Inspection on 03/05/06 for Francis Lodge

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Francis Lodge 30/03/10

Francis Lodge 02/12/08

Francis Lodge 06/12/07

Francis Lodge 19/02/07

Francis Lodge 27/09/05

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 Key Unannounced Inspection 3rd May 2006 08:55 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.V287531.R01.S.doc Version 5.1 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.V287531.R01.S.doc Version 5.1 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.V287531.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 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, 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. The Inspector viewed no information about the care home’s fee levels during the unannounced inspection. This information should be obtained from Mrs Maxwell. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection of Francis Lodge commenced on 3/5/06 (from 8.55am till 1.45pm) and was later completed on 17/5/06 (between 10am and 11.55am) when the Inspector arranged to meet Mrs Maxwell in the care home. The unannounced inspection covered all the key standards. The Inspector was pleased to meet/speak with the 3 residents living in the care home, staff on duty and Mrs Maxwell. In addition time was spent observing care practice in the home, viewing statutory records and inspecting the building. The Inspector discussed with Mrs Maxwell her progress in meeting the outstanding statutory requirements from previous inspections. Mrs Maxwell indicated that she had recently undertaken some professional training that would assist the work needed to comply with requirements. This work was to begin. Mrs Maxwell planned to focus on offering staff a mainly internal training programme in addition on working on tightening up the care home’s staff recruitment procedures. The Inspector was made most welcome and would wish to thank those in Francis Lodge for the assistance received during the unannounced inspection visit. What the service does well: What has improved since the last inspection? There had been some decorative updating of the care home since the last announced inspection. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 6 The Inspector viewed evidence of two of the requirements arising from the previous announced inspection having been complied with. What they could do better: Residents living in Francis Lodge and prospective residents must have access to an up to date and complete ‘Statement Of Purpose’ and Service Users Guide for the care home, that documents the services available, aims and objectives etc. Residents living in Francis Lodge have care plans though they did not reflect the care practice observed during the unannounced inspection. Residents are facilitated by staff to access their healthcare needs, though more information is required within care plans to ensure that staff have adequate guidance on how to provide residents with consistent care and support. Residents are administered their medication by staff, though the Registered Provider must ensure that that requirements to ensure the safety of medication administration systems in Francis Lodge are complied with. Work needs to be done to ensure that resident choices and preferences are fully evaluated as part of the care home’s care planning processes. It remains an outstanding requirement that there must be an ‘Access to Records’ policy for the care home. Care must be taken that food is stored safely in the fridge. Work must be done to ensure that the care home’s arrangements in terms of Complaints and Protection of Vulnerable Adults from Abuse comply with Regulations, in order to ensure that complaints are listened to and residents protected from abuse. Areas of the residents’ accommodation require attention. Attention must be paid to ensure that the hot water taps run at a safe temperature. Residents must be assured that they are cared for by a staff team that has undertaken the required NVQ level 2 training in care. Residents must be assured that they are supported and protected by the care home’s recruitment procedures that ensure that only those who are fit to work with vulnerable adults are employed in the care home. Residents must be assured that care staff employed in Francis Lodge receives the required training to do their jobs. Residents do not benefit from living in a care home that is managed effectively. Residents must be assured that their views and those of other stakeholders are sought as a means of contributing to the care home’ effective quality assurance and quality monitoring systems. More work must be done to ensure that resident’s health, safety and welfare are fully protected. There remain outstanding requirements in this area. Please contact the provider for advice of actions taken in response to this Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents living in Francis Lodge and prospective residents must have access to an up to date and complete ‘Statement Of Purpose’ and ‘Service Users Guide’ for the care home, that documents the services available and its aims and objectives. No new residents had been admitted to Francis Lodge since the last announced inspection of Francis Lodge and there was no evidence of the implementation of the care home’s assessment and admission policies. EVIDENCE: There remain outstanding requirements in respect of the content of the care home’s Statement Of Purpose and Service Users Guide. These documents must be made available to current and prospective residents. They were not viewed within the records held in the care home or on the notice board in the corner of the kitchen. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 10 The resident group remains the same as at the last announced inspection in September 2005. There was no evidence noted of any assessments of potential residents having been carried out in respect of placements in Francis Lodge. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents living in Francis Lodge have care plans though they do not reflect the care practice observed during the unannounced inspection. Residents are facilitated by staff to access their healthcare needs, though more information is required within care plans to ensure that staff have adequate guidance on how to provide them with consistent care and support. Residents are administered their medication by staff, though the Registered Provider must ensure that that requirements to ensure the safety of medication administration systems in Francis Lodge are complied with. Residents were observed to be treated with respect, during the unannounced inspection. EVIDENCE: The Inspector viewed each of the residents’ care plans that were held in a filing cabinet within the care home. Care plans included the resident’s medical, social, hearing, psychological and sight needs. A review entitled ‘ Summary of Progress’ had been completed for each resident on 4/4/06. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 12 The Inspector discussed with Mrs Maxwell the need to have clear written guidance for staff of the actions that they need to take in order to appropriately and consistently care for each resident living in Francis Lodge. Care plans must offer guidance for staff on the care and support needs of residents in terms of their health and welfare, in order to ensure a consistency of care provision. This is a previous requirement. The Inspector gathered that the GP and district nurse had agreed the care arrangements for one resident in terms of their pressure area care. This guidance was, however, not reflected in their care plan. Mrs Maxwell and the member of staff on duty spoke about the practical care needs of this particular resident. Staff maintain a daily record of the care received by residents in terms of bathing etc. This record, however, was not completed and up to date for all residents. In addition staff note the mood of the residents as observed. Residents were judged to have been in a “good” mood although it was unclear how this conclusion had been reached. . Staff must use age appropriate and non-judgemental terminology to describe residents’ moods observed. Whilst residents signed their care plans there was little indication of their inclusion in the formulation and review of their care plans. Care plans present as being written about residents. A risk assessment for one resident was viewed in their care plan. This was dated 13/5/04 with no record of subsequent review or updating. Inspection of individual residents’ care records indicated some risks for which no risk assessments were in place. This included falling and pressure areas. Risk assessments must be developed in respect of all areas of identified risk for residents. Care plans did not provide clear information for staff on the residents’ preferences in terms of their personal and oral hygiene with any risk assessment. This must be developed. The Inspector discussed with Mrs Maxwell the need to have appropriate guidance for staff on any secondary mental health needs of the residents, as well as any medical conditions that they may suffer from, for example diabetes. The Inspector observed information about various healthcare professional appointments that residents attend. This includes GP, District Nurse and Continence Advisor. Mrs Maxwell accompanied a resident to attend a hospital appointment during the first unannounced visit to the care home. There is some information in one resident’s care plan regarding their pressure area care arrangements. From discussions during the unannounced inspection it was clear that the care provided to this resident is more extensive than indicated in the care plan. Mrs Maxwell was advised that the care plans must reflect the full care and support needs of the resident. One resident’s weight had last been monitored on 4/3/06 with a record of the outcome kept. This must be continued on a monthly basis. One resident had been out for a walk when the Inspector arrived on the second day of the inspection. Another resident spoke of the occasions when they went out. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 13 The Inspector viewed the medication storage facilities and recording systems in Francis Lodge. The pharmacist supplies residents’ medication to the care home in a weekly dossette pack. A ‘Medication’ policy was viewed on the medication file with examples of staff signatures. The record of medication administered to residents was viewed. Staff had mostly signed for the medication that they had administered to residents, though one omission was noted on 2/5/06. This was discussed with Mrs Maxwell. In addition the sections marked allergies on residents’ individual medication administration records had been left blank. Mrs Maxwell was advised of the need to ensure that this information is completed. There is written information for staff regarding the administration of medication to residents on a PRN basis. Mrs Maxwell stated that she planned to arrange for staff employed in the home to undertake medication training. This is a previous requirement. The member of staff on duty kindly advised the Inspector of the medication training that they had undertaken in their previous employment. The Inspector observed that residents were treated with respect during the unannounced inspection. There was some conversation between staff and residents on matters not relating to their care. The Inspector observed staff on duty asking a resident about their choices in terms of food and preferred recreational activity for the afternoon. Staff knocked on a resident’s bedroom door before entering. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents living in Francis Lodge were observed to be offered some choices in terms of their leisure activities and food during the unannounced inspection. This, however, is an area that requires some development to ensure that residents are able to exercise some individual choices in terms of their routines of daily living and activities. Residents confirmed to the Inspector that they have visitors. Residents indicated that they “liked” the food in Francis Lodge. EVIDENCE: Residents’ care plans contain some information about their ‘social needs’. Information about the care home’s weekly activities was displayed in the kitchen. This included am and pm activities, mostly were in house and included crosswords, cooking, dominoes and board games. The Inspector observed that staff offered one resident a puzzle book to do in the afternoon of the unannounced inspection. Discussion with residents indicated that they were largely satisfied with the care and facilities available to them in Francis Lodge. One resident confirmed that they preferred things to be “quiet”. Another resident indicated that they would like more things to do in the care home. It must be ensured that the care home’s care planning practice Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 15 evaluates and includes the social and recreational needs of residents as part of their agreed care plans Mrs Maxwell advised the Inspector that the weekly menu for the care home is decided in conjunction with the residents. The menu displayed on the kitchen notice board covered 2 days (Wednesday and Thursday). It was unclear how residents had contributed to these choices. The Inspector observed a member of staff ask what alternatives to rice they would prefer for lunch. One resident spoke to the Inspector about a visitor that they had received in Francis Lodge. Inspection of the ‘Visitors Book’ confirmed that there was a range of visitors to the home. During the unannounced inspection the Inspector gathered that some residents occasionally go to church. There remains an outstanding requirement regarding Standard 14. During the first day of the unannounced inspection the Inspector observed that two residents were served a lunch of turkey stew, boiled potatoes and vegetables with an orange drink. This was followed by strawberry angel delight. There was a bowl of fresh fruit on the dining table. One resident was served their lunch in liquidised form. The dining table was set for the lunch that was served at 12.10pm. One resident let the Inspector know that they had eaten scrambled eggs for breakfast. Residents were served drinks with their lunch as well as in the mid morning and afternoon. One resident indicated that they eat breakfast, lunch and dinner in Francis Lodge. Two residents kindly indicated to the Inspector that they “like” what they eat in Francis Lodge. One resident indicated that the care home was able to supply them with specialist foodstuffs of their choosing. Staff maintain a record of the meals eaten by residents in Francis Lodge. This includes such items as sausage hot pot, steak pie and roast meats. The home’s fridge and freezer contained a variety of foodstuffs. Care, however, must be taken to ensure that items of food stored in the fridge are covered appropriately. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Work must be done to ensure that the care home’s arrangements in terms of Complaints and Protection of Vulnerable Adults from Abuse comply with Regulations in order to ensure that complaints are listened to and residents protected from abuse. EVIDENCE: The Inspector did not view a ‘complaints Procedure’ within the documentation in the care home and was unable to judge if previous requirements had been complied with. Two residents kindly indicated to the Inspector that they would speak to Mrs Maxwell or staff in the event of any concerns. The Inspector viewed no indication during the unannounced inspection that requirements in respect of Protection of Vulnerable Adults from Abuse had been complied with. Mrs Maxwell stated that she planned to arrange for staff to attend external training on Protection of Vulnerable Adults from Abuse. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ accommodation is largely fairly well maintained though some areas requiring attention were identified during the inspection. Residents spoke positively about their accommodation in Francis Lodge. Residents’ accommodation presented as clean and pleasant though attention must be paid to ensure that the hot water taps run at a safe temperature. EVIDENCE: The building presented to the Inspector as clean, tidy and free of offensive odours during the unannounced inspection. Mrs Maxwell spoke of her plans with regard to updating the building. This includes interior works such as updating the bathroom and some external works to make the patio area safer. This is required. There had been some decorative updating since the Inspector last visited, though it largely remains unchanged. The hot water tap in the bathroom remains very hot to the touch and steaming. This is a previous requirement and must be attended to. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 18 The Inspector observed that a resident used the en suite toilet in the ground floor bedroom as a communal facility. It must be ensured that resident’s ensuite toilets are not used as communal facilities. Residents do not have access to an alarm call system within the building and have to call for help by shouting. This method of calling for help must be kept under review to ensure that it is appropriate to meet the needs of residents. The laundry is located in the care home’s garage. This building is separate from the care home. It can be accessed through areas where food is not stored, prepared, cooked and served to residents. The washing machine is a domestic type and was observed to wash to a maximum of 95ºC. The Inspector did not view an Infection Control policy for the care home within the policy documentation. This is required. Staff were observed by the Inspector to be using protective clothing in the course of their work. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents are supported by a rota’d staff team that presents as sufficient to meet their care and support needs. Residents must be assured that they are cared for by a staff team that has undertaken the required NVQ level 2 training in care. Residents must be assured that they supported and protected by the care home’s recruitment procedures that must ensure that only those who are fit to work with vulnerable adults are employed in the care home. Residents must be assured that care staff employed in Francis Lodge receives the required training to do their jobs. EVIDENCE: The Inspector viewed a staff rota displayed in the kitchen. This indicated that one member of staff was on duty each day from 9am to 7pm with another member of staff rota’d to work 7pm till 9am. Mrs Maxwell is rota’d to work on Saturday and in addition advised the Inspector that she visits the home at other times during the week. The staff rota included the name of 3 members of staff and Mrs Maxwell. Mrs Maxwell indicated to the Inspector that the current staffing levels were sufficient to meet the varying needs of residents. There were no indications to the contrary during the unannounced inspection. The Inspector observed that one resident has higher dependency care needs and is cared for in their bedroom. This did not present to the Inspector as causing any difficulties for the other 2 residents. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 20 The staffing levels meet the minimum requirements of the previous regulatory authority for a home of this size. Mrs Maxwell advised the Inspector that she plans to arrange for NVQ Level 2 in care (internal and external) training to be made available to staff employed in the home. This is required. Mrs Maxwell kindly passed the Inspector a copy of the ‘ Staff Recruitment Guidelines’ for Francis Lodge. This indicated that 2 references are sought for each applicant and new staff are confirmed in post following receipt of a satisfactory CRB check. The Inspector did not view any recruitment documentation in respect of those members of staff who had been more recently recruited. This is required. The Inspector was unable to view evidence of previous requirements regarding staff recruitment having been met. These requirements were discussed with Mrs Maxwell who indicated that she planned to take a tighter grip on the care home’s recruitment procedures. The Inspector indicated that the requirements in respect of staff recruitment are to ensure the protection of residents. Statutory records in respect of staff recruitment must be available for inspection in the care home. The Inspector viewed a copy of a ‘Disciplinary procedure’ for the care home. This was a brief document and it was the Inspectors’ view that it needs some review and expansion to ensure the inclusion of statutory areas. This was discussed with Mrs Maxwell. Mrs Maxwell kindly passed the Inspector a copy of the ‘Staff Training’ policy for Francis Lodge. This indicated that new care staff were to receive induction training within 6 weeks of appointment and each member of staff would have an individual training and development assessment and profile. Mrs Maxwell informed the Inspector that she planned training for staff in dementia, first aid, food hygiene, Protection of Vulnerable Adults from abuse, health and safety, mental health and medication. Staff were said to have recently done training in moving and handling. It is required that care staff employed in Francis Lodge undertake all required training to ensure that they fulfil its ‘Statement Of Purpose’ and meet the changing needs of residents. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents do not benefit from living in a care home that is managed effectively. Residents must be assured that their views and those of other stakeholders are sought as a means of contributing to the care home’ effective quality assurance and quality monitoring systems. Mrs Maxwell indicated that she does not hold any money on resident’s behalf. Therefore Standard 35 is not applicable. More work must be done to ensure that resident’s health, safety and welfare are fully protected. There remain outstanding requirements in this area. EVIDENCE: Mrs Maxwell is the Registered Provider and Registered Manager in respect of Francis Lodge. Mrs Maxwell stated that she had recently undertaken a professional training course. As a consequence of this training she planned to Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 22 focus on staff training & recruitment in addition to the care home’s administrative systems and recording. Mrs Maxwell indicated awareness of the care home’s shortfalls in these areas. Mrs Maxwell indicated that she feels the care home is able to offer an excellent level of care and support to residents. There remain 27 outstanding requirements from the previous announced inspection. Most have been outstanding for some time. The Inspector spoke about the need for the care home to meet statutory requirements. Continued non-compliance may result in the Commission for Social Care Inspection taking enforcement action against the care home. 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 and medication, there were areas that remained in need of improvement. This particularly includes health and safety, staff recruitment and staff training and there have been requirement outstanding in these areas for some time. The Inspector discussed with Mrs Maxwell the need to display the care home’s Certificate of Registration (as issued by the Commission for Social Care Inspection) conspicuously in the care home. One page only was pinned to a small notice board in the kitchen and had been obscured. This was to be addressed and is required. It cannot be judged that the care home is managed effectively. The Inspector spoke to Mrs Maxwell of the need to ensure that effective quality assurance and quality-monitoring systems are in place that seeks the views of residents, their representatives and stakeholders. This is a previous requirement. Mrs Maxwell spoke of having received positive verbal feedback from various healthcare professionals who visit the care home and in addition feedback about the service provided in Francis Lodge is constantly sought from residents. The Inspector spoke of the need to record this feedback and use it as part of the care home’s quality assurance and quality monitoring systems. Mrs Maxwell indicated that she does not hold any monies on behalf of residents living in Francis Lodge. A ‘Health and Safety’ policy in respect of Francis Lodge was viewed that covered visitors to the care home only. This must be extended to all required areas. There was no written guidance or evidence of staff training in respect of moving and handling, fire safety, first aid, safe use of chemicals in the care home, food hygiene and infection control. The risk assessments viewed were in respect of individual residents and did not cover safe working practice. The Inspector did not view a Fire Risk Assessment for the care home or evidence that the smoke detectors had been tested There was no evidence of fire safety training and practice exercises for staff having been carried out in Francis Lodge. The Inspector viewed a procedure for the care home in respect of ‘Fire Evacuation routes’. No up to date Certificates of Worthiness were viewed in respect of the care home during the unannounced inspection. A copy of the certificate of Worthiness in respect of the care homes’ electrical appliances was previously Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 23 forwarded to the Commission for Social Care Inspection as required. It remains a requirement that 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 none were recently recorded. Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 24 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 1 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 2 x x 2 x x 2 3 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x N/A x x 1 Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 25 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 timescales of 17/10/03, 10/06/04, 10/8/04, 11/01/05 & 29/01/06 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 timescales of 17/10/03, 10/06/04, 10/08/04, 11/01/05 & 29/01/06 not met) When available, full copies of the Statement Of Purpose and Service Users Guide for Francis Lodge are required by the Commission for Social Care DS0000017571.V287531.R01.S.doc Timescale for action 03/09/06 2. OP1 5 03/09/06 3. OP1 4&5 03/09/06 Francis Lodge Version 5.1 Page 26 4. OP7 15 5. OP7 13 6 7 OP7 OP7 13 12 8 9 OP7 OP8 17 15 10 OP8 15 11 OP8 17 Inspection. (Previous timescales of 17/10/03, 10/06/04, 17/08/04, 18/01/05 & 05/02/06 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). (Previous timescale of 29/12/05 not met) 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 timescale of 29/12/05 not met) Risk assessments must be developed in respect of all areas of identified risk for residents. Staff must use age appropriate and non-judgemental terminology to describe residents’ moods observed. Ensure that daily records of residents’ care arrangements are maintained and up to date. Care plans must provide clear information for staff on the residents’ preferences in terms of their personal and oral hygiene with any risk assessment completed. Care plans must reflect the full care and support needs of the resident, including any specialist needs in terms of their pressure area care. Appropriate written guidance for staff on any secondary mental health needs of the residents, as DS0000017571.V287531.R01.S.doc 03/09/06 03/09/06 03/09/06 03/09/06 21/08/06 03/09/06 03/09/06 03/09/06 Francis Lodge Version 5.1 Page 27 12 OP8 17 13. OP9 13 14 OP9 13 15 OP9 13 16 OP12 16 17 OP14 12 18 19 OP15 OP16 13 22 well any medical conditions that they may suffer from, for example diabetes, must be available for staff caring for residents Ensure that resident’s weights are monitored on monthly basis with a record of the outcome kept. 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 not met) There must be a full record of medication administered to residents by staff, including reasons for any nonadministration. Ensure that there is information on each resident’s individual medication administration records regarding their allergies. It must be ensured that the care home’s care planning practice evaluates and includes the social and recreational needs of residents as part of their agreed care plans Develop an ‘Access to Records’ policy for the care home. (Previous timescales of 17/11/03, 20/09/04, 21/01/05 & 29/01/06 not met) It must be ensured that items stored in the fridge are covered appropriately. The ‘Complaints Procedure’ must be updated to include all aspects required by Regulation. (Previous timescales of 17/10/03, 27/07/04, 21/01/05 & 29/01/06 not DS0000017571.V287531.R01.S.doc 21/08/06 03/09/06 21/08/06 21/08/06 03/09/06 03/09/06 21/08/06 03/09/06 Francis Lodge Version 5.1 Page 28 met) 20. OP16 22 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 timescales of 10/08/04, 11/01/05 & 29/01/06 not met) A ‘whistle-blowing’ procedure must be developed to ensure the safety and protection of residents. (Previous timescale of 29/01/06 not met) Staff must receive training in adult protection. (Previous timescales of 17/10/03 & 21/02/05 & 29/01/06 not met) An up to date Fire Risk Assessment for the care home must be in place that is reviewed annually. (Previous timescales of 21/01/05 & 29/01/06 not met) Arrange for the bathroom ceiling wallpaper to be re-instated where it has become unstuck and redecorate. Arrange for the rear side steps to the garage area to be resurfaced and levelled to avoid a trip hazard for residents. It must be ensured that resident’s en-suite toilets are not used as communal facilities. The Manager is required to provide training in the safe use of the stair lift. (Previous timescales of 15/06/05 & 29/12/05 not met) Mechanisms must be in place to prevent the risk of Legionella in DS0000017571.V287531.R01.S.doc 03/09/06 21 OP18 13 03/09/06 22. OP18 13 03/10/06 23 OP19 22 21/08/06 24 OP19 23 03/09/06 25 OP19 13 03/09/06 26 27. OP19 OP22 12 22 03/09/06 03/09/06 28 OP25 13 03/09/06 Page 29 Francis Lodge Version 5.1 29 OP25 13 30 31 OP25 OP28 13 18 32 OP29 17 33 OP29 19 34 OP29 19 35 OP29 19 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 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 not met) An Infection Control policy for the care home must be developed as is required. It is required that 50 of the care staff employed in Francis Lodge undertakes NVQ Level 2 in care. Statutory records in respect of staff recruitment must be available for inspection in the care home. A Grievance Policy must be developed for staff working in the care home. (Previous timescales of 17/11/03, 21/02/05 & 29/01/06 not met) New staff, employed after April 2002, must have a satisfactory ‘Enhanced’ CRB check before starting work. (Previous timescales of 17/09/03 & 21/12/04 & 29/12/05 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 timescales of 20/07/04, 21/12/04 & DS0000017571.V287531.R01.S.doc 21/08/06 03/09/06 03/10/06 03/09/06 03/09/06 03/09/06 03/09/06 Francis Lodge Version 5.1 Page 30 36 OP29 19 37 OP30 18 38 OP30 18 39 OP31 10 40 OP31 12 29/12/05 not met) The Registered Provider must ensure that applicants for jobs in Francis Lodge are physically and mentally fit for the purposes of the work that they are to perform. (Previous timescales of 27/07/04, 21/12/04 & 29/12/05 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 timescales of 17/11/03, 17/01/04, 20/09/04, 21/02/05 & 29/01/06 not met) It is required that care staff employed in Francis Lodge undertake all required training to ensure that they fulfil its Statement Of Purpose and meet the changing needs of residents. This must be recorded. The Registered Manager must ensure that they undertake and comply with requirements relating to staff recruitment, staff training and health and safety in order to protect residents. (Previous timescale of 29/01/06 not met) It must be ensured that the care home’s Certificate of Registration (as issued by the Commission for Social Care Inspection) is displayed conspicuously in the DS0000017571.V287531.R01.S.doc 03/09/06 03/10/06 03/10/06 03/09/06 21/08/06 Francis Lodge Version 5.1 Page 31 41 OP33 24 42 OP38 13 43 OP38 13 44 OP38 24 45 OP38 13 care home. 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 timescales of 17/12/03, 21/02/05 & 29/01/06 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 timescales of 20/09/04, 21/02/05 & 29/01/06 not met) Ensure that the home has available risk assessments in respect of safe working practice topics and record of significant findings. (Previous timescales of 20/09/04 21/02/05 & 29/01/06 not met) 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 not met) A ‘Health & safety’ policy for Francis Lodge, including compliance with all relevant legislation, is required. (Previous timescale of 20/08/04 & 21/02/05 & DS0000017571.V287531.R01.S.doc 03/10/06 03/09/06 03/09/06 03/09/06 03/09/06 Francis Lodge Version 5.1 Page 32 46 OP38 13 29/12/05 not met) Copies of certificates of 21/08/06 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 timescales of 30/06/05 & 29/12/05 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.V287531.R01.S.doc Version 5.1 Page 33 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. Extracts may not be used or reproduced without the express permission of CSCI Francis Lodge DS0000017571.V287531.R01.S.doc Version 5.1 Page 34 - 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. 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