Inspection on 08/06/06 for Franklyn Lodge 8 Forty Lane

This inspection was carried out on 8th June 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Franklyn Lodge 8 Forty Lane 24/11/09

Franklyn Lodge 8 Forty Lane 25/11/08

Franklyn Lodge 8 Forty Lane 13/09/05

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

CARE HOME ADULTS 18-65 Franklyn Lodge 8 Forty Lane 8 Forty Lane Wembley HA9 9EB Lead Inspector Clive Heidrich Key Unannounced Inspection 8th June 2006 8:30 Franklyn Lodge 8 Forty Lane DS0000064186.V298580.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 8 Forty Lane DS0000064186.V298580.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 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Franklyn Lodge 8 Forty Lane Address 8 Forty Lane Wembley HA9 9EB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8904 6821 TBC Residential Care Services Ltd Ms Milly Suyi Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: 8 Forty Lane was registered in June 2005 to provide accommodation and care support to 9 people with learning disabilities. The home is a detached property located near to Wembley Stadium and the town centre. The home is suitable for people who would benefit from a group living while still maintaining their individualism and identities. The home is not suitable for people who are wheel chair users. Application to live at the home is normally made through relevant social services departments and completion of a multidisciplinary care needs assessment. The home has 9 ensuite bedrooms, a staff room, an office, a dining room, a laundry area, a large open plan communal lounge, an activities room, a kitchen, a separate dining room, and a large garden with storage sheds. Service user accommodation is on the ground and first floors. The home is located near to public transport routes, and shopping & leisure facilities. The home is staffed by a registered manager and a compliment of staff with relevant training, qualification and experience in residential care work. There were three vacancies at the time of this inspection. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across two warm days in early June. It comprised of three visits. These were an early morning and late afternoon visit on the first day to meet people in the home and observe care, and a visit a week later to inspect records and discuss findings with management. The site visits lasted seven and a half hours in total. The purpose of the inspection was to assess all of the key standards, and to check on compliance with the small amount of requirements from the last inspection. The inspector attempting to meet with most of the six service users to discuss the services provided in the home. Communication between most service users and the inspector was however very limited, with little more than ‘yes/no’ responses generally understood. The inspector also discussed aspects of the service with the staff who were working during the visits, with the manager who was present during some of the afternoon visit, and with the deputy manager on the final visit. Additionally, care practices were observed, records were read, and aspects of the environment were checked on. The inspector thanks all involved in the home for the patience and helpfulness with this inspection. What the service does well: Three service users were able to give positive feedback about the home. One said that it is a happy home. Observations found that service users generally appeared calm and content in the home. Service users receive good support to access and use community facilities, and to pursue individual lifestyles within the home. There is focus on the development of their skills. The home itself is spacious, includes an activities room with appropriate equipment, and has individual bedrooms that have toilet and shower facilities. Standards were judged as exceeded in the areas of supervision (36) and management (37) due to good feedback from staff and managers, and supporting records. The are strong management systems in support of staff, such as through very regular staff meetings and supervisions, and these were seen to positively benefit service users. The manager additionally has many years’ experience of residential care for people with learning disabilities, and has a number of relevant qualifications. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.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 8 Forty Lane DS0000064186.V298580.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, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users’ needs are assessed and considered according to a suitable and standard procedure. They and their representatives are enabled to visit the home in advance. The home is generally able to meet the needs of people who move in. EVIDENCE: The home has a suitable admission procedure that was last reviewed in 2005. Feedback and records show that the procedure is consistently followed. The assessment records and procedure for a recently-admitted service user were checked in detail. Suitable assessment documentation was in place, both from a social worker and from the home’s management. There was evidence of the service user being involved in the assessment, and of good detail in respect of some of the service user’s needs. A care plan was consequently in place for the service user. It included reasonable reference to the key points of the assessment process. Management explained how, for one recently-admitted service user, the service user and their family had visited the home as part of deciding whether to move in. A number of short stays including overnights were arranged for the service user before they moved in permanently. The funding authority’s care Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 9 manager also visited the home. This all shows suitable procedures being in place. Three service users were able to give positive feedback about the home. One said that it is a happy home. Observations and feedback, along with positive formal review meeting minutes, confirmed that service users’ needs are generally met by the service provided at this home. The manager in particular was able to explain how the service has helped to improve the lifestyles of individual service users, such as through skills improvements, liaisons with family members, and gaining the involvement of community health professionals. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 10 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, 8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are generally supported to make decisions about their lifestyles, with assistance if necessary. These are backed by individual care plans and risk assessments. Improvements are needed to ensure that care plans and risk assessments are kept up-to-date, and with making sure that service user meetings are always held in a manner that enables decision-making. EVIDENCE: The care plans of three service users were checked through. The organisations standard format is used. The plans were individualised with clear information about each service users’ needs and how staff should address these needs. Formal review meetings, involving the service user, their family, and social workers as applicable, were in place and up-to-date. One plan was dated from shortly after the service user had moved in. The other two dated from prior to the service user’s last formal review meeting. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 11 Management clarified that the expectation is for the plans to be updated with respect to decisions made at these meetings. Updated plans are needed to help enable staff to provide consistent and agreed care to the service user. The manager must ensure that updated plans are always available. Written risk assessments were in place based on the individual needs and concerns presented by each service user. Each assessment clearly indicated the actions needing to be taken to minimise the impact of the risk. The risk assessments for two established service users dated from before their admission into this particular home. Risk assessments must be updated upon moving into the home, as the new environment can change the nature of the hazards and risks involved. They also need to include about all restrictions on the service user, such as having their bedroom doors locked during the day, to explain why the restriction is necessary. Restrictions in terms of community presence, for such things as road safety awareness, are however documented about. Service users were observed to have the freedom of the communal areas of the home, and to do such things as acquire drinks independently. Staff supported them to be ready for going to day services, and with such things as looking for sunglasses. Staff spoke of being there to support service users. One service user now has communication cards to assist them to explain what they want. Management also gave good examples of how choice is enabled. Service user meeting minutes showed a monthly occurrence. They generally addressed issues around enabling service users to make decisions about the service, such as for activities and menus. One recent meeting however mainly addressed behaviours that staff wanted individual service users to change. Whilst the idea behind this may have been well-intentioned, addressing these issues in a group setting may have caused distress to service users. Management must ensure that service user meetings always focus on positively enabling service users to make choices, not on modifying individual service user’s behaviours. The home’s finance records for two service users were checked through. No concerns arose from these checks. Records were clear, and corrections were made where needed. For the one service user where the service looks after the service user’s bank book, the records tallied with the bank book. Rent is clearly stated within records. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 12 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): All of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported to use community facilities, and to take part in activities that they enjoy. They are supported to develop skills, and to maintain family relations. They are provided with a good standard of meals. Improvements are suggested to make the menus more user-friendly. EVIDENCE: Feedback and records showed how service users are supported to develop skills, for instance with household activities such as watering the garden, dealing with compulsive behaviours, and enabling staff to understand communications. Skills development goals are monitored by a daily tick chart. Staff explained that every service user has a day centre or college placement that they attend for five days a week. Various centres are used depending on need, and consequently a variety of transportation is used to enable attendance. Communication books are used to pass on relevant information Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 13 between the home’s staff and day centre staff. Management noted that they are supporting one service user to acquire a college placement at the next intake. Staff noted that service users are supported to access community activities frequently, both during the evenings and at weekends. Local recreational clubs such as Gateway are used, local shops are accessed, and a couple of service users regularly attends church with support. Records confirmed this. The home has a designated van to assist with transportation needs. A 5-day holiday for service users is planned for July 2006, at Butlins in Minehead, as part of the organisation’s annual trip away. Staff explained that a coach is hired to assist with transport. A day trip to Brighton is also due shortly. The home has a designated activities room, containing such items as an electric keyboard, an X-Box games console, a music centre, and smaller items like puzzles. The lounge and dining areas both have flat-screen televisions. There is garden furniture at which service users were seen to eat in the warm weather. Staff and records confirmed that service users’ families visit the home. Records showed good family involvement for many service users. Some service users visit family regularly, and some have family support to attend religious services. Management noted that family can visit anytime and that they need not phone in advance. Some service users maintain phone contact with family. Service users have small amounts of responsibilities around the home, such as for cleaning their rooms. Staff provide support for this as needed. There was a reasonable supply of food in the home. Fruit, biscuits, and drinks were freely available. One service user confirmed that they had had breakfast, and based on what they had, it was clear that it was individual to their wishes. Text-menus, for both meat and vegetarian options, were on display in the kitchen. Consideration should be given to providing these menus in more userfriendly formats, to enable service users to understand what is on the menu. A large dinner was served to service users in the garden at about 6:15pm on the first day of inspection. Service users reported enjoying it, and observations confirmed this. The meal was a mince and potato mix with vegetables and salad. Vegetarian mince was used for the vegetarian service user. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 14 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, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive good standards of personal and health support, and reasonable medication support. Improvements are needed to update health-care records, and to ensure good standards of practice with medications. EVIDENCE: From the start of the inspection, service users were seen to be appropriately and individually dressed in casual but well-maintained clothing. Staff prompted service users to address personal care needs appropriately. Reasonable hair and nail care was evident, including with respect to cultural needs. Management feedback showed how they have helped some service users to progress in terms of looking after clothing and personal hygiene better. Care plans were seen to provide good detail on each service user’s support needs around personal care and hygiene. Finance records showed that toiletries are acquired where needed, including such relevant items as suncreams. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 15 Health record summaries were in place for each service user. They were not being consistently used. For instance, chiropody visits had not been recorded about here despite records of payment. The complete health records were blank for one service user, despite feedback and other records showing how suitable health support is provided. The manager must ensure that health summary sheets are used, to show which health professionals have been involved when, and what their advice was. None of the service users self-medicate. Staff provide support to service users for taking prescribed medications. Checks of the administration records found them to be up-to-date and signed off in each case by two people. There were no discrepancies with the actual medications. The medication cupboards were too small to suitably store all medications. One shelf and its contents were sticky due to a bottle of lactulose leaking slightly. The bottle could not stand upright due to the size of the cupboard, and so was tilted sideways. This causes a hygiene issue, and so must be addressed. It was established that no service users currently take PRN (as-needed) medications. Individual guidance sheets were previously available when this did apply. Two old PRN medications for one service user were found in the medication cupboard. The manager must ensure that completed medications are promptly returned to the pharmacist for disposal, to help minimise the risk of the medication being incorrectly administered. It is also recommended that out-of-date PRN guidance sheets be archived to prevent them being mistaken for current advice. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 16 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): Both of them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a reasonable complaints process. Service users are appropriately supported to reduce challenging behaviours through calm staff intervention. EVIDENCE: The evidence examined indicated the home has a relevant complaints policy in place. There was no record of complaints at the home during this inspection. Complaints procedures were on display in bedrooms. Staff stated that service users do not have any difficult behaviours. They came across as confident in working with the service users, and with working calmly with any challenging behaviours. Care plans and risk assessments documented challenging behaviours. Risk assessments included about how to positively and calmly support service users to overcome any challenging behaviours that they presented. There was good emphasis on discussion with the service user after the behaviour, to try to help them gain insight into their behaviour. Management explained how these responses have helped service users to be less anxious and to reduce challenging behaviours. They noted that sanctions are not used in the home. The home’s incident book had no entries since August 2005. Staff explained that two service users have specific monitoring books in respect of specific behaviours. These were being recorded in consistently. There was evidence of Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 17 acquiring support with community health professionals in respect of concerning behaviours. Management confirmed that all staff have undertaken recent training in the prevention of service users from abuse. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 18 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, 25, 26, 28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is spacious and has some useful facilities such as an activities room and a spacious garden. It was generally clean and well-decorated at the time of the visit. Improvements are needed to fix some broken equipment, to address some unhygienic areas of the kitchen and dining room, and with upholding suitable standards of infection control in the laundry area. EVIDENCE: All bedrooms are single occupancy with ensuite toilet and shower facilities. All bedrooms were seen to have suitable furnishings including generally colour cocoordinated bedding, curtains, and carpeting. All had window restrictors, and suitable door locks. One bedroom chair lacked a seat. Staff explained that this was in relation to the service user’s particular behaviour. Management explained that a sturdier seat is on order. The communal areas of the home were also well-decorated and with suitable furnishings. They comprise a large lounge, a separate dining area, and an Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 19 activity room. The dining area has new, sturdy chairs after previous chairs had been broken through the use of some service users. There is a kitchen next to the dining room that had all reasonable facilities. It was found that the dishwasher therein was not working, that the oven coverdoor was missing, that the fridge door handle was broken making access more difficult, and that the storage area under the microwave was heavily greasestained. Additionally, the dining room carpet was heavily stained and grubby near the kitchen. Staff confirmed that it had not been professionally cleaned recently. All of these issues are either health & safety concerns or detract from a suitably homely atmosphere, and so must be addressed, which management agreed to do. The home has a laundry area containing industrial washing machine and domestic tumble drier. The room lacked a bin and soap, which puts people at risk of poor hygiene. This must be addressed. A supply of disposable gloves was available to staff. The home was generally being kept in a good state of cleanliness, and with no offensive odour apparent. Staff were seen to attend to cleaning generally when service users had left for day services. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has good standards of recruitment procedures, ensures generally suitable staffing, and places good emphasis on training. Over 50 of staff have achieved NVQs, and other training courses are attended. There are good standards of supervision and staff meetings, which combined with close monitoring and encouragement by management, enables service users to be very well supported by staff. EVIDENCE: Staff were seen to generally attend to service users’ needs and requests in a calm and respectful manner. Staff organised themselves to ensure that there was always someone attending to or overseeing service users, including those needing 1:1 support. Feedback from service users, where possible, was positive about staff. Staff presented, through discussion, as knowledgeable about the service users. This reflects on there being few changes to the staff in the team since shortly after the home opened, and that the same agency staff are generally used. There was always a clear shift-leader during the visits. The manager noted that everyone is expected to take on this role, to help ensure ongoing development. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 21 Management explained about how they addressed previous staffing tensions, through higher levels of phone monitoring and physical presence on shifts, and through discussions. Staff continue to call management at the start of each shift to clarify the shift plans. There were four staff working at the start of the visit. All finished their shifts by around 10am that morning. Three staff worked the evening shift. Staff stated that these levels are normal for the home. Management confirmed this. Staff sign in on the shift-planner to keep a record of who actually works the shift. The same shifts are planned for each week. These plans showed that four staff work each morning except for Saturdays, with three staff working afternoons and evenings, and two as waking nights. Additionally, either the manager or the deputy are present across each day of the week. Management stated that most permanent staff have relevant NVQs, whilst all agency staff must have NVQs to be hired. They ensure that 50 of staff working on any shift have an NVQ, which is good practice. Staff stated that they have had suitable training for the job. Refresher training takes place regularly, and they have received training in autism, as befits some of the service users at this home. Checks of training records showed that established staff have completed courses in all standard topics, such as infection control, emergency first aid, and food hygiene. Management explained that refresher courses are generally organised when needed, for all staff as a service-wide group. They noted that induction records are kept at head office. The induction package was seen to conform to the current national training organisation’s expectations. Staff stated that they receive supervision sessions from the manager or the deputy once a month. Records confirmed this. The services standard forms are used for this, which prompt for discussion on key topics such as development and keyworking. Personal Development Plans are being set up for all staff. Similarly, staff meetings for the home are held monthly, within which key issues about service users are discussed. The meetings are held in the evening so as to enable night staff to attend. This is good practice. The recruitment files of two newer staff were checked through. Suitable checks of identification, work permits, and written references were in place. There was evidence of application forms and interviews, and both staff had contracts of work. Criminal Record Bureau (CRB) checks were not made available as they are stored at head office, but management explained about the individual circumstances of the check for each worker, and these tallied with the dates of other documents. Management should ensure that details of the CRB checks are recorded about within individual staff files, to confirm that the checks have been undertaken at the correct time and that outcomes are suitable. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 22 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, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has an experienced manager and strong management support. Service users consequently benefit from a home that is run very well, particularly in terms of their development and of staff support. The home has reasonable systems of health and safety, including numerous daily and weekly checks by staff. Improvements are needed with ensuring that professional checks of equipment are kept up-to-date. EVIDENCE: Records show that the manager has many years’ experience in working with people with learning disabilities. She managed another home for the organisation for six years prior to the opening of this home. She has relevant and extensive professional qualifications. Discussions with the manager showed that she is knowledgeable, experienced, and motivated to run the home in service users’ best interests. She was able to Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 23 discuss how all service users have developed in their placements since the home opened. She is ably supported by the deputy manager. The overall positive management of the home consequently enables the relevant standard to be judged as exceeded. Management noted that the organisation has achieved Investors in People status, an award for positive employment practices. Renewal is due in 2007. In terms of quality assurance, management explained that they typically send out questionnaires to people involved with service users such as families and day services. They use recommendations from these. This process will take place shortly for this service, as the service was not yet a year old at the time of the inspection. The organisation’s owners undertake monthly monitoring checks of the home, as required. Reports of such visits were seen, and are made available to the home’s management. Management stated that they ask staff for policy feedback as part of their policy reviews. Policies are clearly discussed within staff meetings. This is good practice. An annual development plan, about what the service aims to achieve particularly for service users, based on consultation with all involved parties, was discussed with and recommended to management. There was good evidence that a lot of the groundwork for such a plan is already in place. A detailed risk assessment in respect of house systems, and hazards to anyone in the home, was seen to be in place and addressed. Daily health and safety checks were seen to be recorded about, such as for kitchen safety, water temperatures, and cleanliness. Weekly fire drills were also evident. Professional safety checks were in place and up-to-date for electrical wiring and appliances, water systems, and gas supplies. Shortfalls were identified, in terms of being up-to-date, for the fire system and equipment. Management booked for this to be addressed during the inspection, and confirmed consequently that the issues had been addressed by a visit from their fire safety contact. They must ensure that professional checks of equipment are kept up-to-date. Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 24 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 3 4 3 5 X 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 3 26 3 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 4 3 3 X X 2 X Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2) Requirement The manager must ensure that updated individual plans are always available in respect of each service user. Management must ensure that service user meetings always focus on positively enabling service users to make choices, not on modifying individual service user’s behaviours. Individual service user risk assessments must be written/updated upon moving into the home. They must also include about all restrictions on the service user, such as having their bedroom doors locked during the day, to explain why the restriction is necessary. The manager must ensure that the health summary sheets available within each service user’s file are used, to show which health professionals have been involved when, and what their advice was. The registered provider must ensure there is adequate storage DS0000064186.V298580.R01.S.doc Timescale for action 15/08/06 2 YA8 12(4) 15/07/06 3 YA9 13(4), 15(2) 15/08/06 4 YA19 17(1)(a) s3 pt 3(m) 15/07/06 5 YA20 13(2) 01/08/06 Franklyn Lodge 8 Forty Lane Version 5.2 Page 26 facility for all prescribed medication. Previous timescale of 30/12/05 not met. Hence of otherwise, liquid medications must be stored upright. The manager must ensure that completed medications are promptly returned to the pharmacist for disposal, to help minimise the risk of the medication being incorrectly administered. The registered people must ensure that the following issues are suitably addressed: • That the dishwasher in the kitchen doesn’t work; • That the oven cover-door is missing; • That the fridge door handle is broken making access more difficult; • That the storage area under the microwave is heavily grease-stained; and • That the dining room carpet is heavily stained and grubby near the kitchen. The laundry room lacked a bin and soap, which puts people at risk of poor hygiene. This must be addressed. The manager must ensure that professional checks of health and safety equipment such as the fire systems are kept up-to-date. 6 YA20 13(2) 01/08/06 7 YA24 23(2)(b, c, d) 01/09/06 8 YA30 16(2)(j) 01/07/06 9 YA39 23(2)(c), 23(4) 01/08/06 Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 27 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 YA17 YA20 YA34 Good Practice Recommendations Consideration should be given to providing the menus in more user-friendly formats, to help enable service users to understand what is on the menu. It is recommended that out-of-date PRN medication guidance sheets within service users’ files be archived, to prevent them being mistaken for current advice. Management should ensure that the key details of the Criminal Record Bureau checks are recorded about within individual staff files, to confirm that the checks have been undertaken at the correct time and that outcomes are suitable. An annual development plan, about what the service aims to achieve particularly for service users, based on consultation with all involved parties, is recommended. 4 YA39 Franklyn Lodge 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 28 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 8 Forty Lane DS0000064186.V298580.R01.S.doc Version 5.2 Page 29 - 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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