CARE HOMES FOR OLDER PEOPLE
Francis Lodge 4 Belsize Road Harrow Weald Middlesex HA3 6JJ Lead Inspector
Andreas Schwarz Unannounced Inspection 2nd December 2008 09:30 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 Francis Lodge DS0000017571.V373355.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. Francis Lodge DS0000017571.V373355.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 francisservicesltd@yahoo.com Ms Monica Maxwell Care Home 4 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (4) of places Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 4 6th December 2007 Date of last inspection 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 to 4 adults, aged 65 years and over. The home is registered to care for people with Dementia. The home has a garden that can be accessed by steps through the newly built conservatory. Two bedrooms (with an ensuite) are located on the ground floor and the other two bedrooms are on the first floor. There is a bathroom and toilet on the first floor of the building. The home has a stair lift. 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 start from £650.00 per week. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is a one star service, people using the service experience adequate outcomes.
This key inspection took place in December 2008 and lasted 7 ½ hours. The registered manager Ms Maxwell and the new manager Mrs Fyffe were available throughout this inspection. We spoke to all residents, one volunteer, the registered manager and manager during this inspection. The home forwarded a completed Annual Quality Assurance Assessment within the given timescale. We received one staff survey and three service users’ surveys; comments of these surveys are included in the report. We sampled two care plans and four staff files during this key inspection. We looked at a range of records and documents. We undertook a random inspection on 09/04/08 and the home has met twelve of the thirteen requirements made during the key inspection on 06/12/07. The home applied for a major variation to increase the number of spaces to four and to admit people with Dementia. We would like to thank everybody involved in this key inspection. What the service does well: What has improved since the last inspection? Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 6 The home has met two of the three outstanding requirements from the last key inspection. The fire risk assessment is now in place and peoples risk of injuries have been minimised. Views of people have been taken into account and a annual development plan for 2008 has been completed. During a random inspection on 19 April 2008 we observed a birthday party of one of the people living in the home. Staff and friends of the person attended the party. We spoke to one visitor during this inspection who told us that she is very happy with the care provided by the home and that she has no concerns. We sampled one care plan; this care plan was judged to be of good standard and detailed. The family has been involved in the care planning process and a life history of the person was obtained and put together. Care plan objectives are achievable and visits to/from health care professional are recorded. The daily records are detailed and provide the reader with the necessary information of the person’s activities, food intake, mood and behaviour. We viewed records of regular weight checks, which were incomplete during our last key inspection. We spoke to one member of staff, who was very happy with working at the home and informing us of having attended training, such Adult Abuse, Manual Handling. We have also have been informed that two members of staff are on duty during each shift, a rota viewed by us confirmed this. We viewed two weekly menus, meals provided are judged as healthy, varied and nutritious. People using the service informed us that they enjoy the meals. Fresh fruit were available and home cooked leftovers have been appropriately labelled and stored in the homes fridge. We viewed fire records, the home has undertaken two fire drills over the past two month, and the smoke alarm has been tested regularly. The updated fire risk assessment was not available for inspection and we informed the registered manager that this requirement would be repeated. All fire doors were self-closing and regular water temperature checks have been undertaken by the home. We sampled a Medication Administration Sheet, which was of good standard, allergies have been recorded and no medication was omitted. The registered manager showed us a standard form of contract and staff spoken to confirm that they received a contract and terms and conditions when starting employment with Francis Lodge. The registered manager informed us that the homes induction lasts over six months, during that time new staff will attend mandatory training such as First Aid, Manual Handling, Adult Protection, etc. We have viewed one induction record, which was signed and dated by the registered manager and member of staff. Staff spoken to confirm of having had an induction when commencing employment.
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 7 The registered manager informed us that she has done an annual development plan, which has been viewed during this inspection. We informed the registered manager that more work is required to this document to fully meet National Minimum Standards. All the above issues have been addressed and requirements have been found as met during the random inspection on 19th April 2008. 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 Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 8 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 Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 9 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): We looked at National Minimum Standards 1and 3 during this inspection. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. New prospective people using the service are provided with detailed information about the home enabling them to choose if they want to move in. People using the service are needs assessed by a qualified person, but more work is required to include the information in the care plan. EVIDENCE: You told us in your Annual Quality Assurance Assessment: That all prospective residents are provided with information about Francis Lodge and the services provided.
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 10 All prospective residents undergo an assessment of needs prior to them moving in. When a care needs assessment is carried out, we communicate and actively involve the prospective resident/representative/advocate and or family members. People using the service told us: “We received a report which suggested that the home is adequate for my relative. We still believe that this is true.” “I was shown around before I moved in.” “I did receive the correct information about the home.” This is what we found during this key inspection: We viewed the statement of purpose and service users guide, both documnents have been reviewed since the last inspection. We judge the documents as very good and compliant with National Minimum Standards. The home has also produced a brochure, which outlines the care provided, room sizes, what the home offers, etc. The home is using pictures, signs and symbols in the brochure, the manager explained that this enables people who are unable to read due to their Dementa, can access the brochure. We viewed two care plan files during this inspection. One of the people has been admitted to the home recently, an assessment has been undertaken by the new manager. The mental capacity of the person using the service has been assessed. The assessment focuses on the persons skills and abilities and is very detailed. The second assessment we looked at was less detailed and not all the forms provided have been used during the assessment process. We also noted that assessed needs have not been included in the persons care plan, which is required. People using the service were not able to tell us, if they have been involved in the assessment process. The registered provider informed us that eveidence of this could be found in the visitors book. The home does not provide intermediate care and National Minimum Standard 6 has not been assessed during this key inspection. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 11 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): We looked at National Minimum Standards 7, 8, 9 and 10 during this inspection. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care which affects their lifestyle and quality of life, but care plans must be reviewed regularly. The home is supporting people using the service to meet their health care needs and procedures are in place for the safe administration of medicines. People using the service are treated with dignity and respect and are involved in their personal care support. EVIDENCE: You told us in your Annual Quality Assurance Assessment: Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 12 • • • • • Residents experience care in an environment that actively encompasses individual value/beliefs, residents spaces are actively promoted by all staff. We ensure that staff at Francis Lodge are trained to show great tact and care in carrying out some tasks, particularly those relating to intimate personal care as this places ones privacy and dignity at severe risk. Francis Lodge respects the privacy and dignity of all residents, we are sensitive to and respects our service users religion, spiritual and cultural needs. We treat service users fairly and accordingly to their healthcare needs, regardless of age, sex, disability, race or sexuality. We focus on the respect of service users ensuring they feel that their views/opinions are always taken on board. People using the service told us: • “Francis Lodge staff always listen to what I have to say.” • “Staff is always available when I need them.” • “I am very happy here.” • “My mother is regularly visited by nurses.” This is what we found during this key inspection: We looked at two care plans during this inspection. We noted that assessed needs have not been included in one of the care plans assessed. This is important ensuring the home is meeting people using the service needs fully. Overall care plans are of good standard addressing needs such as peoples’ mobility, capacity, health needs, activities, etc. One of the care plans we viewed has been reviewed on 08/09/08, the person was admitted to the home in April 2008. Care plans must be reviewed regularly. The home records visists and appointments to and from health care proffesionals in peoples care plans.The home informed us that currently none of the people being cared for have pressure sores.The home is assessing on admission peoples’ risk of developing pressure sores. We viewed mobility assessments in care plans. The home is using a stairlift supporting residents accessing the first floor. A nutritional assessment is undertaken and peoples’ weight is monitored and their food intake is recorded. All residents are registered with a local GP, who will visit the home if required. The registered manager told us that the home has no controlled drugs. A signatory list is in place. Five staff including the registered manager are authorised to administer medication. We noted that out of four staff files assessed only one file had evidence of medication training in place. We discused this with the registered manager and the home must ensure that all staff administering medication receive medication training from an accredited training provider. All People using the service have a medication profile on file, allergies are recorded on the MAR sheet. MAR sheets had no gaps. None of the residnets are self administering. People using the service told us that they are
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 13 happy in the home and surveys filled out by relatives told us that their relatives are treated with respect. People using the service were nicely and appropriatly dressed. We spoke to two residents, one of the people told us that staff is looking after her very well. Francis Lodge DS0000017571.V373355.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): We looked at all National Minimum Standards above during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. EVIDENCE: You told us in your Annual Quality Assurance Assessment: • Residents of Francis Lodge have a wide variety of choices when it comes to their daily living activities and their meal/mealtimes. Knitting, card making, scrabble, walk to the local park, drive to hairdressers/local supermarkets or whatever else they choose to do on any given day.
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 15 • • • • Food is freshly prepared on a daily basis - menu is shown to residents so they can choose - residents also help to create menus on a monthly basis. A local priest visits Francis Lodge monthly to offer Holy Communion and residents are visited by their relatives/friends without prior notice. Service users at Francis Lodge enjoy a lifestyle which is preferably and compatible with their social, cultural, religious and recreational needs. Three meals are served everyday. People using the service told us: • “The home is arranging activities for my mother to take part.” • “I really like the food here.” • “I don’t know what I will eat for lunch today.” This is what we found during this key inspection: One of the people living at the home is regularly visited by a family member, who has taken her out proviously. One resident told us that she is going to see her hairdresser before Christmas. We observed residents sitting together during mealtimes and a conservatory has been built by the home to do this in a comfortable and spacious environment. A volunteer visits the home daily, who is responsible for activities. Residents told us that they hand crafted some of the Christmas decoration on the window sill. Peoples paricipation is recorded in daily records, we noted however, that the majority of times staff record “did activities”. We recommend to be more specific, when recording peoples participation in activities. One of the people living at the home does not speak English, the home is providing a translator on a voluntary basis. The home informed us that a priest visits once a months to serve Holly Communion. Residents were not able to confirm this. Residents told us that they have regular visits from families and friends. We observed residents moving around freely in the home. The home is not handling peoples finances. The registered manager told us that she would invoice relatives and/or appointees with any expenditures made on behalf of the person. One of the people invited me to see her room, which was nicely decorated and personal possessions were displayed. The home is cooking meals freshly, residents told us that they like the food. Food eaten is recorded in peoples’ records. The fridge was fully stocked and we observed lunch, which was nicely presented and appeared healthy. One of the residents was not able to tell us what is served for lunch. We recommend to display the daily menu visisble for all residnest living at the home. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 16 Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 17 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): We looked at National Minimum Standards 16 and 18 during this inspection. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Some staff have had training around safeguarding adults. There are policies and procedures for safeguarding people who use the service EVIDENCE: You told us in your Annual Quality Assurance Assessment: • We have not received any complaints since the last key inspection. People using the service told us: • “I know whom to complain to.” • “I would speak to manager if I am not happy.” This is what we found during this key inspection: The homes complaints policy is compliant with National Minimum Standards. Residents spoken to told us that they would complain to the manager. The home has not received a complaint since the last key inspection.
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 18 The home has a abuse policy in place. We spoke to one member of staff, who was clear whom allegations of abuse should be reported to. We viewed four staffing records, none of the assessed records had evidence of safeguardng adults training. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 19 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): We looked at National Minimum Standards 19 and 26 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service live in a nicely decorated and comfortable home. The home is clean and free of any offensive odours. EVIDENCE: This is what you told us in your Annual Quality Assurance Assessment: The home environment is very tranquil and peaceful, residents always feel at home. Support workers also provide added support to residents respecting their wishes and belief. Residents have their own bedrooms with their own provisions/possessions.
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 20 This is what people told us about the home: “The home is always smelling fresh and clean.” This is what we found during this inspection: The home has completed the refurbishment. Communal areas have been repainted and the lounge has been refurbished. The home built an extension into the garden, which can be used by residents for meals and activities and has created extra space. A new room has been built on the groundfloor. The home has applied for a major variation with the Commission for Social Care Inspection. This application has been granted and the home has now space for four people with Dementia. We noted loose lino in the hallway on the ground floor, this could lead to residents tripping and must be repaired. The utility room is located in a shed, which can be accessed through the garden. The utility room was very untidy and must be cleaned; ensuring residents can use it safely. The washing machine and dryer is in good working order. The home was clean and free of any offensive odours during the day of this inspection. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 21 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): We looked at all the above National Minimum Standards during this inspection. People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service does not support the development of a competent staff team. Training provided is very limited and weak, with areas not being identified and not targeted at relevant individuals. Training provided tends to be internal, with a lack of willingness to seek external providers to deliver training. The service has a poor recruitment procedure with shortfalls in recording and processes being evident. EVIDENCE: This is what you told us in your Annual Quality Assurance Assessment: • Over 80 of our staff team has a NVQ level 2 qualification. • All staff are CRB checked and two written references are obtained before commencing work at Francis Lodge. • Staff are given a written contract of employment upon commencing employment. This is what people told us about the home: “Staff looks after me very well.”
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 22 This is what we found during this inspection: The registered manager told us that the home has currently four staff employed; the rota shows that the manager is fully involved within the care of people using the service. During the day of this inspection two members of staff were on shift one of the staff was the registered manager. Care staff is responsible for the cooking and cleaning at the home. The home is using a volunteer to support people using the service around their activities. The registered manager informed us that the home has two people in the morning, two staff in the afternoon and one member during the night on duty. The registered manager told us that approximately 65 of staff have National Vocational Qualifications in Care. We found in one folder a NVQ certificate issued by a college, we told the registered manager that this must be verified with the awarding body. Out of four staffing files assessed two had the required two references; the other two contained one or none. Three out of the four assessed staffing files contained CRB checks obtained by the previous employer. The two volunteers did have no CRB checks. We explained to the registered provider that CRB checks are not portable between employers and the home must ensure all staff have a valid enhanced CRB check. We left an immediate requirement form during the day of this inspection regarding the missing CRB checks. The home has responded within the given 48 hour’s timescale and told us that all staff have applied for an enhanced CRB check. Staff told us that they did not receive training since starting this year. There were no training records on any of the files assessed. Staff has attended some training during this year, i.e. Mental Capacity Act training. Any other training was obtained during previous employment or last year. The home is providing care to people with Dementia, but none such training has been provided to staff, since the change of registration in March 2008. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 23 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): We looked at National Minimum Standards 31, 33, 35, 36 and 38 during this inspection. People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is managed by a qualified and experienced manager. People using the service are encouraged to raise their views about the home and information of this is included in the annual report. All sections of the Annual Quality Assurance Assessment were completed and the information gives a reasonable picture of the current situation within the service. Checks show that records are generally up to date although some gaps are found in recording and entries are not always clear EVIDENCE:
Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 24 This is what you told us in your Annual Quality Assurance Assessment: The management team at Francis Lodge creates an open, positive and inclusive atmosphere in the home. The quality of care provided at Francis Lodge is strongly influenced by the competence of the manager and the relationship with the owner of the home. This is what we found during this inspection: The manager Mrs Maxwell is registered with the Commission for Social Care Inspection. The manager informed us that she has a teaching degree and an Open University Qualification in Care. The registered manager demonstrated that she is making efforts in complying with requirements. Staff told us that the manager is supportive and listens to problems staff may have. The home employed a manager, who is planning to register with the CSCI and replace the current registered manager. We viewed an annual development plan for 2008, which includes people using the service views. The home had two residents meetings since the last key inspection. The last team meeting was held on 05/10/07. We recommend arranging staff and residents meetings more frequently allowing staff and service users to take part in the running of the home. We have received a completed Annual Quality Assurance Assessment. The information provided was of good standard and have been referred to throughout this report. As stated earlier in this report the home does not hold, money for people using the service. The registered manager told us that she will invoice appointees of any expenditures made by residents. We viewed four staff files, none of the files had any evidence of regular supervisions, with the exception of the newly appointed manager who met with the registered provider regularly for induction and handover of responsibilities. The Landlords Gas Certificate has been updated on 15/01/08. The registered manager told us that an up to date Portable Appliance Test is in place. A current and up to date fire risk assessment is in place. The weekly fire alarm test was last done on 10/11/08, there were no records of regular fire drills and monthly emergency light tests. Staff did not receive training in the use of fire equipment and what to do in the event of a fire. The fire equipment was last serviced in August 2008 and fire alarm was last serviced in April 2008 Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 25 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 4 X 2 X X X 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(2) Requirement The responsible person must ensure that all new people using the service are assessed to the same standard ensuring consistency in the assessment process. The responsible person must include assessment information in the care plan ensuring peoples needs are addressed. The responsible person must ensure that care plans are reviewed regularly; ensuring people using the service changing needs are fully met. The responsible person must provide medication training to all staff involved with the administration of medicines. Ensuring people using the service are safely supported around the administration of medication. The responsible person must provide safeguarding adults training to all staff. Ensuring that safeguarding allegations made are dealt with appropriately. Timescale for action 15/01/09 2. OP3 15 15/01/09 3. OP7 15(2)(b) 15/01/09 4. OP9 13(2) 01/02/09 5. OP17 13(6) 15/01/09 Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 27 6. OP19 23 7. OP26 23 9. OP29 19 Schedule 2 10. OP30 18 11. OP30 18(1)(c) (i) 12. OP30 18(1)(c) 13. OP36 18(2) 14. OP38 23(4) The responsible person must ensure to repair the loose lino in the hallway, protecting residents and visitors of accidentally tripping and injuring themselves. The responsible person must ensure to tidy up the utility room providing safe access for residents wishing to do their laundry independently. The responsible person must ensure that all staff and volunteers employed by the home have two references taken before employment is offered. This is to ensure only vetted staff support people using the service. The responsible person must ensure that all staff have an up to date training and development plan in their file. The responsible person must provide a minimum of three paid training days per calendar year, ensuring staff can update their knowledge and skills and service users’ needs can be fully met. The responsible person must provide specialist training in Dementia ensuring people with this condition are cared for appropriately. The responsible must ensure that all staff and volunteers receive a minimum of six planned supervisions per calendar year. This is to ensure only supervised staff is provided. The responsible person must ensure to undertake regular fire drills, regular checks of emergency lighting and staff are provided with up to date fire training. This is to ensure a safe environment is provided for people using the service.
DS0000017571.V373355.R01.S.doc 15/01/09 15/01/09 01/01/09 01/01/09 01/04/09 01/02/09 15/01/09 15/01/09 Francis Lodge Version 5.2 Page 28 15. OP38 13(4) The registered manager must ensure to undertake Health and Safety checks every three months, as stated in the Health and Safety policy and to ensure peoples safety. Timescale of 15/05/08 not met. 01/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP12 OP15 OP28 OP33 Good Practice Recommendations Staff should be clearer when recording people’s participation in activities. The responsible person should display the daily menu accessible to all people living at the home. We recommend that the responsible person verify the authenticity of NVQ certificates with the awarding body. We recommend arranging staff and residents meetings more frequently allowing staff and service users to take a greater part in the running of the home. Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI Francis Lodge DS0000017571.V373355.R01.S.doc Version 5.2 Page 30 - 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!
