Inspection on 27/09/05 for Francis Lodge

This inspection was carried out on 27th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/05/05

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 Ms Sue Barker Announced Inspection 27th September 2005 09:00 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 Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V252741.R01.S.doc Version 5.0 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 Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 2005 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 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 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 in respect of the care home. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second statutory inspection of Francis Lodge during the 2005/6 inspection year. All the key standards were inspected during these 2 inspections. The announced inspection took place on a Tuesday in September. The Inspector arrived in the care home at 9am and left at 5.10pm. The Inspector spoke with 2 of the 3 residents, Mrs Maxwell and the member of staff on duty. The Inspector would wish to thank all in Francis Lodge for the hospitality received and time made available to facilitate the inspection process. Mrs Maxwell did not forward a completed pre-inspection questionnaire to the Commission for Social Care Inspection as preparation for the announced inspection. Mrs Maxwell indicated that she aims to provide a home from home experience for residents in Francis Lodge that encourages them to maintain independence whilst also providing a good quality of care. Residents spoke positively about their experience of living in Francis Lodge and it was described as “comfortable” and “quiet”. Residents also spoke positively about the meals that they eat in Francis Lodge. What the service does well: What has improved since the last inspection? A Statement Of Purpose for the care home has been produced since the last inspection that includes most of the required information. Work has been done to review care plans with reviews for all the residents having recently been carried out. Mrs Maxwell has worked to comply with some of the requirements arising from the last statutory inspection. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 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 the following standard(s): 1, Prospective residents and their families have access to some information about the home and its services in order to make an informed choice. Residents have care plans in place that indicate some of their care and support needs. EVIDENCE: The Statement Of Purpose and Aims and Objectives documents were viewed during the announced inspection. This had been worked on by Mrs Maxwell since the last inspection and covered most of the areas required by Regulation 4. The Inspector spoke to Mrs Maxwell about some of the areas that require expanding with regard to complaints, bedroom sizes, numbers of staff employed in Francis Lodge with their qualifications and experience, arrangements for respecting resident’s privacy and dignity, arrangements for consultation with residents about the operation of the care home, social activities, range of care needs that the care home is intended to meet and organisational structure of the care home. The Inspector advised Mrs Maxwell of the need to compile a Service Users Guide for the care home as required by Regulation 5. Some of the required elements of the Service Users Guide were viewed, for example the ‘Complaints Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 9 Procedure’, and most recent inspection report. This remains an outstanding requirement, as does the need to forward copies of both of these documents to the Commission for Social Care Inspection. No new residents had moved into the care home since the last unannounced inspection. Inspection of one care plan indicated that the assessment of a potential resident had included a trial visit. There was a care plan for each resident. An intermediate care service is not provided in Francis Lodge. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 & 9 There are written care plans in order to ensure the provision of appropriate care to residents. These care plans had been reviewed and some residents had signed to indicate their agreement to the outcomes. Residents are enabled to attend or access various health appointments and are visited by their GP’s in the care home. The medication systems in Francis Lodge largely ensured that medication is administered to residents safely. EVIDENCE: Three care plans were viewed that covered resident’s social, communication, spiritual, physical and medication needs. In addition there were statements of the resident’s preferred dietary likes and dislikes in addition to their allergies. The Inspector acknowledged that Mrs Maxwell had undertaken work to update the care plans since the last unannounced inspection. All care plans had been reviewed in September 2005. Previous reviews had been carried out usually on a monthly basis. This review also included resident’s psychological needs. Each review indicated a varying number of care goals. During the inspection it was apparent that some resident’s care needs were more extensive than identified within their care plans. The Inspector advised Mrs Maxwell of the need to ensure that care plans include those actions that need to be taken by Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 11 care staff to ensure that all aspects of the health, personal and social care needs of residents are met. Some care plans had been signed by the resident. Staff maintain a daily record of residents’ welfare and well-being. A risk assessment was included on each resident’ care plan. This covered whether the resident can walk independently, is at risk of falls, what physical support is needed, is client capable of taking his/her medication independently and level of support required and the risk of wandering. The risk assessments require some expansion to incorporate the required actions by staff etc to minimise the risks to residents and in addition must be reviewed as part of the care planning processes in the care home. In addition there must be individual risk assessments in respect of all areas of risk identified for each resident. Staff maintain a record of the personal care provided to residents. The individual care plans and risk assessments include little reference to those residents who are at risk or have developed pressure areas. This is an area that requires inclusion. Inspection of the daily records indicated staff were turning one resident as part of their daily care routine. The district nursing service supports residents in Francis Lodge. A record is maintained of professional visitors to Francis Lodge including the GP and district nurses. Residents were observed moving around the ground floor of the care home. Two residents spoke of their trips out into the community. Staff maintain a daily record of the food eaten by residents. Monthly monitoring of residents’ weights had been carried out to 25/5/05. This must be continued on a monthly basis with a record maintained. There was a Medication Policy for Francis Lodge and medication was stored within a locked cupboard in the care home. The contracted pharmacist supplies a pre-filled weekly medication dossette box to the care home and it is administered to residents by staff. No residents self-administered their medication at the time of the announced inspection. Staff maintain a record of medication administered to residents, this was mostly fully recorded though a signature was missing on 25/9/05. Guidance was available for staff on the administration of painkillers for residents on a PRN basis. One other resident was being prescribed another medication on a PRN basis for which there was no written guidance for staff evident. This requirement was discussed with Mrs Maxwell. The Inspector did not see any evidence of accredited medication training having been undertaken by those staff employed in the care home that administer medication to residents. Mrs Maxwell has planned to arrange medication training for staff between June and December 2006. One member of staff spoke about the medication training that they had received in a previous job. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 & 15 Residents are enabled to partake in recreational pursuits of their choosing and are largely able to go out when they want to. Residents are able to make choices in terms of their daily routines. Residents are offered a range of home cooked food in Francis Lodge and their specialist cultural and dietary needs are met. EVIDENCE: Residents spoke about their lifestyles in Francis Lodge. Residents confirmed that they enjoyed a flexible routine and could go to bed when they wanted. One resident confirmed that the social activities available in Francis Lodge were as they preferred. One resident confirmed that they enjoyed a quiet lifestyle in Francis Lodge. Minutes of a resident’s meeting confirmed that menus and activities were discussed. The home’s weekly activity was displayed in the kitchen. This consisted of music and movement and scrabble on Monday, day trip to hairdressers and shopping on Tuesday and out for a walk on Wednesday. Staff record residents’ individual outings that included going to church on 21/9/05. A visitor’s book is maintained that the Inspector signed on arrival. One resident received a visitor on the day of the announced inspection. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 13 Two residents kindly confirmed that enjoyed the meals available to them in Francis Lodge. On the day of the announced inspection lunch was a homemade shepherds pie with boiled vegetables. This was to be followed by fresh fruit and yoghourt. The meal smelt and looked appetizing. Hot and cold drinks were served to residents. Individual records are maintained of the food eaten by residents. Recent lunches had been pork hot pot, roast steak with potatoes and cabbage, sausages and mash and fish and chips. Mrs Maxwell spoke of recent initiatives to improve the appearance of meals served in Francis Lodge. This had included buying new crockery. Mrs Maxwell also spoke of her aim to meet any specialist dietary or cultural food requirements that residents may have. The fridge and freezer contained a variety of foodstuffs. A large bowl of fruit was available to residents on the dining table. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 & 18 Residents receive some protection from the care home’s complaints and Protection of Vulnerable Adults from Abuse procedures, but more work needs to be done in these areas to comply with requirements. EVIDENCE: A ‘Complaints Procedure’ was viewed. Mrs Maxwell was advised of some amendments that are needed to ensure that the policy meets requirements. This includes a stated timescale of 28 days for the complainant (whether it is a resident or someone acting on their behalf) to receive a response to their complaint. The procedure in addition must include clear contact details for the local Commission for Social Care Inspection office as well as the right of the complainant to approach the Commission for Social Care Inspection at any time. The Inspector also viewed a Protection of Vulnerable Adults procedure for Francis Lodge. Mrs Maxwell was advised of the need to amend the procedure to ensure it links with the local authority Protection of Vulnerable Adults procedures. This applies to situations where a strategy meeting may make decisions about how the allegations of abuse are to be investigated. A policy has been developed for Francis Lodge in respect of the management of resident’s aggression or challenging behaviour. A ‘whistle-blowing’ procedure was not viewed and this element must be incorporated to ensure the safety and protection of residents. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19, 22, 26 & 25 Residents live in accommodation that is warm, and homely. Some areas of the building have been redecorated for residents. Residents live in accommodation that is kept clean by staff. Resident’s clothing is washed in the care home’s laundry area. EVIDENCE: Residents live in accommodation that (on the day of the announced inspection) was warm, clean and comfortable. There is a large garden to the rear that is accessed by a flight of steps from the patio. The garden can be viewed from the patio area. Mrs Maxwell has developed a ‘Home Maintenance Plan’ for the period August 2005 to August 2006. This includes work to exterior pathways/walkways and internal flooring and décor. The Inspector viewed some of the internal work that had been done in communal areas and bedrooms. One resident described their accommodation in Francis Lodge as “comfortable”. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 16 The Inspector viewed a Fire Risk Assessment for Francis Lodge that was not dated or showing evidence of review. This is a previous requirement. A stair lift remains in use within Francis Lodge. Mrs Maxwell advised the Inspector that a new remote control was to be purchased for the stair lift in order enable it to be used more safely when residents require the assistance of staff to use it. There are grab rails in the communal areas of the building. Mrs Maxwell advised the Inspector that she is planning to purchase a call bell system for the care home in order to enable residents to call for assistance. Mrs Maxwell stated that currently staff on duty would be able to hear when residents need assistance at night. Residents confirmed that they were felt warm in Francis Lodge. There were radiators in the two bedrooms viewed by the Inspector. Mrs Maxwell indicated that she would be arranging to have the previously required works carried out on the hot water systems in the care home in order to prevent the risk of legionella when a suitable contactor has been found. The care home’s laundry is located in the laundry. This contained a washing machine and dryer. The washing machine washed to a maximum of 95°C. There was guidance for staff on the washing arrangements in the care home. The location of the laundry does allow staff to take washing to the laundry through the front of the building therefore ensuring that it is not taken through areas where food is stored, prepared, cooked and served. The building was found to be clean and free of offensive odours during the announced inspection. Cleaning tasks are included in staff’s daily shift responsibilities. The Inspector viewed some guidance for staff on the use of bleach in Francis Lodge. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 &30. Staff employment history and documentation are not checked appropriately and residents are not protected appropriately by the home’s recruitment practice. Residents are not cared for by a staff team that are provided with training in all appropriate areas. EVIDENCE: The care home’s staff rota was displayed in the kitchen. This indicated that there was one member of staff on duty in the care home on a 24 hour basis. Mrs Maxwell is also rota’d in Francis Lodge for parts of 6 days a week. Mrs Maxwell and a member of staff were on duty during the announced inspection. Mrs Maxwell indicated that in her opinion there were sufficient staff to meet the needs of residents. On the day of the announced inspection no staffing shortfalls were noted. Mrs Maxwell stated that she is reviewing the rota structure in Francis Lodge. One resident introduced the Inspector to a member of staff. Staff presented as knowledgeable regarding residents’ care needs and personal preferences. The residents stated that staff were very caring. The Inspector viewed the recruitment information for 3 members of care staff employed in the care home. No satisfactory ‘Enhanced’ CRB checks had been obtained for these staff prior to their starting work in Francis Lodge. The Inspector informed Mrs Maxwell that this was a pre-employment requirement. Mrs Maxwell stated that she was unaware that this is a requirement. The Inspector passed Mrs Maxwell a copy of the Department of Health ‘Protection of Vulnerable Adults Scheme for care homes and domiciliary care agencies. A Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 18 Practical Guide including changes to the requirement for CRB Disclosures in certain circumstances’. A full range of satisfactory checks (including 2 written and verified references, statement of physical and mental health etc.) must be carried and obtained prior to the member of staff commencing employment. This is a previous requirement. A copy of the staff contract was viewed during the inspection. There is an ‘Equal Opportunities’ policy for Francis Lodge. Mrs Maxwell stated that one member of staff was shortly to commence an NVQ Level 2 in care through a training agency. A staff training plan was viewed for the year commencing October 2005. This included training in dementia, first aid, dealing with emergencies and medication. The Inspector did not view any evidence of any staff training having been undertaken including induction. This is a previous requirement. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 & 38 Residents do not benefit from living in a care home that is managed in such a way to require that they are afforded protection in all required areas. Significant shortfalls were noted in health and safety, staff recruitment and staff training and there have requirement outstanding in these areas for some time. This is a cause for concern. EVIDENCE: Mrs Maxwell is the Registered Provider and Registered Manager in respect of Francis Lodge. Mrs Maxwell stated that she had recently undertaken management training. Francis Lodge is a small care home that employs 3 care staff. Whilst it was noted that there had been improvements in the care home’s care planning arrangements, medication and provision of food, there were areas that remained in need of improvement. This particularly includes health and safety, Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 20 staff recruitment and staff training and there have requirement outstanding in these areas for some time. This is a cause for concern. Mrs Maxwell stated that she did not hold any money on behalf of residents but this situation will be changing. Full records must be maintained in respect of any money held on behalf of residents with receipts retained and all money accounted for. Mrs Maxwell stated that each bedroom has a lockable place for residents to store their possessions if the wish. In addition a record must be maintained of any possessions held on residents behalf, with receipts issued. A ‘Health and Safety’ policy in respect of Francis Lodge was viewed that covered visitors to the care home. This requires expanding in order to cover all required areas. There was no written guidance or evidence of staff training in respect of moving and handling, fire safety, first aid, food hygiene and infection control. There was written guidance for staff regarding the use of chemicals in the care home. The risk assessments viewed were in respect of individual residents and did not cover safe working practice. There is a Fire Risk Assessment for the care home that was not dated or showing evidence of review. The smoke detectors had been tested on 1/9/05 with a record maintained of the outcomes. There was no evidence of fire safety training and practice exercises for staff having been carried out in Francis Lodge. Current certificates of Worthiness were viewed in respect of the care homes’ portable electrical appliances and stairlift. Copies of certificates of Worthiness must be forwarded to the Commission for Social Care Inspection in respect of the care homes’ gas appliances and installation and the electrical installation and hard wiring. Accident records are maintained though there was none recorded since the last unannounced inspection. Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 21 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x 2 x x 2 3 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x 1 Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 22 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 The required ‘Statement Of Purpose’ must include a statement of the facilities and services that are provided by the Registered Provider to service users and those items identified within Regulation 4 (1) (c) Schedule 1, 1 to 18. (Previous timescale of 17/10/03, 10/06/04, 10/8/04 & 11/01/05 not met) 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 timescale of 17/10/03, 10/06/04, 10/08/04 & 11/01/05 not met) When available, full copies of the Statement Of Purpose and Service Users Guide for Francis DS0000017571.V252741.R01.S.doc Timescale for action 29/01/06 2 OP1 5 29/01/06 3 OP1 4&5 05/02/06 Francis Lodge Version 5.0 Page 23 4 OP7 15 5 OP7 13 6 OP8 17 7 OP9 13 8 9 OP9 OP14 13 12 10 OP16 22 Lodge are required by the Commission for Social Care Inspection. (Previous timescale of 17/10/03, 10/06/04, 17/08/04 & 18/01/05 not met) Ensure that care plans include those actions that need to be taken by care staff to ensure that all aspects of the health, personal and social care needs of residents are met (for example pressure area care). 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. Monthly monitoring of residents’ weights must be carried out on a monthly basis with a record maintained. This is as required by Regulation 17 (1) (a) Schedule 3, 3, (m) 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. The Manager must include PRN guidelines within the medication procedure. Develop an ‘Access to Records’ policy for the care home. (Previous timescale of 17/11/03, 20/09/04 & 21/01/05 not met) The ‘Complaints Procedure’ must be updated to include all aspects required by Regulation. (Previous timescale of 17/10/03, 27/07/04 & DS0000017571.V252741.R01.S.doc 29/12/05 29/12/05 29/12/05 29/12/05 29/12/05 29/01/06 29/01/06 Francis Lodge Version 5.0 Page 24 11 OP16 22 12 OP18 13 13 OP18 13 14 OP19 22 15 OP22 22 16 OP25 13 17 OP25 13 18 OP29 19 21/01/05 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. (Previous timescale of 10/08/04 & 11/01/05 not met) A ‘whistle-blowing’ procedure must be developed to ensure the safety and protection of residents. Staff must receive training in adult protection. (Previous timescale of 17/10/03 & 21/02/05 not met) An up to date Fire Risk Assessment for the care home must be in place that is reviewed annually. (Previous timescale of 21/01/05 not met) The Manager is required to provide training in the safe use of the stair lift. (Previous timescale of 15/06/05 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 timescale of 17/12/03, 27/08/04 & 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 the risk of Legionella. (Previous timescale of 21/01/05 not met) A Grievance Policy must be developed for staff working in the care home. DS0000017571.V252741.R01.S.doc 29/01/06 29/01/06 29/01/06 29/01/06 29/12/05 29/01/06 29/01/06 29/01/06 Francis Lodge Version 5.0 Page 25 19 OP29 19 20 OP29 19 21 OP29 19 22 OP30 18 23 OP31 10 (Previous timescale of 17/11/03 & 21/02/05 not met) New staff, employed after April 2002, must have a satisfactory ‘Enhanced’ CRB check before starting work. (Previous timescale of 17/09/03 & 21/12/04 not met) Two written 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. (Previous timescale of 20/07/04 & 21/12/04 not met) The Registered Provider must ensure that applicants for jobs in Francis Lodge are physically and mentally fir for the purposes of the work that they are to perform. (Previous timescale of 27/07/04 & 21/12/04 not met) Staff induction must be to NTO specification and available to new staff within 6 weeks of appointment. 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 training must be recorded and form part of their individual training and assessment profile. (Previous timescale of 17/11/03, 17/01/04, 20/09/04 & 21/02/05 not met) The Registered Manager must ensure that they undertake and DS0000017571.V252741.R01.S.doc 29/12/05 29/12/05 29/12/05 29/01/06 29/01/06 Page 26 Francis Lodge Version 5.0 24 OP32 24 25 OP38 13 26 OP38 13 27 OP38 24 28 OP38 13 comply with requirements relating to staff recruitment, staff training and health and safety in order to protect residents. 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 Commission for Social Care Inspection and service users. (Previous timescale of 17/12/03 & 21/02/05 not met) The Registered Manager must ensure safe working practice in the care home regarding moving and handling, fire safety, first aid, food hygiene and infection control. This includes staff training and written guidance. (Previous timescale of 20/09/04 & 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. (Previous timescale of 20/09/04 & 21/02/05 not met) It is required that fire drills and practices are carried out on a quarterly basis with a record maintained. (Previous timescale of 20/07/04 & 21/01/05 not met) A ‘Health & safety’ policy for Francis Lodge, including DS0000017571.V252741.R01.S.doc 29/01/06 29/01/06 29/01/06 29/12/05 29/12/05 Page 27 Francis Lodge Version 5.0 29 OP38 13 compliance with all relevant legislation, is required. (Previous timescale of 20/08/04 & 21/02/05 not met) Copies of certificates of 29/12/05 Worthiness must be forwarded to the Commission for Social Care Inspection in respect of the care homes’ gas appliances and installation and the electrical installation and hard wiring. (Previous timescale of 30/06/05 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Francis Lodge DS0000017571.V252741.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Harrow Area office Fourth 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. 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