Inspection on 06/12/07 for Francis Lodge

This inspection was carried out on 6th December 2007.

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 19/02/07

Francis Lodge 03/05/06

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 Andreas Schwarz Key Unannounced Inspection 09:00 6th December 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000017571.V333520.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000017571.V333520.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 F/P 020 8931 2108 Ms Monica Maxwell Ms Monica Maxwell Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places DS0000017571.V333520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th February 2007 Brief Description of the Service: Francis Lodge is a semi-detached house that is located in a quiet residential street in Harrow Weald. Francis Lodge is registered as a care home to provide personal care only to 3 adults, aged 65 years and over. It does not offer a specialist service. The home has a garden that can be accessed by steps through the rear of the house. One bedroom (with an en-suite) is located on the ground floor and the other 2 bedrooms are on the first floor. There is a bathroom and toilet on the first floor of the building. The home has a stairlift. The Proprietor maintains a private room on the first floor. The care home is fairly close to community and leisure facilities within Harrow Weald and Stanmore. The care home has off road parking on its driveway in addition to unrestricted street parking. Mrs Maxwell is the Registered Provider and Manager. The fees are £450 per week. DS0000017571.V333520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection lasted over two days in December 2007. The registered provider Mrs Maxwell was available during both days of this key inspection. I spoke to both people using the service and one member of staff. I viewed care plans and other documents relating to the care and support provided by the home. The home returned a completed Annual Quality Assurance Assessment to the Commission for Social Care Inspection. I would like to take this opportunity thanking people using the service, staff and manager for assisting me during this key inspection. What the service does well: What has improved since the last inspection? The home has met 18 of the 22 requirement made during the last inspection. The refurbishment is completed and an additional en-suite bedroom has been built. The home has been repainted and new carpets have been provided. DS0000017571.V333520.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000017571.V333520.R01.S.doc Version 5.2 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 DS0000017571.V333520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose that is specific to the home and the resident group they care for. Admissions are not made to the home until a full needs assessment has been undertaken. Not all people using the service are provided with a statement of terms and conditions or a contract. EVIDENCE: I have viewed the home statement of purpose, which has been updated since the last key inspection, the document is judged as basic but compliant with National Minimum Standards. The home has updated the service users guide, which contains all necessary information. Both documents can be accessed on the notice board in the dinning area of the home. DS0000017571.V333520.R01.S.doc Version 5.2 Page 9 The home has currently to people living at the home; both have been living in the home for a number of years. I have viewed a detailed needs assessment in one of the files viewed. The residents’ handbook provides information to new prospective people using the service regarding assessments and trial visits. The home has a contract with the funding authority in place, but only one of the people living in the home have a contract with the service in place. It is required to that all people using the service have a contract with the service provider in place. The home does not provide intermediate care. DS0000017571.V333520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The care plan is a working document reviewed regularly involving the person and their representatives, as appropriate. People have access to health care services both within the home and in the local community. Medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. EVIDENCE: I have viewed both care plans during this key inspection. People using the service informed me that they know about their care plan and meet their key worker regularly. Care plans are reviewed monthly and updated when and if necessary. People using the services are encouraged signing the care plan. Care plans have falls assessments in place, which have been reviewed. DS0000017571.V333520.R01.S.doc Version 5.2 Page 11 The home supports people using the service to visit the optician and dentist. One of the people was going for a hospital appointment during the second day of this inspection and was accompanied by a member of staff. The home undertakes Dementia assessments on all people using the service, which are reviewed three monthly. Pressure sore assessments are in place and the home supports people using the service to obtain the necessary equipment for the prevention of pressure sores. During the first day of this inspection, I observed the manager engaging people using the service in exercise. People using the service informed me that this does happen regularly. The home is recording peoples weight, this however was not done since 08/09/07 and the registered manager was advised to ensure that peoples weight is monitored monthly. People using the service are registered with their own General Practitioner. I viewed both Medication Administration Sheets during this inspection. Both have been handwritten. The General Practitioner has recently reviewed one of medication administered to a person. People’s pictures are on the medication file and there were no gaps on the Medication Administration Sheets. The home has an agreement with the local Primary Care Trust. Medication is stored in a lockable cabinet and a signatory list of staff authorised to administer medication is in place. Staff have received medication administration training from an accredited training provider. I noted that people’s allergies are not recorded, which is required. People using the service told me that they are treated with respect and I have observed staff asking people what they want to do, or what they want to have for a snack. Mail was given to people unopened. The home is currently not having any shared rooms. People using the service informed me that they are happy at Francis Lodge and staff is very nice and listens to their needs. DS0000017571.V333520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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 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. The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. EVIDENCE: The home is providing planned activities for people using the service. People using the service told me that they do crosswords, Arts and Craft sessions, scrabble, etc. Daily records viewed during this inspection confirmed this. One of the people using the service likes to read the bible; this has been recorded in the persons care plan and was observed during this key inspection. DS0000017571.V333520.R01.S.doc Version 5.2 Page 13 The home supports people using the service to do personal shopping in Waitrose, daytrips to Clayton on Sea and Alderham Farm has been recorded in people’s daily records. One person using the service told me that she would visit friends over the coming Christmas holidays. The home has an open visiting policy. The home does not handle people’s finances and expenses are invoiced. Families manage finances. Rooms are decorated with personal items brought to the home by the person. The home has a confidentiality policy, which stipulates access to personal records. The home is providing a varied and healthy diet; a sample menu is available in the kitchen. I have observed staff asking people using the service if they are still happy with their chosen meal. I observed mealtimes during the first day of this inspection, which were unrushed and food was nicely presented. People using the service informed me that the food provided in the home is of good standard and that they enjoy mealtimes. DS0000017571.V333520.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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 has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. There are policies and procedures for safeguarding people who use the service but these do not fully meet required standards. EVIDENCE: The home has a complaints policy in place, which is complaint with National Minimum Standards. People using the service told me that they would complain to the registered manager if they had any issues. The home did not receive any complaints since the last key inspection. The complaints policy was displayed on the notice board and in the handbook. The home has a Protection of Vulnerable Adults leaflet in place; staff have received Protection of Vulnerable Adults training. Following this inspection the registered manager send me a whistle blowing policy. The Protection of Vulnerable Adults leaflet must refer to the whistle blowing policy and state that the Commission for Social Care Inspection can be contacted at any stage people want to raise any adult protection issues. DS0000017571.V333520.R01.S.doc Version 5.2 Page 15 DS0000017571.V333520.R01.S.doc Version 5.2 Page 16 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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. EVIDENCE: Furnishing is of domestic character and the environment is homely and nicely decorated, pictures, photos, ornaments and plants are displayed throughout the home. The home has recently completed an extension and is in the process of applying for a variation of registration to increase beds provided. People using the service told me that the disturbance during the refurbishment was minor. Previous inspections raised the issue of putting mechanisms into place to prevent the risk of Legionella; the registered manager informed me that she DS0000017571.V333520.R01.S.doc Version 5.2 Page 17 has approached a number of companies and is currently waiting for quotes. The home has now two bedrooms on the ground floor and two bedrooms on the first floor. A stair lift enables people with mobility problems accessing the upstairs of the premises. People using the service can access a large wellmaintained garden. The home is spacious light and airy and was free of any offensive odours during this key inspection. The utility room is in a separate building located in the garden. A washing machine and dryer is available to launder people’s clothes. During the last Environmental Health visit the home received a four star rating. DS0000017571.V333520.R01.S.doc Version 5.2 Page 18 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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are generally satisfied that the care they receive to meet their needs. There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. The manager is aware that there are some gaps in the training programme and plans to deal with this. People using the service report that staff working with them knows what they are meant to do, and that they meet their individual needs in a way that they are satisfied with. EVIDENCE: The registered manager told me that the home has currently two staff employed; the rota shows that the manager is fully involved within the care of people using the service. People using the service told me that there is enough staff on duty to support them with their needs. I have observed additional staff supporting a person using the service to a hospital appointment. Care staff undertakes cleaning duties. DS0000017571.V333520.R01.S.doc Version 5.2 Page 19 One of the two staff employed hold National Vocational Qualification in Care, this meets the required 50 . The home does not employ staff under the age of 18. One of the assessed files did not contain references and proof of the right to work in the United Kingdom. I informed the registered manager of this who informed me that this member of staff returned to the home following an absence due to personal reasons. It was previously recommended to provide an internal reference for this employee. The registered manager forwarded a Grievance policy to the Commission for Social Care Inspection, which should be made available to all staff. Staff spoken to inform me that they did not receive a statement of terms and conditions, this is required. Staff have attended training such as Breakaway, First Aid, Food Hygiene, Manual Handling, Protection of Vulnerable Adults, etc. One staff member informed me that she has attended management training provided by a local college. I was also informed that new staff is inducted, but I could not find any documentation of this. DS0000017571.V333520.R01.S.doc Version 5.2 Page 20 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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are involved and consulted about he care and support provided by the home. The manager is suitably qualified to manage a registered care home and provide care to the elderly. There is a lack of regular monitoring of fire equipment, which could people using the service into danger. EVIDENCE: The manager Mrs Maxwell is registered with the Commission for Social Care Inspection. The manager informed me that she has a teaching degree and an Open University Qualification in Care. The registered manager demonstrated since the last inspection that she is making efforts in complying with DS0000017571.V333520.R01.S.doc Version 5.2 Page 21 requirements. Staff told me that the manager is supportive and listens to problems staff may have. The manager has undertaken service users surveys in December 2007, both surveys have been very positive about the support and care provided by the home. The annual development plan is in place and was displayed on the notice board in the dinning area. The home must forward a copy of this development plan to the Commission for Social Care Inspection. Staff informed me that they have regular staff and residents meetings; records of these meeting could be viewed during this key inspection. The home is not managing peoples finances, the person, their representative or their family manages finances. The registered manager informed me that she would invoice any expenditure made by the person. The home has a Health and Safety policy in place. The home is undertaken monthly recorded Health and Safety checks. During this inspection, the home was visited by an engineer to assess the new fire detection system. I noted that not all fire doors are self-closing and informed the manager that this must be dealt with. I viewed the homes fire risk assessment, which is very basic and must be reviewed and updated. The risk assessment is currently a handwritten diagram. The fire equipment was last checked on August 2007 and the last recorded fire drill was undertaken on the 23/08/07. There was however no clear evidence that a minimum of four planned fire drills has been undertaken during the last year, which is required. The manager informed me that the water temperature is monitored daily, record however did not confirm this. The Portable Appliances Test Certificate was updated on 03/12/07. I noted that the Landlords Gas Safety Certificate has expired and informed the manager that this has to be renewed and a copy must be send to the Commission for Social Care Inspection. DS0000017571.V333520.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 DS0000017571.V333520.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1) Requirement Each service user must be issued with a contract or statement of terms and conditions of the their residency, with a signed copy kept on their file. (Previous timescale of 01/05/07 not met) The registered manager must ensure that peoples weight is monitored and records are updated monthly, to give any indication in changes to peoples health. The registered manager must ensure to record peoples allergies on the Medication Administration Sheet. Timescale for action 01/02/08 2. OP8 12(1)(a) 15/01/08 3. OP9 13(2) 15/01/08 4. OP18 13(6) The Protection of Vulnerable 01/02/08 Adults leaflet must refer to the whistle blowing policy and state that the Commission for Social Care Inspection can be contacted at any stage people want to raise any adult protection issues. Mechanisms must be in place to DS0000017571.V333520.R01.S.doc 5. OP25 13(4) 01/02/08 Page 24 Version 5.2 prevent the risk of Legionella in Francis Lodge. This includes the maintenance of the hot water temperatures at required levels in the tank and pipe work. (Previous timescales of 17/12/03, 27/08/04, 21/01/05, 29/01/06, 03/09/06 & 01/05/07 not met). 6. OP29 18(4) All staff must be issued with a contract and a statement of terms and conditions. Induction of new staff must be recorded and these records must be made available for inspection. The home must forward a copy of the annual development plan to the Commission for Social Care Inspection. It is required that fire drills and practices are carried out on a quarterly basis with a record maintained. (Previous timescales of 20/07/04, 21/01/05, 29/12/05, 03/09/06 & 01/05/07 not met). 10. OP38 23(4) The existing fire risk assessment must be reviewed and updated to take the new fire system into consideration. The Landlords Gas Safety Certificate must be renewed and a copy of the certificate must be send to the Commission for Social Care Inspection. The prevent the spreading of fire, all fire doors must be self DS0000017571.V333520.R01.S.doc 01/02/08 7. OP30 17 15/01/08 8. OP33 24(2) 01/02/08 9. OP38 23(4) 01/02/08 01/02/08 11. OP38 13(4) 15/01/08 12. OP38 23(4) 01/02/08 Page 25 Version 5.2 closing. 13. OP38 13(4)(a) Hot water temperatures must be taken and recorded weekly at all points throughout the home where people using the service have access. (Previous timescale of 01/05/07 not met) 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP29 Good Practice Recommendations It is recommended to ensure that all people using the service have a contract with the service provider in place. As the Regulations require two employment references for each employee, where a potential employee has previously worked at Francis Lodge, an internal written reference could be used. The grievance policy should be given to all members of staff. 3. OP29 DS0000017571.V333520.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 DS0000017571.V333520.R01.S.doc Version 5.2 Page 27 - 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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