Inspection on 16/09/05 for Franklyn Lodge 9 Grand Avenue

This inspection was carried out on 16th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Franklyn Lodge 9 Grand Avenue 12/02/07

Franklyn Lodge 9 Grand Avenue 10/01/06

Franklyn Lodge 9 Grand Avenue 29/11/04

Franklyn Lodge 9 Grand Avenue 07/06/04

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

CARE HOME ADULTS 18-65 Franklyn Lodge 9 Grand Avenue Franklyn Lodge 9 Grand Avenue Wembley Middlesex HA9 6LS Lead Inspector Julie Schofield Unannounced Inspection 16th September 2005 3:00 Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Franklyn Lodge 9 Grand Avenue Address Franklyn Lodge 9 Grand Avenue Wembley Middlesex HA9 6LS 020 8902 3070 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 Dr Frank Eribo Ms Milly Suyi Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2004 Brief Description of the Service: Franklyn Lodge, Grand Avenue is a care home providing personal care to 6 adults with learning disabilities. At the time of the inspection there was one vacancy. The house is in a quiet residential part of Wembley but close to the Harrow Road and with easy access to the shops on Wembley High Road. There are bus routes along the Harrow Road and there are underground stations relatively close by. The property is a corner plot and the house is slightly elevated from the road with steps in the front garden, leading from the pavement to the front door. There is off street parking outside the home. The house consists of 2 floors, ground and first floor, and the office is situated on the ground floor at the front of the house. There is also a resident’s bedroom (with en-suite bathroom), kitchen, staff sleeping in room (with en-suite toilet) and open plan lounge and dining area. The laundry room is situated in the back garden. On the first floor there is a bathroom, five residents’ bedrooms (one of which has an en-suite shower room), shower room (with toilet) and a separate toilet. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on an afternoon and early evening in September 2005. It started at 3pm and finished at 7pm. The Inspector would like to thank members of staff and residents who took part in the inspection. The inspector would also like to thank Ms Suyi who assisted during the inspection and was about to take up her new post as registered manager in another of the company’s care homes. During the inspection residents’ records and records relating to the running of the home were inspected, the serving of an evening meal was observed and a partial site inspection took place. A second visit took place a week later on the 23rd September, by appointment, for 40 minutes to inspect staff records. These records had not been available in the home on the 16th September, as they are normally kept at head office. What the service does well: What has improved since the last inspection? Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 6 The company purchased a computer software package for producing userfriendly documents and has now introduced a new contract for residents, a new care plan and a fire procedure (a copy which is placed in each resident’s bedroom). The open plan lounge and dining room has been redecorated and a new carpet and curtains have been purchased. The room looks attractive and comfortable and with ornaments and pictures provides a “homely” atmosphere in which to relax. 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 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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, 5 Prior to admission information is received about the prospective resident and the manager carries out an assessment to ensure that the needs of the resident can be met within the home. Residents are involved in the process of choosing a care home that can meet their needs. New residents receive a contract, in a format suitable to their needs, as part of the admission process. EVIDENCE: One resident has been admitted to the home since the last inspection. Their case file was inspected. During the pre-admission procedure the home collected information, which was used to determine the suitability of Grand Ave as a placement for the prospective resident. This information included a copy of the minutes of the review meeting held in the previous care home, a copy of the most recent local authority care plan (dated May 2005) and a copy of the registered manager’s assessment of the needs of the prospective resident (dated May 2005). The company already knew the prospective resident as the resident had been placed in another of the company’s care homes, on a short-term basis. The prospective resident had visited Grand Ave and knew the residents at Grand Ave from attending social events and the day centre. The resident said that they had been pleased that a placement had been arranged at Grand Ave. A new contract for residents, which contains illustrations and is user-friendly, has been developed and a copy of this was on the file of the resident who was Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 9 admitted to the home since the last inspection. The resident had signed the contract. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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, 9 Care plans are evaluated on a regular basis to ensure that changes in the needs of residents are identified and can be addressed. Regular review meetings are held but the home must ensure that a copy of the minutes of the meeting is placed on file. Staff support residents to take responsible risks so that residents can enjoy an independent lifestyle. EVIDENCE: Case files were inspected and included care plans, which assessed the social, personal and health care needs of the resident. The file of the resident who had been admitted to the home since the last inspection contained the minutes of the initial review meeting that had been held shortly after admission. Copies of the minutes of the review meetings convened by the home at the end of 2004, for 2 of the other residents were not initially on file. The manager said that the member of staff working in the office at the time the meetings were held was employed on a short-term basis and was not familiar with all the office routines. The minutes of the meetings were retrieved from the computer files and copies were added to the case files. There was evidence that family members were invited to attend review meetings, if the resident wished. Review meetings were held on a six monthly basis. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 11 Case files contained copies of risk assessments, which are tailored to the individual needs of the residents. The risk assessment included an assessment of the likelihood of risk and risk management strategies. Risk assessments included using the oven, helping in the kitchen, personal hygiene, going swimming and self-harm. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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): 12, 13, 14, 15, 17 Residents have access to day centres and courses, which provide an opportunity to develop their social and communication skills. Taking part in activities and using community resources gives residents the opportunity to become more independent and to enjoy an interesting and stimulating lifestyle. The support of staff enables residents to maintain family contact. Residents have a varied and balanced diet and said that they enjoyed the meal served. EVIDENCE: Each resident has a day care programme. Four of the residents attend the day centre, which is run by the company, on 5 days per week and 1 resident attends a day centre in Ealing for 2 days per week and the company day centre on the other 3 days. Residents have access to BACES courses via the day centre and residents have certificates for drama courses and gardening courses. Two residents said that they enjoyed going to the day centre and taking part in the arranged activities. One of these residents said that they liked going swimming. Another resident said that they enjoyed sewing, colouring and exercise sessions at the centre. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 13 Residents have access to facilities and resources in the community. They confirmed that the facilities used included shops, restaurants, cinema and leisure centres. They can either use public transport, taxis or vehicles owned by the company. The home arranges swimming sessions for residents as an evening activity. Staff confirmed that residents also attend clubs in the evenings and at weekends. Staff said that outings have been arranged for residents, at the weekends, to Hastings, Reading and the Galleria (for the cinema and lunch). Social events are arranged in the home and residents from other homes are invited e.g. a barbecue. The residents at Grand Ave are in turn invited to events held in other care homes run by the company. A resident talked about the holiday that she had been on recently, which had been arranged by the company. They liked watching the videos that were played on the coach during the journey to Minehead and dancing in the evenings. Another resident also said that they enjoyed the holiday. Residents enjoy watching television in the evenings and some like watching the “soaps”. Staff said that all the residents enjoyed regular contact with their families. Two residents said that relatives visited them in the home and that the visits could take place either in the communal areas or in their rooms. They enjoyed the contact with their family. They confirmed that when their relatives visited the home they were made welcome by the staff on duty. One resident spends some weekends with their family. During the inspection the evening meal was prepared and served. The member of staff confirmed that it was the meal specified on the menu. The member of staff prepared spaghetti Bolognese, with potato wedges and salad. The dessert was fruit cocktail or rice pudding. Before the preparation started staff asked residents whether they wanted any changes made to the meal. Residents said that they enjoyed the meal. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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): 19 Residents’ health care needs are met through access to health care services in the community. EVIDENCE: Case files were inspected. There was evidence that new residents register with a local GP shortly after being admitted to the home. Residents attend outpatient appointments escorted by a member of staff, if necessary. Access to local health care services is demonstrated on file and there were appointments with the dentist, optician etc. Requests have been made for assessment by a health care professional e.g. speech and language therapist. There was a record of regular appointments with the psychiatrist. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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 The rights of residents are protected by a clear and simple complaints procedure. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. This training must be arranged for new members of staff, as a priority. EVIDENCE: A copy of the complaints procedure was on display in the home. The simple procedure included timescales for each stage of the procedure and referred complainants to the directors of the company, if the home’s manager could not resolve matters. Information regarding access to other agencies e.g. the CSCI was included, with the address and telephone number of the local office. The manager said that no complaints have been recorded since the last inspection. The manager said that no allegations or incidents of abuse have been recorded since the last inspection. She also said that restraint is not practiced in the home. It is the policy of the company that each member of staff attends a 2day protection of vulnerable adults training course. The manager said that they also attend management of challenging behaviour training. One of the 2 members of staff has recently joined the staff team working at Grand Avenue and is waiting to attend the adult protection training course. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 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): 30 Residents live in a home where standards of cleanliness are good. EVIDENCE: A partial site inspection took place and it was noted that the areas seen were clean and tidy and free from offensive odours. Staff on duty confirmed that they had undertaken training in infection control procedures. Access to the laundry room is not through areas where food is prepared or consumed. The manager said that the washing machine does not have a sluicing cycle. She confirmed that none of the residents have problems with continence. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 17 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, 36 The rota demonstrated that there were sufficient staff on duty to support the residents. Residents are supported by staff that undertake NVQ training to develop their skills and knowledge and to understand the needs of the client group. The recruitment process protects the welfare of the residents. Individual supervision sessions enhance the overall support available to staff and is an opportunity to encourage personal development. EVIDENCE: A discussion took place with the manager regarding NVQ training and she said that currently members of the staff team were undertaking NVQ training at levels 2, 3 and 4. The senior member of staff on duty confirmed that they were undertaking NVQ level 4 training and another member of staff confirmed that they were undertaking NVQ level 2 training. A copy of the rota was seen. It included post titles and the hours worked by the manager were included. Either 2 or 3 staff are on duty in the home when residents are not attending day centre, depending on whether residents are visiting their families. The number of staff on duty is sufficient to give residents a choice of activities both inside and outside the home. At night there are 2 staff on duty in the home, sleeping in but on call. A resident said that the member of staff who is their key worker is “my second dad”. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 18 The home uses agency staff but the home requests the same personnel so that residents enjoy continuity. There was evidence that the agency sends confirmation of a satisfactory CRB disclosure, proof of ID, confirmation of satisfactory references, verification of qualifications etc. Staff files are kept at head office and the files selected by the Inspector were made available in the home on the second visit. It was noted that a satisfactory CRB disclosure, 2 satisfactory references, proof of ID etc are received prior to a new member of staff commencing duties in the home. Staff confirmed that monthly staff meetings took place and that they received monthly individual supervision sessions. The manager said that she attended monthly manager’s meetings. She said that staff appraisals had taken place in April. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 19 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, 42, 43 A competent and experienced manager supports residents and staff. The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents. In the event of an accident or incident occurring in the home, insurance cover protects residents, members of staff and visitors to the home. EVIDENCE: The manager has attained her RMA in addition to previous management training qualifications and confirmation of this was given to the CSCI as part of an application for registration as manager for another care home, owned by the company. She said that her portfolio for the NVQ Assessor’s Award is ready for submission. Since the last inspection she has undertaken training in respect of Autism. The members of staff on duty confirmed that they had undertaken manual handling, fire safety, first aid, food hygiene and infection control training i.e. training in safe working practice topics. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 20 A copy of an Employer’s Liability insurance certificate was on display in the home. It was valid for the period 12/12/04 to 11/12/05. It was valid for cover up to a minimum of £5 million. It did not specify the name of the home. Franklyn Lodge 9 Grand Avenue DS0000017452.V254677.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Franklyn Lodge 9 Grand Avenue Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 3 DS0000017452.V254677.R01.S.doc Version 5.0 Page 22 NO 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 2 Standard 6 23 Regulation 14.2 & 15.2 13.6 Requirement That the minutes of review meetings are placed on file. That all staff receive training in the protection of vulnerable adults. Timescale for action 01/12/05 01/12/05 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 43 Good Practice Recommendations That insurance certificates name the individual care home. 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