Inspection on 07/01/08 for Franklin House

This inspection was carried out on 7th January 2008.

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

Franklin House 20/11/06

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 Clare Henderson Roe Unannounced Inspection 10:20 7 & 8 January 2008 th th 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.V356232.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. Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 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.V356232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 66 20th November 2006 Date of last inspection 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 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 are two lifts in the home, one is a passenger lift and the other is a service lift. 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 £565 to £775 per week. Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 5 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 24 hours was spent on the inspection process and 2 Regulation Inspectors carried out the inspection. A tour of the home was carried out, and service user plans, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. 12 residents, 12 staff and 6 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report, plus comment cards from service users, staff, representatives/visitors and health care professionals have also been used to inform this report. What the service does well: What has improved since the last inspection? Medication management on the ground floor has improved. It is acknowledged that staff have received training in the completion of service user plan documentation, however shortfalls were again identified and this area needs to be effectively audited and managed to ensure all documentation is complete and up to date. Franklin House DS0000056134.V356232.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. Franklin House DS0000056134.V356232.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 Franklin House DS0000056134.V356232.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): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to admission, thus the home ensures they are able to meet each persons needs. The home has an intermediate care unit where residents are helped to maximise their independence in preparation for returning to their own homes. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. Those viewed had been well completed. For prospective residents for the intermediate care unit, referral information is sent through and this is reviewed by the multidisciplinary team on the unit to ensure the unit is able to meet the needs. A full assessment is then carried out on admission. The intermediate care unit is purpose built and there are dedicated rooms for occupational therapy and physiotherapy. Hillingdon Primary Care Trust Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 9 employs the full time physiotherapist and the part-time assistant. The occupational therapist and the assistant are employed by Hillingdon Social Services. One Inspector was informed that the hours at the home for the full time physiotherapist are to be cut to a 3 day week, due to budgetary constraints. This is concerning as there are 21 residents who require rehabilitation treatment programmes, to include physiotherapy. At the last inspection the intermediate care unit had a dedicated social worker who ensured that people were being appropriately referred to the unit, and this person has since left and has not been replaced. The nurse consultant for the unit is also no longer in place. The need to contact the PCT and Social Services to discuss the issues in provision on the unit was discussed with the Registered Manager and the Regional Director. Franklin House DS0000056134.V356232.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): 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 are in place for each resident, however shortfalls in the information contained in the care plans could lead to residents needs not being fully met. Overall, medications are being well managed at the home, thus safeguarding residents. Staff care for residents, however some staff attitude issues have caused residents to feel unsettled. Shortfalls in identifying end of life care needs place residents at risk of not having there needs fully met. EVIDENCE: Service user plans were sampled on each unit. The home uses a computerised system for resident documentation. Care plans had been formulated, however some of the information was very general and did not reflect individual needs or changes in care following assessment by healthcare professionals. Where it was not possible to weigh a resident, the care plan had not been updated to reflect this fact. Care plans had not always been formulated for all areas of need. In one care plan the sentences did not all make sense and needed to be rewritten. In some instances the care plans had not been printed off so that they could be discussed, agreed and signed by the resident or their Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 11 representative. There was evidence that the care plans had been updated monthly, however changes in need or care regimes had not always been recorded. Risk assessments for falls were not in place for all residents, and those seen had not been fully completed, thus they did not give a clear picture of the level of risk to each individual. Risk assessments had not always been formulated for all areas of risk identified, for example, smoking. Bedrail assessments and written consent for their use were in place. On the intermediate care unit no progress had been made since the last inspection with ensuring that a care plan for each individuals rehabilitation programme was in place. Documentation was viewed for wound care. In one case care plans had not been formulated for all wounds and in another no care plan was available. In some instances more than one wound had been recorded on one care plan, and it is recommended that an individual care plan be available for each wound. Information had been recorded on the wound assessment chart, however this did not provide a full picture of the wound and the dressing regime. Pressure sore risk assessments were in place. Pressure relieving equipment was seen in use on each unit. Manual handling assessments were in place, however the information in the assessment did not always tally with the information in the manual handling care plan. Nutritional assessments and continence assessments had been completed with one exception in each case. There was evidence of input from healthcare professionals to include GP, practice nurse, chiropodist, physiotherapist, occupational therapist, tissue viability nurse and speech and language therapist. Positive comment was received from healthcare professionals spoken with. Medication management was viewed on each unit. Medications are being securely and appropriately stored. With one exception liquid medications had been dated when opened and the one medication was removed from use at the time of inspection. The temperatures of the medication fridges and clinic rooms were within safe range. A list of staff signatures and initials was available on each unit. Receipts, administration and disposals of medications had been recorded and signed. The controlled drugs registers were complete and up to date and stocks checked were correct. The home uses a monitored dosage system for medications on the first and second floor units, and on the ground floor medications are dispensed in boxes. Approved lancing devices were available, however an additional device was being used on the second floor and the Registered Manager said that this would be disposed of. Medication audits had been carried out and shortfalls identified had been addressed. On the second floor one medication had been out of stock for 2 days and the importance of ensuring adequate stocks of all medications are available was discussed. On the ground floor several envelopes containing residents monies and valuables were found in the drug cupboard. A satisfactory explanation for this finding was not forthcoming and the Inspectors requested that the money and items be removed to the safe. This was carried out at the time of Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 12 inspection. Overall medications are being well managed, however the shortfalls identified need addressing to ensure they do not occur again. Staff were seen caring for residents in a caring manner, respecting their privacy and dignity. Some comment was received regarding the attitude of some members of staff, and it was clear that this was a minority of staff but that their attitude could sometimes cause residents to be unsettled. The Registered Manager said that she was aware of this and was arranging for more staff to attend Customer Care training. Residents were dressed to reflect individuality. Residents can have their own telephone, either land line or mobile and newspapers are also arranged for those who wish. Some of the bedrooms were very personalised and looked homely. There were no care plans in place for deterioration in condition or end of life care wishes. A questionnaire had been completed for some residents to give basic information on this topic, however it is important that information regarding the wishes of residents and their relatives is ascertained, so that these wishes can be respected. Where residents and their relatives do not wish to discuss this topic this can also be recorded. Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision at the home is good and individual hobbies and interests are taken into consideration. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has a full time activities co-ordinator who is very experienced in this area of care and has introduced new activities to meet the residents’ needs. These include a monthly ‘happy hour’ where residents and relatives can get together socially within the home and enjoy refreshments and socialise together. A reminiscence room has also been set up and much care and thought has gone into this, providing an environment of music and items of memorabilia and the residents’ benefit from using this facility. The activities co-ordinator has meetings with residents and relatives to discuss outings, entertainments and other activities, so that the programme can reflect their wishes. There is a moderate budget for activities, which does therefore limit expenditure in this area. The home is also introducing ‘ABC’ which is activities Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 14 based care, and this is a system whereby the activity ethos is incorporated into all areas of care and undertaken by care and nursing staff. Care plans for work and play were in place, however much of the information was very general and did not reflect individual interests. A requirement regarding care plan content is made under Standard 7. The home has an open visiting policy and visiting is encouraged. Residents can receive visitors in their own bedroom or in one of the communal areas, as they so wish. The visitors spoken with said that they are always made very welcome at the home and are offered refreshments. One visitor said that they visit at various times throughout the day and their relative is always being well cared for. Representatives are kept up to date with any issues. The home has advocacy information on display for Age Concern and the Hillingdon Residents and Relatives Association. The Registered Manager said that on the intermediate care unit an advocacy representative attends the multidisciplinary meetings so that should a resident require advocacy input following their discharge home, this can be arranged. One Inspector viewed the kitchen and it was clean and tidy, with records up to date. The home uses a ‘cook-chill’ system for the provision of meals. The annual residents survey had identified some issues with the food provision and these are being addressed. The Registered Manager said that the menus are regularly reviewed in line with resident preferences. There is a cooked breakfast provided once a week. The Inspectors sampled the lunchtime meal on the first day of inspection and this was tasty and well presented. All meals to include liquidised meals are presented in an appetising manner and staff were available to assist residents as they needed. Each floor has a kitchenette and drinks and snacks can be prepared, with food and drink being available throughout the 24 hour period. Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 15 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): 16 & 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 policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The home had received 1 complaint since the last inspection. This had been addressed and clear records maintained to show it had been investigated and responded to. The complaints procedure is on display and is contained in the Statement of Purpose and Service User Guide documents. Of the 8 resident surveys received 7 people had indicated that they knew how to make a complaint. People spoken with said that any issues are addressed promptly. The home has a POVA policy and also follows the Hillingdon Safeguarding Adults procedures. Staff spoken with were very clear to report any concerns and understood the ‘Whistle Blowing’ procedures. There was evidence that staff had received POVA training. Franklin House DS0000056134.V356232.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): 19, 21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is showing evidence of wear and tear to the décor, fittings and furnishings, so residents are not living in a well-maintained environment. Infection control is being well managed, thus protecting residents, visitors and staff. EVIDENCE: A tour of each unit was carried out. There was evidence of some areas requiring redecoration and some furnishings and fittings were in need of attention. Some of the furniture drawers were broken and in the first floor kitchenette the laminated worktop was badly worn. An area of carpet had lifted and needed attention. On the second floor, in one shower room, the flooring near to the shower tray was ‘soft’ and this was possibly caused by water leakage and needs to be investigated. Some of the chairs in the day room were marked. Some of the walls are marked and in need of redecoration. Staff work hard to keep the carpets clean, however it was identified that alternative Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 17 suitable flooring was needed in some rooms to better cater for residents with specific continence care needs. A full environmental audit needs to be carried out and a redecoration and refurbishment plan, with timescales for completion, drawn up to evidence that the work will be completed in a timely manner. The Registered Manager reported that work has been carried out to redecorate the reminiscence room. The home continues to have an issue with storage, and items are stored in the bath and shower rooms. It is acknowledged that with a lack of designated storage space this is a problem. A broken wheelchair was found in one bathroom, and no action was taken to remove it during the 2 days of inspection. Pressure relieving equipment was found in one bathroom. The portable telephone was found in a bathroom. Action needs to be taken to ensure that only essential and appropriate items are stored temporarily in bath and shower facilities when not otherwise in use. One Inspector viewed the laundry room. There are 2 washers and 2 dryers and there are programmes for infection control in place. There was a large pile of laundry bags and several full baskets of laundry, all waiting to be washed. The Housekeeper and Registered Manager were aware that there have been intermittent issues with a backlog in the laundry and are looking at ways of addressing this. Relatives commented that laundry is not always returned promptly and in some cases items are mislaid. It is acknowledged that new items that are not labelled or identified in some way can easily be lost in the system. Items of personal laundry viewed were marked with the room number for ease of identification. Protective clothing to include gloves and aprons was available. On the first floor there was a problem with removing the plates and cutlery after lunch, with piles of plates still in the kitchenette at 3pm. The home smelled fresh throughout. Franklin House DS0000056134.V356232.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): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some shortfalls were noted with the staffing, thus residents needs are not being met at all times. Training provision is good, thus providing staff with the skills and knowledge to care effectively for the residents. Systems are in place for the vetting and recruitment of staff, thus safeguarding residents. EVIDENCE: The staffing rosters were viewed for each floor. There was evidence of days where some units had been short staffed, and this was confirmed by the staff and by residents. One concern voiced was the length of time it sometimes takes for someone to answer the call bell and in another instance a resident had been unable to go out with their family, due to staff not being available to get them fully ready. Several of the resident surveys indicated that staff are ‘usually’ or ‘sometimes’ available when they need them. The Registered Manager said that they do have bank staff to call upon and she also has used agency staff to cover some shifts. Although staff work hard to ensure the residents physical needs are met, the importance of looking at the holistic needs of each person was discussed, so that all aspects of care are provided. One example of this is that time is allocated in the reminiscence room for residents from each unit, and currently this is not being utilised by those on the second floor. The Registered Manager is aware of the need for some staff to improve their skills and attitudes in relation to providing complete care for each individual. The hours allocated for domestic duties are limited, with one Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 19 floor being provided with only 3 hours of domestic input per day during the week of inspection, plus weekend hours are also short. It was explained that one domestic worker was on holiday and the budget did not allow for someone to be employed to cover these hours. Information provided on the AQAA evidenced that over 50 of staff have either already attained NVQ level 2 in care or are currently studying for this qualification. 2 ancillary staff have completed NVQ level 2 in hospitality. 2 senior carers are currently undertaking their A1 Assessor training. 10 of the qualified nurses have registered to do NVQ level 2 in management. Staff also confirmed that they do receive regular training in topics relevant to the care of the residents. One Inspector viewed 3 sets of staff employment records and these contained the information required under Schedule 2 of the Care Home Regulations 2001. The home has an induction programme that meets the Skills for Care common induction standards. Staff spoken with confirmed that they do undertake induction training. There is a training matrix where all training undertaken throughout the year is recorded. Franklin House DS0000056134.V356232.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): 31, 33, 35 & 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 has the experience and qualifications to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of management and practice review. Monies held on behalf of residents are being securely stored, thus safeguarding them. Systems for the management of health and safety at the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a certificate in management studies and NVQ level 4 in Health & Social Care. She is a qualified NVQ assessor and has an advanced certificate in Health & Safety Management. Staff spoken with said that the Registered Manager is approachable and supportive, and visitors also commented on this. One of the Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 21 responsibilities of the Deputy Manager is the overseeing of the management of the service user plans and work is needed in this area to improve their completion. From the rosters viewed it was noted that there is no management presence in the home at the weekends, and this is something that should be considered, for continuity of management. Care UK have clear systems in place for quality assurance. There is an area for audit each month, for example, care plans, bedrails, pressure sores, hoists. The residential care division of Care UK then collates the results from each audit and a report is generated for the Directors to view so that action can be taken to address any shortfalls identified. There is a monthly and a quarterly home report and these cover all aspects of the home and are very comprehensive. Regular staff meetings, resident and relatives meetings are held and minutes taken and distributed. Separate surveys for staff, residents and representatives are done annually and the results are collated and published. There is a very informative and colourful newsletter and residents and relatives contribute items for inclusion. The home holds personal monies on behalf of several of the residents. 4 records and money amounts were viewed and the records of income and expenditure were accurate and up to date. Receipts are kept for expenditure and are given for any monies received from representatives. On the first day of inspection monies and valuables were found in the drug cupboard on the ground floor and this has been commented on under Standard 9. The administrator completed the necessary documentation without delay and ensured the money and items were securely stored. Servicing and maintenance records were sampled and those viewed were up to date. The in house checks were up to date and thorough checks are carried out. The fire risk assessment had been completed in April 2007 and several shortfalls had been identified. The Registered Manager had drawn up an action plan and assured the Inspector that action had and was being taken both in house and by Care UK to address these. Risk assessments were also in place for equipment and safe working practices. Fire drill records showed that some drills had been carried out, however more drills are needed to ensure all staff are involved in fire drills at the required intervals. The training matrix evidenced that staff have received training in health & safety topics and staff confirmed this. Franklin House DS0000056134.V356232.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 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 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 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 X X 2 Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 17 Requirement Care plan documentation must be complete, up to date and accurately reflect all the needs of each resident, so that their needs can be met. Input from the resident and/or their representative must be sought for the formulation and review of the service user plans, unless it is impracticable to carry out such consultation. Risk assessments for falls must be completed in full to identify the level of risk for each individual so that action can be taken to minimise the risk. All assessment documentation must be complete, up to date and clearly reflect the condition of the resident. Service user plan documentation for residents on the intermediate care unit must include treatment and recovery programmes with goals for residents to reestablish community living. Previous timescale of 22/12/06 not met. Care plans must be in place for DS0000056134.V356232.R01.S.doc Timescale for action 08/02/08 2. OP7 17(1)(a) 01/03/08 3. OP7 13(4) 08/02/08 4. OP8 15(1)2 08/02/08 5. OP8 12, 17 01/03/08 6. OP8 17 08/02/08 Page 24 Franklin House Version 5.2 7. OP9 13(2) 8. OP9 13(2) 9. OP10 12(4)(a) 10. OP11 12 11. OP19 23(2)(b) & (d) 12. OP21 23(2)(l) 13. OP26 13(3) 14. OP27 18 all wounds and identify the dressing products and regime for each wound. These must be kept up to date and accurately reflect the condition of each wound. Appropriate stocks of all medications must be maintained to ensure a continuous supply for each resident. Monies and valuables must not be stored in the medications cupboards. These must only be used for the storage of medications. Staff must care for residents in a respectful manner at all times, so that residents feel safe and well cared for. The wishes of residents and their families must be clearly recorded with regard to end of life care, so that their wishes can be identified and respected. A full environmental audit must be carried out and from this a redecoration and refurbishment programme, with timescales for completion, drawn up so that the home environment is brought back to a good standard in a timely manner. Bathrooms must not be used as storage areas. Previous timescale of 01/12/06 not met. There must be systems in place to ensure that after meals action is taken promptly to clear the plates and cutlery and clean them, to minimise any infection control issues. There must be sufficient numbers of staff on duty to meet the assessed needs of the residents at all times. This must include care and ancillary staff so that the needs of the home are met. DS0000056134.V356232.R01.S.doc 08/01/08 08/01/08 08/01/08 01/03/08 08/02/08 08/02/08 18/01/08 18/01/08 Franklin House Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP6 OP8 OP12 OP31 Good Practice Recommendations It is strongly recommended that the home discuss the multidisciplinary input issues on the Intermediate Care Unit with the PCT and Social Services. It is strongly recommended that individual care plans be formulated for each wound. It is strongly recommended that the budget for the activities provision be reviewed to ensure sufficient funds are available to meet the needs of the residents. That the management cover to include the weekends be reviewed. Franklin House DS0000056134.V356232.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Franklin House DS0000056134.V356232.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. 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