Inspection on 06/09/06 for Franklyn Lodge 71a District Road

This inspection was carried out on 6th September 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Franklyn Lodge 71a District Road 13/12/05

Franklyn Lodge 71a District Road 20/09/05

Franklyn Lodge 71a District Road 08/03/05

Franklyn Lodge 71a District Road 09/11/04

Franklyn Lodge 71a District Road 23/02/04

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

CARE HOME ADULTS 18-65 Franklyn Lodge 71a District Road Franklyn Lodge 71a District Road Wembley Middlesex HA0 2LF Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 6th September 2006 10:00 Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 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 Franklyn Lodge 71a District Road DS0000017442.V311176.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 Adults 18-65. 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. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Franklyn Lodge 71a District Road Address Franklyn Lodge 71a District Road Wembley Middlesex HA0 2LF 020 8902 5205 020 8903 9860 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) Residential Care Services Ltd Ms Margaret Avan-Nomayo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Franklyn Lodge belongs to Residential Care Services Ltd, a private company, based in Brent specialising in providing personal care and accommodation for younger adults with learning disabilities in care homes. The home is located in a residential area of Sudbury. There are some shops about five minutes walk from the home. The home is accessible by public transport, which is available on the main road, where District Road starts. There is a driveway in front of the home with parking for one to two cars. Additional parking is available on District Road, which does not have parking restrictions. The home is a detached bungalow, with most of the accommodation on the ground floor. The attic is used for storage. There are three single bedrooms (one with en-suite toilet and wash hand basin), a through lounge/dining area, a bathroom with a bath and shower and a kitchen. There is a paved area in front of the home with wheelchair access and a garden at the back and a patio, which can be reached from the lounge/dining area. The service users placed into the home are funded by Local Authorities. There are no self-funding service users. At the time of the inspection there were three service users in the home. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the findings of this key unannounced inspection. It took place on Wednesday the 6th September, started at about 10:00 and finished at about 13:45. The inspector was able to speak to two service users, three members of staff and the manager, observe care practices, toured some of the premises and looked at a sample of records in the home. He is grateful to all the residents, the manager and her staff for a kind welcome to the home and for their support during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that statutory requirements are met within the time scales set by the Commission. Four requirements from the last inspection were found not to have been met during this inspection. The requirements were mostly to do with care plans and risk assessments. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 6 All service users must be offered a statement of the terms and conditions of their stay in the home. Care plans must be made more comprehensive by using the information provided by the placement authorities, previous places of stay of the service users and by a comprehensive assessment of needs carried out by staff from the home. Care plans of service users must be clear with regard to the actions that should be taken to meet the needs of the service users. The care plans and risk assessments, which have been drawn up, must also be signed by the members of staff and by the service user or by his representative to show that they have agreed to the care plans. The social and recreational needs of service users were not comprehensively assessed and recorded. Without this, it would not be possible to know if these needs of service users were being met. While there was evidence that service users were encouraged to be involved in the local community, to develop independent living skills and to engage in some activities involving some element of risks, risk assessments were not always available to address these risks. Service users did not have keys to their bedrooms and risk assessments were not in place to address the reasons for this. Meals were prepared to suit the needs of the service users. The menu should however be reviewed to reflect the choices of the current service users in the home. A few issues were noted with the environment which needed attended to. The outside of the home could also be made more attractive and pleasant for service users to use. The service must develop an effective quality management system based on the setting of standards and a cycle of audits and action planning. The outcomes of the satisfaction survey must be made clearer and be used more productively by a detailed analysis and the production of a report and action plan. 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. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are appropriately assessed prior to them being offered a place in the home. Service users do not always have access to a statement of the terms and conditions of their stay in the home. EVIDENCE: The inspector looked at the care records of the service user who was last admitted to the home, and spoke to him. There was evidence that he was offered the opportunity to visit the home with his relatives and social worker to see his new room and to meet staff and service users in the home, prior to making a decision about moving into the home. Copies of the care plan of the service user in his previous place of stay and of the needs assessment of the placing authority were available for inspection. The service user was also offered a service users’ guide and information about the home at the time of admission. The inspector however noted that the service user did not have a statement of the terms and conditions of his stay in the home which has been agreed by him and by the home. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans were not comprehensive enough to ensure that the needs of the service users were identified. Risk assessments were not adequate to promote the independence of service users and the development of living skills. EVIDENCE: Two care plans were inspected. They were in good condition and kept in a filing cabinet. The care plans were written in an easy to read format but were noted not to be detailed enough to contain all the information required to meet the needs of the service users. For example the assessments of needs were not comprehensive and the plan of action was not specific enough to provide the necessary information about how the needs of the service users were to be met. One service user was described as a Christian and his religion was not identified. Although he has been identified as having ‘emotional needs’, these were not described and the care plan was not clear about meeting these needs. Information contained in the needs assessment of the service user by the funding authority and in the care plan from the service user’s previous place of stay was not included in the care plan. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 10 The care plans and risk assessments were not signed by the members of staff who have drawn them and by the service users to show that they have agreed to them, although the manager stated that service users were consulted when these were drawn up. The personal goals of the service users although identified in care review meetings were not always translated to the care plans. Risk assessments were not always in place to ensure that the personal goals of the service users will be met as safely as possible. For example risk assessments about going out of the home and about developing individual living skills such as making cups of tea and helping with cooking were not in place for one of the service users and were not detailed and comprehensive for the other service user. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are offered the opportunity to take part in activities and in maintaining contact with the local community and with their relatives and friends, but records were not comprehensive enough to demonstrate that their needs with regard to this aspect of care are being met. EVIDENCE: Although staff were in the main familiar with the service users’ social and recreational needs, these were not comprehensively assessed and recorded in the care records. As a result it was not always clear what was expected of service users and what was in place to ensure that their social and recreational needs were being met. The attempts that have been made by staff to address these areas were also not clear. While there was evidence that staff were respecting the choices of service users, it was not clear what encouragements were being provided to service users with regard to getting them involved in learning new skills and in taking part in valued and fulfilling activities. An individual plan was not always available with regard to how service users were going to spend their day. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 12 The manager and staff said that service users were encouraged to go for walks in the local community and to take part in shopping activities. It was noted that one service user was offered the opportunity of going out at the time of the inspection which he declined. The manager clarified that service users are accompanied by members of staff when they go out in the local community because of risks that they may be faced with, but as mentioned in the previous section, risk assessments were not always in place addressing these issues. It was noted in the daily records and from conversation with members of staff that service users were being encouraged to use public transport within the abilities of the service users. Service users were also encouraged to maintain contact with their friends and relatives and visits to the home by the relatives of service users were also promoted. On one recent occasion staff accompanied a service user while the latter visited his relatives. The manager informed the inspector, that service users were offered the opportunity to go on holidays. Service users however made the decision not to go on holidays and those who are more dependent were not able to go on holidays. With regard to social events the manager said that service users have the opportunity to take part in social events that are arranged in the day centre belonging to the organisation on a monthly basis and in a monthly event held by the local authority in one of the local authorities’ day centres. The inspector observed that service users were being offered choices about their meals and about the things that they wanted to do. They were noted to move freely in the communal areas, into the kitchen and going outside the home. Bedrooms’ doors had locks on them and staff stated that none of the service users had keys to their doors, as they did not want to have them. There were however no risk assessments in the care records to show why service users were not offered a key to their bedrooms. On the day of the inspection, the inspector noted that service users were offered a lunch which consisted of chicken and rice. This was according to the choices of the residents. Meals cooked in the home were recorded on a daily basis and showed that service users were being offered appropriate meals. The meals were prepared according to a four weekly menu. However the inspector noted that the menu needed to be updated, as some meals on the menu did not reflect the choices and tastes of the current service users in the home. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home ensure that the healthcare needs of service users are met. Medicines management in the home is on the whole good. Service users and their relatives can be reassured that staff in the home will look after service users who are not well as long as it is possible for them to do so. EVIDENCE: The inspector observed that the personal care of service users was provided to service users in a sensitive manner to ensure the privacy and dignity of the service users. It was noted that one service user needed some attention with a particular aspect of his personal care. This was immediately addressed by care staff when pointed out by the inspector. Care records showed that all service users were registered with a GP. Records were also kept about the input of other healthcare professionals, such as the optician, dentist and chiropodist, who were involved in the care of the service users. Service users were supported by members of staff when they attend appointments with healthcare professionals. It was noted that the key workers tended to accompany service users to these appointments to ensure that staff in the home were kept up to date with the healthcare management of the service users. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 14 The home did not yet have a health action plan for each service user. It was noted during the inspection that service users might benefit from this, particularly with regard to health promotion such as with regard to understanding the need to have a balanced diet and smoke cessation. While service users have a right to choose their meals and make decision about aspects of their lifestyle, this needs to be balanced with the service’s responsibility to ensure that the health of service users is being promoted. Medicines in the home are dispensed in ‘dossette’ boxes by the chemist after the relevant prescription has been obtained. The prescription are ordered and received by the chemist who then dispenses the medicines. Staff check the medicines when these are received into the home. The amounts of the regular medicines received into the home are not recorded, as these can easily be checked by looking at the dossette boxes. This is however more difficult to do for medicines which are prescribed as required. The amounts are carried over every month as the medicines are not ordered on a regular basis. In these cases it is recommended that the amounts are recorded when received and that the amount of medicines carried over are also recorded. The inspector also noted that the home had a stock of paracetamol which the manager explained is used similar to a homely remedy. There was however no homely remedy policy in the home for inspection. The manager then said that she would return the medicines to the chemist as all service users do see the GP if they have pain or if they are unwell and that the home does not use the homely remedy as such. All MAR sheets were appropriately completed and signed when medicines were given or codes used when these were not administered. In cases where medicines have to be returned to the chemist, a form is available to make a record of the medicines. Care plans of service users were noted to address aspect of end of life care and wishes of service users with regard to the arrangement for funeral. In cases where this information was not available on care records, there was evidence that the home had written to the relatives of the relevant service user requesting this information. The home’s view is that, service users are able to stay in the home when they are poorly as long as their needs can be met in the home. In the past the home has looked after a service user who was poorly in an appropriate manner. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and allegations and suspicions of abuse are treated seriously by the service. EVIDENCE: The manager stated that the home has not received any complaints since the last inspection. Service users receive copies of the complaint procedure in the service users’ guide. A copy is also available in the bedroom of service users. The manager stated that staff receive training on abuse and safeguarding adults. Staff and the manager were aware of the actions that need to be taken in cases of allegations and suspicions of abuse. The manager also has line management support to help in decision making should these circumstances arise. The home supports one service user with managing his personal finance. The other two service users’ finances are managed by their representatives. The home however keeps a small amount of personal money for each service user. Service users where possible are encouraged to manage their own money. One service user had some money which he kept himself. The personal money of two service users was inspected. Receipts were kept for expenditures. A sample of records and receipts inspected, allowed to conclude that the personal money of service users was being appropriately managed. The inspector was informed that the personal money of residents is checked when the directors or when head office staff visit the home. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 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 provides a suitable environment where the needs of the service users can be met. EVIDENCE: The front of the home appeared in the main tidy. The back of the home consisted of a large garden with shrubs and small trees mostly along the edges, and a patio area which could be accessed via the lounge. The patio area was reached by some steps. It was observed that some of the paving on the steps needed to be repointed as the concrete holding them was becoming loose and breaking. It was also noted that the patio would benefit from cleaning and from the use of more flowers and colours. The metal railings at the edge of the patio looked like they would also benefit from repainting. The inside of the home was generally in good condition but a few areas were noted where attention was needed. The bathroom in the home has been retiled but an area was noted where the tiles were coming off. This needs to be attended to. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 17 The kitchen was also noted to be in good condition except for the flooring, which was looking as needing attention. Cracks were appearing in some areas of the lino. Bedrooms of service users were clean and in good condition. There were no odours. They were all appropriately painted, furnished and personalised. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is appropriate number of skilled and trained members of staff on duty. Staff could benefit from more regular supervision sessions. EVIDENCE: There are normally two members of staff on duty during the day and a sleep-in member of staff at night. The manager stated that there has not been a change of staff in the home for a long time. Some of the members of staff also work in the other services provided by the organisation and have been in post for a number of years. They were therefore familiar with the needs of the service users who are accommodated in the home. As there were no new members of staff, the inspector did not request for the personnel records which are normally kept at the Head office. He therefore did not assess this standard. The manager stated that all the records/checks are kept for each member of staff as required by legislation, including appropriate references and CRB checks. The inspector was also informed that all members of staff have completed NVQ training except for one who was nearly at the end of the course. There was however little evidence that staff in the home were involved in the development of the Learning Disability Award Framework. A training plan was Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 19 provided to the inspector which shows that staff on the whole receive training which is appropriate for their position (see standard 42). The inspector noted that supervision of care staff was not being carried out six times a year or once very two months. The manager however stated that she does carry out informal supervision sessions with members of staff when they work together. After talking to the manager and her staff, the inspector concluded that staff in the home were valued and were being involved in the management of the home and in the development of the service. Minutes of staff meetings were available for inspection. These were arranged at an interval of 3-4 months. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensures that the service users are well cared for. The home does not yet have an effective quality management system. Health and safety aspects of running the service are attended to, to ensure the safety of staff and service users. EVIDENCE: The manager has now been in post for many years, prior to the inception of the Current Commission and the one before it. She is the registered manager and has recently completed a diploma in social care. She has a certificate in advance management. Minutes of staff meetings were available for inspection. These are held on an average every three months. Minutes of service users meetings, which according to the manager are held every two months, were also available for inspection. Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 21 A number of requirements imposed on the service since the last inspection remained unmet. It is the legal responsibility of the manager to ensure that requirements, which fall within her remit, are met within the timescales. The home had a quality assurance policy available for inspection. It makes reference to satisfaction questionnaires and a quality management system based on a Total Quality Management (TQM) approach, which will be underpinned by the setting of standards, against which the service will be audited. The manager stated that the questionnaires are normally sent prior to the review of the care of a service user to parties involved with the service user. It was however not clear how the outcomes of the questionnaires were affecting the quality of the service. There was no report or summary of the findings of the questionnaires. While a quality management system is mentioned in the quality assurance policy, the inspector was unable to find evidence that the quality management system was available in the home. The components of the quality system such as the standards and the audits were not available for inspection. There was a wiring certificate, PAT certificate and a gas safety certificate available for inspection. There was also evidence of two weekly fire test and drills. Records were kept about the maintenance of the fire detection system and of the fire fighting equipment. A health and safety risk assessment was available for inspection as well as a fire risk assessment but an emergency fire plan was not yet in place. From the training records provided by the home, most members of staff were up to date with regard to statutory training, except for food and hygiene training where two members of staff had the training four years ago and another one about three years ago. The training certificate is normally valid for three years after which staff have to be retrained. Franklyn Lodge 71a District Road DS0000017442.V311176.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 Adults 18-65 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 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 x 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 x Franklyn Lodge 71a District Road DS0000017442.V311176.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 YA5 Regulation 5(1)(c) Requirement Timescale for action 31/10/06 2 YA6 All new service users must be given a copy of the statement of the terms and conditions of his/her stay in the home, which has been agreed by the service user and/or his/her representative and by the home. 31/10/06 14(1),15(1) Care plans and risk assessments must be signed by the member of staff responsible for drawing them. Service users or/and their representatives must also be encouraged to sign them to show that they have agreed to them (Previous requirement-Timescale of 31/01/06 not met). 14(1,2) Care plans including the assessment of needs must be comprehensive and must include the assessment of the mental health needs of the service users. Care plans must then be in place where there are identified needs. (Previous requirement-Timescale of 28/02/06 not met) 31/10/06 3 YA6 Franklyn Lodge 71a District Road DS0000017442.V311176.R01.S.doc Version 5.2 Page 24 3. YA9 14(2) There must be clear risk 31/10/06 assessments in cases where service users are being encouraged to develop individual living skills. Risk assessments must also be reviewed at least every six months or when the condition of service users changes and must be agreed with the service user/representatives (Previous requirement-Timescale of 31/01/06 not met). The social and recreational needs of service users must be comprehensively assessed and recorded. There must a planned programme of activities to keep service users occupied in the home, according to their assessed needs (Previous requirement-Timescale of 31/01/06 not met). That the following, in reference to the environment and building, is attended to: • Re-point paving where concrete is becoming loose and coming off • Re-tile areas in the bathroom where the tiles were coming off • That consideration is given to replace the flooring in the kitchen where cracks are appearing. The registered person must ensure that members of staff have supervision six times a year or once every two months. The registered person must ensure that there is an effective quality management system in place. Satisfaction surveys must DS0000017442.V311176.R01.S.doc 4 YA12 16(2)(m,n) 31/10/06 5 YA14 16(2)(m,n) 31/10/06 6 YA24 23(2)(b) 30/11/06 7 YA36 18(2) 31/10/06 8 YA39 24(1) 31/12/06 Franklyn Lodge 71a District Road Version 5.2 Page 25 9 YA42 13(4)23(4) be carried out and the result/report must be produced outlining the outcome of the survey. The registered person must ensure that a Fire Emergency Plan is in place in the home (Repeated requirementtimescale 31/01/06 not met). 31/10/06 10 YA42 13(4),18(1) The registered person must ensure that members of staff are up to date with regard to food hygiene training. 31/12/06 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 Refer to Standard YA16 YA26 Good Practice Recommendations That the registered person give serious consideration to residents being offered a key to their bedrooms, which can be locked from the inside and outside, and which can be disabled in emergency. The registered person should review the menu to reflect the needs of service users. It is recommended that each service user have a Health Action Plan as advised by the Department of Health. That the home clarifies its position with regard to homely remedy policy. A policy should be in place if the home keeps homely remedies. That a record is made of the amounts received of medicines, which are to be used as required, to facilitate audit of the medicines. The registered person should ensure that the patio area is cleaned and that more flowers and colours are used to make the area more attractive. The metal railing at the edge of the patio could also be repainted. The home should continue in its efforts to ensure that members of staff achieve the Learning Disability Award Framework. 2 3 4 5 6 YA17 YA18 YA20 YA20 YA24 7 YA35 Franklyn Lodge 71a District Road DS0000017442.V311176.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: 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 Franklyn Lodge 71a District Road DS0000017442.V311176.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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