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. (Previous timescales of 17/12/03, 27/08/04, 21/01/05, 29/01/06 & 03/09/06 not met). It must be ensured that the hot water runs at a temperature close to 43º C in order to avoid the risk of Legionella. (Previous timescales of 21/01/05, 29/01/06 & 21/08/06 not met). The rear garden must be made safe and attractive for service users by removing a broken tumble drier and a felled tree. The rickety occasional table in the lounge must be repaired or replaced to ensure the safety of service users. It is required that 50 of the care staff employed in Francis Lodge undertakes NVQ Level 2 in care. (Previous timescale of 03/10/06 not met.) A Grievance Policy must be
DS0000017571.V325203.R01.S.doc 01/05/07 01/05/07 01/05/07 01/05/07 01/05/07 01/05/07 01/05/07 01/10/07 01/05/07
Page 27 Version 5.2 19. 20. OP34 OP38 25(2)(e) 24 21. OP38 13 22 OP38 13(4)(a) developed for staff working in the care home. (Previous timescales of 17/11/03, 21/02/05, 29/01/06 & 03/09/06 not met). The CSCI require to see a copy of a current insurance certificate. It is required that fire drills and practices are carried out on a quarterly basis with a record maintained. (Previous timescales of 20/07/04 21/01/05, 29/12/05 & 03/09/06 not met). A ‘Health & safety’ policy for Francis Lodge, including compliance with all relevant legislation, and a regular premises check, is required. (Previous timescales of 20/08/04, 21/02/05, 29/12/05 & 03/09/06 not met). Hot water temperatures must be taken and recorded weekly at all points throughout the home where service users have access. 01/05/07 01/05/07 01/05/07 01/05/07 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 OP29 Good Practice Recommendations As the Regulations require two employment references for each employee, where a potential employee has previously worked at Francis Lodge, an internal written reference could be used. DS0000017571.V325203.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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
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