Inspection on 20/11/06 for Franklin House

This inspection was carried out on 20th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Franklin House 07/01/08

Franklin House 19/10/05

Franklin House 07/06/05

Franklin House 11/01/05

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Franklin House The Green Swan Road West Drayton Middlesex UB7 7PW Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 10:25 20th November 2006 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 Franklin House DS0000056134.V294831.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. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Franklin House Address The Green Swan Road West Drayton Middlesex UB7 7PW 01895 452 480 01895 448 132 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) Care UK Mrs Wilma Thomson Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The ground floor accommodates the 21 bedded intermediate care unit. The middle floor will accommodate a 31 bedded general nursing unit. The top floor will accommodate the 14 bedded continuing care unit. Staffing levels as agreed at point of registration must be maintained unless negotiated with the Regulation Authority, prior to any changes being made. For Charlie Chaplin Unit, the following staffing levels: A.M Shift: 17-21 service users, one Registered Nurse and Five Care Assistants 13-16 service users, one Registered Nurse and Four Care Assistants 9-12 service users, one Registered Nurse and three Care Assistants 8-0 service users, one Registered Nurse and two Care Assistants P.M shift: 17-21 service users, one Registered Nurse and Four Care Assistants 13-16 service users, one Registered Nurse and three Care Assistants 9-12 service users, one Registered Nurse and two Care Assistants 8-0 service users, one Registered Nurse and two Care Assistants Nocte shift: 17-21 service users, one Registered Nurse and 1.5 Care Assistants (.5 CA to be employed between 8pm and 12am). 13-16 service users, one Registered Nurse and one Care Assistant 9-12 service users, one Registered Nurse and one Care Assistant 8-0 service users, one Registered Nurse and one Care Assistant. Date of last inspection 19th October 2005 Brief Description of the Service: Franklin House is a purpose built 66-bedded nursing home situated in West Drayton. There are 66 single en-suite bedrooms. The home has three units: the intermediate care unit, frail elderly nursing unit and a continuing care unit. Each unit is located on a separate floor and have their own team of staff. On the intermediate care unit there is also good physiotherapy and occupational therapy provision. A kitchenette is available in each unit and there is a main kitchen and laundry on the ground floor. There is a rear garden, which can be accessed by service users. Each unit has a dining room and two lounges. There Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 5 are two lifts in the home, one is a passenger lift and the other is a service list. The home is close to local shops and West Drayton High Street. All referrals to the home are made through the Care Management Team. The fees range from £570 to £735 per week, dependent on assessed need. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 21 hours was spent on the inspection process. A tour of each unit was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The CSCI pharmacist Inspector carried out a medication inspection on 23/11/06 and a separate report is available. The requirements and recommendations from the pharmacist inspection have been incorporated in this report. 10 service users, 6 visitors, 12 staff and 1 healthcare professional were spoken with as part of the inspection process. The pre-inspection questionnaire completed by the Registered Manager has also been used to inform this report. What the service does well: What has improved since the last inspection? Staff had received wound management training. Picture boards have been formulated for service users with communication difficulties. The cook had undertaken food hygiene training. Food storage issues had been addressed. The practice of wedging the kitchen door open had ceased. A system for formal supervision had been implemented. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 7 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. Franklin House DS0000056134.V294831.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 Franklin House DS0000056134.V294831.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, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information they need to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. The home has an effective intermediate care unit, where service users are helped to maximise their independence and return home. EVIDENCE: Copies of the Statement of Purpose and Service User Guide are available in the main entrance and are given to service users and their representatives. The information was up to date. All the placements at the home are on a block contract, either from the Primary Care Trust, Social Services or for Continuing Care. The Registered Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 10 Manager said that she had recently issued new terms and conditions to all service users and/or their representatives and had examples of signed copies available to view. The home has a pre-admission assessment document and those viewed were comprehensive and provided information so that the home could ascertain if they are able to meet the service users needs. On the intermediate care unit, initial information is received via fax and the registered nurse, physiotherapist and occupational therapist view the assessment and make a decision to admit the service user or not. A full assessment is then carried out on arrival at the home. The intermediate care unit is purpose built and there is dedicated space for occupational health and physiotherapy. The home employs one full time physiotherapist, one part time physiotherapy assistant, one full time occupational therapist and two part time occupational therapy assistants. Since the last inspection a dedicated social worker from Hillingdon Social Services has been allocated to the home to ensure the referrals to the unit are made appropriately. The service user plan documentation available for use does provide appropriate assessments for service users accommodated for intermediate care. Comment was received regarding the lack of rehabilitation provision during the weekend, and action should be taken to address this to ensure ongoing provision for the 7 day period. Franklin House DS0000056134.V294831.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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans were not always promptly completed, kept up to date and did not accurately reflect the condition and needs of the service user, thus placing service users at risk of not having their needs met. Although generally well managed, shortfalls in the medication management could place service users at risk. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy and dignity. Management of service users needs during their final days is good, thus regarding service users wishes with sensitivity and respect. EVIDENCE: Service user plans were sampled on each unit. Since the last inspection the home has installed and implemented a computerised service user plan record keeping system. On all 3 units these records were not always up to date. For one service user on the second floor who had been at the home for 10 days, the little of the service user plan documentation had been completed. The service user had specific specialist care needs identified in the pre-admission assessment and no record of this had been made since admission. For a Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 12 service user exhibiting behavioural problems, no care plan had been formulated to address this. The printed copies of the documentation was out of date and in some instances not all the documentation had been printed off, so was only available on the computer. There was evidence of service user and representative involvement in the service user plans. Risk assessments for falls and other identified risks had been completed on the ground and second floors, and a fall was tracked on the second floor and the relevant documentation had been fully completed following the fall. Risk assessments for falls were not available in the service user plans viewed on the first floor. For one service user on the first floor, no risk assessments had been formulated. There was evidence of monthly updating of the care plans, and other documentation is updated whenever a service users condition changes. There was evidence that at times the staff are unable to access the computerised records, and in such an instance written daily records are maintained. Wound care documentation was viewed on each unit. Generally this was comprehensive and up to date. Separate care plans had not always been formulated for each wound. Ground Floor: For one service user on the ground floor there was a discrepancy between the stated dressing in the care plan and that in the wound assessment documentation, plus it was not clear what pressure relieving equipment was in use for this service user. No pain assessments or care plans for pain had been formulated. For one service user there was a marked change of weight recorded in the space of 3 days, and no action had been taken to address this. The Registered Manager said that the scales had been recalibrated, and she would investigate this. The rehabilitation element of the care plans had not been completed. The registered nurse explained that this information is contained in the physiotherapist and occupational therapist notes, but these are not on the same system, and are therefore not available to all staff involved in the rehabilitation process. In some instances the assessments for continence, nutrition and moving & handling had not been completed on the computer system, although some handwritten documentation was available. The GP and Consultant attend the weekly multidisciplinary team meeting each Thursday. First Floor: Wound care documentation was in place and was clear. The specific pressure relieving equipment in use had been identified in the service user plan. One service user was refusing to use certain specific pressure relieving equipment and this had been clearly recorded. Assessments for nutrition, moving & handling, continence and pressure sore risk were in place, plus additional assessments as identified as required for the individual. One service user had a care plan for pain control, however although the current analgesia had been recorded, the previous analgesia had not been removed from the care plan, which could potentially place the service user at risk. Bedrail assessments had been completed and consents for their use were in place. There appeared to have been a long delay in one of the consents viewed being signed, and the Registered Manager said she would investigate this. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 13 Second Floor: For one service user several assessments had not yet been completed. In another service user plan viewed all assessments had been completed and were up to date. Wound care documentation was in place, and clearly identified the progress of the wounds. In one instance 2 wounds had been included on one care plan and the Inspector recommended separate care plans be formulated for each wound. For a service user on regular pain control no pain assessment or care plan for pain had been formulated. The GP carried out weekly visits to the first and second floors. On all units there is evidence of input from other healthcare professionals to include the palliative care Consultant, the Macmillan Nursing Team, the Tissue Viability Nurse Specialist, plus optical and chiropody care. The CSCI Pharmacist Inspector carried out an inspection on 23/11/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen caring for service users in a gentle, courteous and professional manner, and there was a good atmosphere on each unit. Service users were appropriately dressed and clothing was individually labelled. Service users can have their own telephones, either landline or mobile. Service users can bring in personal possessions in line with fire safety. The home has developed an ‘end of life’ questionnaire and is in the process of implementing the Gold Standard Framework introducing the Liverpool Pathway for Palliative Care. There are good links with the palliative care Consultant from Hillingdon Hospital and with the Macmillan Nursing Team who have been involved in the staff training for palliative care. Franklin House DS0000056134.V294831.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet the service users needs. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with service users choices being respected. EVIDENCE: The home has two full time activities co-ordinators in post. On the day of the inspection two service users were going shopping in Uxbridge. Service users were seen participating in activities and it was clear that several service users enjoy joining in as much as they could. Outings are arranged and there were photographs in areas of the home for outings recently undertaken. Service users can choose if they wish to join in with activities. The activities co-ordinator visits each unit and sets up activities that the staff can undertake with service users, as well as having an activities programme for all those who wish to join in with. Outside entertainers also visit the home. Individual and Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 15 group activities take place. Pets for Therapy visit the home monthly, providing contact with domesticated pets. The activities programme was displayed on each unit, and there is a different theme for each week. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. Service users can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. A representative from Age Concern in Hillingdon visits the home monthly and runs an advocacy surgery. Information about advocacy services is displayed in the reception area of the home. The home uses a ‘cook chill’ system for the provision of meals. One Inspector viewed the kitchen. It was clean and tidy and the documentation to include temperature recordings, cleaning schedules and risk assessments was up to date. Foodstuffs were being correctly stored, and any open items had been dated when opened. Both Inspectors sampled the lunchtime meal on the day of inspection and this was well presented and tasty. Since the last inspection a cooked breakfast is provided once a week. The Registered Manager stated that she is hoping to increase the frequency of this. The menus have been reviewed since the last inspection and food sampling is included in the service user and representative meetings. Service users spoken with generally were satisfied with the food provision. Staff were available to assist service users with their meals and were seen doing so in a sensitive manner. Each unit has a small kitchenette where snacks and drinks can be prepared. The Registered Manager stated that the cook had undertaken food hygiene training since the last inspection. A range of fresh fruit was available on each unit. Franklin House DS0000056134.V294831.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. There is a robust system in place for the safeguarding of service users from abuse. EVIDENCE: The home has a clear complaints procedure available in the Service User Guide and is on display in the home. Since the last inspection the home has had three complaints. Documentation viewed was thorough and evidenced that the complaints had been fully investigated and responded to. Since the last inspection there has been one POVA incident that has been fully and appropriately investigated and managed. The training records viewed indicated that staff had received training in safeguarding adults and staff spoken with said that they would report any concerns of this nature. Franklin House DS0000056134.V294831.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, 20, 21, 22, 23, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been built to a high standard, and is well maintained, thus providing a smart, clean and homely environment for service users to live in. Communal rooms are available on each unit, providing the service users with a choice of venue. Equipment in the home is available to meet the service users needs, thus providing for the service users needs. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: A tour of each unit was carried out. The home was purpose built in 2004 and is being maintained in good condition. The décor and furnishings throughout are of good quality. Each unit has a dining room and a separate lounge area. The garden is accessible from the ground floor and was well maintained. Raised flower beds are available. The home has CCTV fitted externally for security purposes. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 18 All bedrooms have en suite toilet and wash hand basin facilities. Assisted bath and shower facilities are available on each unit, and good quality equipment has been installed. Assisted toilets are available near the communal areas. One bathroom was being used for storage and the Registered Manager explained that the bathroom was not in regular use, and said this would be addressed. All the beds in the home are height adjustable, plus some are profiling beds. A range of moving and handling hoists are available on each unit to meet the assessed needs of the service users. The Registered Manager stated that three additional hoists had been purchased. The home has two passenger lifts and there are rails in each corridor. Rails are also available in the en suite and toilet, bath & shower facilities. There is a call bell system throughout the home, and these were being answered promptly. Designated storage areas for aids and equipment are available on each unit. Bedrooms viewed were individualised and personalised and contained suitable furniture and fittings, with varying complementary colour schemes throughout the home. The laundry room was clean and tidy. The two staff working in the laundry were clear about the laundering procedures, and clothing was being carefully ironed and cared for. Items viewed were labelled correctly. Copies of the infection control procedure were available in the laundry. Protective clothing to include gloves and aprons was available on throughout the home. Individual sluice rooms with electronic sluicing disinfectors are available on each unit. The home was clean and smelled fresh throughout. Training records viewed indicated that staff had received training in infection control. For one service user who had MRSA a care plan for infection control was available. The infection control nurse for the company had also undertaken an infection control audit in July 2006, and the recommendations from this audit had been implemented. Franklin House DS0000056134.V294831.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the service users can be met at all times. Systems for vetting and recruitment practices are in place and protect service users. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of service users, to include specialist care needs. EVIDENCE: The home was staffed to meet the needs of the service users. Duty rosters were available and any changes were recorded. The home was not using any agency staff. Staff spoken with said that there is good teamwork and where service users require more than one person to assist with their care this is identified and planned for. The home was clean and fresh throughout and there were appropriate numbers of domestic, maintenance and ancillary staff to meet the needs of the home. 8 care staff are in the process of completing NVQ level 2 in care training and 21 more staff are undertaking this training. The Registered Manager is very aware of the need to have a minimum of 50 of care staff trained to NVQ in care level 2 or the equivalent. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 20 Staff employment records were sampled and contained all the information required under the Care Homes Regulations 2001. Care UK plc have an induction and foundation training to meet the Skills for Care common induction standards. There was evidence of staff undertaking training in topics relevant to the needs of the service users. Franklin House DS0000056134.V294831.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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is competent and skilled and has developed an atmosphere of openness and respect, thus making service users, visitors and staff feel valued. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Service users monies are well managed and securely stored. Staff receive supervision, thus promoting communication and review of practice. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and has a certificate in Management Studies plus she has completed NVQ level 4 in Health & Social Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 22 Care. The Registered Manager is also an NVQ assessor and has an advanced certificate in Health & Safety Management. She has also undertaking periodic training in topics relevant to her role. Staff spoken with said the Registered Manager is supportive, approachable and has an open door policy. Regulation 26 monthly visits are carried out on behalf of the Responsible Individual and copies of the reports from these visits are forwarded to CSCI. Regular staff meetings and service user & relative meetings are held with minutes taken. A survey for registered nurses was carried out in July 2006. A service user satisfaction survey was carried out in September 2006 and a survey is being planned for service users representatives for December 2006. The home has an auditing system in place. This includes audits for medication, care and infection control. The Registered Manager said that the Responsible Individual does carry out some service user plan auditing via the computer system, however the need to carry out a full audit of service user plans and address shortfalls identified was discussed with the Registered Manager. The home has in place a home development and business plan. The home was also in the process of being evaluated against the ‘essence of care’ benchmark standards for record keeping. There are systems in place for the management of service users personal monies and the records viewed were up to date. Receipts are given for all income and expenditure. Secure facilities are provided for the safekeeping of monies and valuables on behalf of service users. Staff confirmed that they were receiving regular supervision. Staff undertaking supervision had received training in supervision. The Registered Manager had developed a supervision matrix. Servicing and maintenance records were sampled and those viewed were up to date. Staff had received health & safety training and updates. Two staff members were trained to provide moving & handling training. A monthly report to monitor accidents is completed. Risk assessments for equipment and safe working practices were in place and had been reviewed. Copies of the assessments relative to the Laundry and Kitchen were available in these areas. Fire records viewed indicated that staff had received fire training, and day and night fire drills are carried out at regular intervals. The home has a fire risk assessment and an updated evacuation plan is being developed in line with the changes in fire safety legislation. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 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 3 3 3 2 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO 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. 2. Standard OP7 OP7 Regulation 17 17(1)(a) Requirement Care plans for new service users must be completed promptly following admission. Care plans must be up to date and accurately reflect the condition of the service user. It must be updated monthly and when a service users condition changes. Previous timescale of 08/08/05 not met. Risk assessments for falls must be formulated for all service users. These must be updated following any falls or relevant change in the service users condition. Assessments for pressure sore risk, nutrition, continence, moving and handling and pain must be completed in full and be reviewed monthly and when a service users condition changes. Previous timescale of 08/08/05 not met. Any changes in weight must be reviewed and appropriate action taken. Service user plan documentation for service users on the DS0000056134.V294831.R01.S.doc Timescale for action 01/12/06 01/01/07 3. OP7 13(4) 08/12/06 4. OP8 15(1)2 12(1)a,b 15/12/06 5. 6. OP8 OP8 12, 17 12, 17 15/12/06 22/12/06 Franklin House Version 5.1 Page 25 7. OP8 17 8. 9. OP9 OP9 13(2) 13(2) 10. OP21 23(2)(l) intermediate care unit must include treatment and recovery programmes with goals for service users to re-establish community living. Documentation for wound care must accurately identify the current treatment to include dressings and pressure relieving equipment in use, and must be kept up to date. That the receipt of medication is accurately recorded on the ground floor That the Medication administration records on the ground floor are all signed and dated Bathrooms must not be used as storage areas. 15/12/06 01/12/06 14/12/06 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP9 OP9 Good Practice Recommendations It is strongly recommended that individual care plans be formulated for each wound. That storage of surplus medication is reviewed on the ground floor to ensure better stock control That documentation for disposal of medication is reviewed and consistent practices maintained within the home. Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Franklin House DS0000056134.V294831.R01.S.doc Version 5.1 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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