Inspection on 12/06/07 for Friern Residential Care Home

This inspection was carried out on 12th June 2007.

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 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Friern Residential Care Home 02/06/09

Friern Residential Care Home 30/09/08

Friern Residential Care Home 29/04/08

Friern Residential Care Home 28/01/08

Friern Residential Care Home 28/11/06

Friern Residential Care Home 26/06/06

Friern Residential Care Home 20/02/06

Friern Residential Care Home 26/09/05

Friern Residential Care Home 07/01/05

Friern Residential Care Home 26/05/04

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

CARE HOME ADULTS 18-65 Friern Residential Care Home 26-30 Stanford Road Friern Barnet London N11 3HX Lead Inspector Pearlet Storrod Key Unannounced Inspection 12th June 2007 10:00 Friern Residential Care Home DS0000010441.V342905.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 Friern Residential Care Home DS0000010441.V342905.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. Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friern Residential Care Home Address 26-30 Stanford Road Friern Barnet London N11 3HX 020 8368 6033 F/P 020 8368 6033 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) Mr Vevegananthan Thambirajah Mrs Bijaye Luxmi Thambirajah Mrs Bijaye Luxmi Thambirajah Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One exception for over 65 years Date of last inspection 28th November 2006 Brief Description of the Service: Friern Residential Care Home is a private care home, which opened in 1989 and is registered to provide care to eighteen adult men and women who have mental health problems. Mr & Mrs Thambirajah are the registered providers and jointly own the home. Mrs Thambirajah is the registered manager and Mr Thambirajah is the deputy manager. The stated aims of the service are to meet resident’s needs in a friendly and efficient way and to strive to preserve and maintain resident’s dignity, individuality and privacy. The premises have been converted from three adjoining houses. All bedrooms are on the ground and first floors. There are fourteen single and two double bedrooms. One of the single bedrooms on the ground floor and first floor have been arranged as self-contained flats with their own kitchen and bathroom. There is one main kitchen. There are also two lounge areas and two dining rooms. To the rear is a garden and patio area. The home is in a quiet residential part of Friern Barnet, close to shops, and transport links. The fee range for residents living in the home is £450 - £650 per week depending on their needs. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Friern Residential Care Home took approximately 10 hours. The inspector spent time in the office talking to the managers and examining a number of records, policies, procedures and the file of staff and people who use services. Surveys were issued to all named relatives outlined in the pre inspection questionnaire but only one was returned. Discussion with some of the people who use the service indicated mixed feelings about life in the home. For example, some liked the food and some did not. Two people felt that it was all right to live at the home as they had no where else to go since moving from a previous establishment that burnt down. The inspector would like to thank all those who participated in the inspection process for their co-operation. What the service does well: The home has robust assessment of needs and good risk assessments and the people who use services are involved in the process. Care reviews occur regularly. People who use the service are supported and where necessary driven to their medical appointments by the deputy manager and good arrangements are in place to meet individuals’ health care needs. Staff with whom I spoke demonstrated caring attitudes and the majority are appropriately qualified, some of who are in the process of doing NVQ qualification courses. Supervision regularly occurs. Carers who spoke with the inspector demonstrated a good understanding of the home’s policies and procedures. Friern Residential Care Home DS0000010441.V342905.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. The summary of this inspection report can be made available in other formats on request. Friern Residential Care Home DS0000010441.V342905.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 Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service users guide is not sufficiently robust and needs further development. Robust assessments continue to occur and the people who use services are involved in the assessment processes. EVIDENCE: The statement of purpose and service users guide requires further development in respect to the name, qualification and experience of the registered manager and range of qualifications held by staff. The complaints procedure included in the statement of purpose needs to be redrafted to demonstrate that the provider manages complaints made about the services on offer; the document instead portrays the idea that the Registration Unit and or Registration Authority takes the lead in this respect. The document additionally refers to accidents being referred to the registration authority. A requirement is made that the contents of the statement of purpose and service users guide are reviewed to aid potential users of the service, those people currently living at the home and placing authorities with information that is clear and succinct. From sampling a number of files for people who use services living at the home and from talking with them, information gathered demonstrates that people who use services have involvement in planning of their individual care and Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 9 support needs. The general views from those spoken with about living at the home was that it was all right. One person said that they wanted to leave and two others said that they were only living there because they were put there following a fire at another home previously. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use services know that their individual needs are assessed but there was no evidence of individual’s planned goals in the care plans. Care plans are reviewed and those seen did not reflect any progress of achievements. Risks assessments are in place but these need to take into account set goals. EVIDENCE: People who use services are involved in their individual care planning systems and process. From discussion with the assistant manager about the planning of care and evaluation process, a good system with regard to the assessments of needs appears satisfactory. There was no operational practice in place to measure the progress of achievements made in respect to people’s individual goals. For example, in discussion with staff and one of the people who use the service, it became evidently clear that a few of the people who use the service rarely left the service, one individual appeared keen to locate voluntary work but staff confirmed that the registered manager confirmed that he is reluctant to do so and needs a lot of support and encouragement. To this end, there needs to be more creativity by staff in encouraging and supporting people who Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 11 use services to take steps to deal with their fears and anxieties. More staff time must be given to individual people who use the service in a consistent and continuous way if realization in respect to set goals are to be reached. The care plans needs to be reviewed so that they contain all aspects of the person and not just information about clinical issues. Their individual likes, dislikes and preferences and hobbies together with information from the day centres attended by individuals must be included in the care plans. Also, information must be obtained from the day centres attended by individual people who use the service and once gathered, must be incorporated in the care planning process so that a coordinated and consistent approach in care delivery is afforded people who use services. Risk assessments are in place but these need to be more robust and include individual tasks, activities and identified goals outlined in the care plans. A requirement is made that the care plans are reviewed to take account of the whole person and that the reviews demonstrate the progress of achievements and outcomes for people who use the service. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More effort needs to be made by staff in respect to people who use services individual personal development. People who use services follow their preferred lifestyle as far as they are able. Staff recognise the importance of positive family relationships. EVIDENCE: I had the benefit of seeing bingo being played on the inspection day and several of the people who use services and a number of staff were spoken to about aspects of life in the home. There is an activities chart available but some of the activities listed do not happen. The chart needs to be reviewed to correctly reflect the activities that occur in the home. Some of the people who use the service who rarely venture outside the home participated in activities of their choice such as drawing and they are encouraged to pursue their own individual interests, but to do so, more practical support is required. People who use service need more encouragement and support to make more use of facilities in the community Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 13 including local transport. Day trips to Margate occur annually; a relative confirmed that a one-day trip take place on a yearly basis. Barbecues are arranged, weather permitting. Staff do try to encourage people who use the service to participate in household tasks and they are supported to maintain contact with friends and families as necessary. There was some negative feedback from a relative in a comment card. They asserted that their family member is happy at the home and can come and go as they please but that the positivism ends there. I also observed three females who live in the home had already changed into their bedclothes by 1900 hours. I pursued the reason for this at a later time with staff and was told that it is customary for an individual to go to bed early, directly after the evening meal; this was the general practice for this person since residing at the home. Another individual would change into their pyjamas early but not necessarily go to bed until 2100 hours. The regime of going to bed early whilst in psychiatric hospital continues to occur and it is not possible to have fulfilled lives if the regime if going to bed early each day remains ingrained in their thinking. In discussion with some of the people who use the service, there was a difference of opinion about the food; some felt that the food was satisfactory and others spoken to were dissatisfied with the food arrangements in the home. A family member described the food as “economy with very little variety”. Staff confirmed that people who use services are involved in planning the menu at the fortnightly meetings. It was difficult to envisage the level of participation of the people who use services in these meetings because of the differing views that emanated around the meal arrangements. There was also no evidence to demonstrate that people who use services led these meetings. People who use services must be encouraged and supported to manage service users meetings and to take into account their educational, social and leisure activities inside and outside the home and menu planning. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal and healthcare supports for people who use services are generally satisfactory. The management of medication may potentially place people who use services at risk. EVIDENCE: There are policies and procedures in place to demonstrate the need for privacy, dignity and independence. These principles are also embedded in the statement of purpose and service users guide. One of the people who use services is incontinent and there was no continent management policy in place. Malodour is evident. As stated earlier under Lifestyles, some of the people who use services are dressed in their pyjamas/night clothes early each evening, this routine has continued to occur since moving from a psychiatric hospital where the custom and practice was to go to bed early. Staff need to be proactive in assisting people who use service to change these regimented routines and to lead more active and fulfilled lives. There is evidence of input from health professionals such as physiotherapist, psychologists and psychiatrists as appropriate. Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 15 People who use the service are supported and where necessary driven to their medical appointments by the deputy manager. Scrutiny of the administration of medication process appeared satisfactory a more in depth examination revealed that medication that some prescribed medication remained stored, which should in fact, have been returned to the pharmacy. Lorazepam 1 mg tablets for example were prescribed on 3/10/2006 was observed in the medication cabinet along with other prescribed medication dating back three months. A review of the management of medication must be undertaken. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedure is included in the statement of purpose and service users guide, the information in respect to both documents are inconsistent. The home has policies and procedures in place to protect people who use services from harm. EVIDENCE: The home has a policy and procedure in place as outlined in the statement of purpose and service users guide but the content of these documents are inconsistent. The policy gives the view that the Commission would carry out complaints made about the home but this is not the case, as the Commission has no statutory responsibility to investigate complaints made about the home. Such responsibility lies with the purchasing authority and the home. The policy does not include a timescale for follow up and outcome to complainants. In respect to the procedure outlined in the service users guide this needs to include information relating to local social services and healthcare authorities. Both documents needs to be reviewed so that clear and succinct information are delivered to prospective people who may want to use the service, placing authorities and those who live in the home. Reference in respect to Registration unit and or the Registration Authority needs to be removed from the documents and replaced with the word “Commission”. No complaints were made to the home since the last inspection. Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 17 During the inspection I learnt from a staff member and an individual that use the service that a large sum of money was held stored in the home on the individual’s behalf, looked after by the assistant manager. The deputy manager was unaware that this money was held in the home and I was asked to speak with the individual person who uses the service about opening a bank or building society account for his convenience. The money was being saved to conduct a shopping spree in respect to personal clothing. Following a talk with the individual concerned, he verbally consented to opening a post office account; he was reluctant to do so previously due to a lack of identification documents. With respect to the protection of vulnerable adults appropriate policies and procedures are in place and there is evidence of staff training. The home should obtain a copy of the policies and procedures in respect to the protection of vulnerable adults from both Brent and Islington local authorities and to align these with the home’s own policy and procedure. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited improvements have been made in respect to maintenance and hygienic standards since the previous inspections. EVIDENCE: Limited improvements have been made since the previous inspections; the wash hand basin has been removed from the dining room, the double room is now used as a single room and some rooms have been decorated to give a more pleasant appearance. In discussion with one of the people who use the service, they stated that the manager has agreed to decorate his room and that he wished to have wallpaper instead of painted walls, which was brought to the attention of the registered manager. During the visit the management staff discussed the issues relating to the temporary decrease in numbers and the areas for improvement, which Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 19 included converting some areas of the home with en suite facilities to enhance the numbers to at least the numbers for which the home is registered. This was discussed at length and the registered manager was advised to write directly to the regional registration team for further advice and support in this area. Carpets in the communal areas of the home are in a poor state; the fabrics to some furniture in the lounge areas were torn and there was malodour in the home, which made the home unpleasant and comfortable to live in. It is recommended that the home consult with the local authority environmental officer for advice in respect to controlling the offensive odour visibly in the home. Senior management said that they plan to put laminated floors in the communal areas of the home and they intend to carry out some refurbishment and conversion work to possibly increase the number of people who use the service in the New Year. In relation to the increased number of people using the service, they were advised to write directly to the Regional Registration Team with their proposals. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement is required in respect to more clearly defined staff roles and responsibilities; an effective staff team do not provide adequate support to people who use the service. EVIDENCE: The morale of some staff were clearly low; in discussion with them they indicated an element of dissatisfaction with their roles and responsibilities since the majority of their time is spent carrying out domestic duties such as cleaning and cooking. A tasks and responsibilities chart reflected the functions undertaken by individual workers. The chart consists of an itemized list and all staff members are required to “engage with clients and activities”. Three staff members are to conduct “one to one reviews with allocated clients”. A cleaner was not employed by the home at the times of this inspection and despite what the staff roster portrays, there are generally only 2 care staff on duty at each shift for a large majority of time. This does not enable more staff time to people who use the service who may need practical support associated with their developmental needs. Staff spoken with confirmed this to be the case. The home must invest in domestic staff to undertake general domestic duties Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 21 in the home and further investment in a qualified cook would benefit the people who use services in this home and staff. This would ensure that staff ratios are satisfactory and that staff members are more appropriately deployed to meet the needs of people who use the service. Considerations must also be given to matching the gender of staff to the gender of people who use the service as currently three men generally undertake the night shifts. Two care workers are not yet allotted senior care worker positions. Their duties are mainly concerned with domestic regimes such as cleaning the oven, kitchen cupboards, bathrooms, and lounge and hall areas for example. One of these individuals’ holds an appropriate NVQ qualification and the other is presently undertaking NVQ 2. Most of the care staff though appropriately qualified, confirmed that they paid for their own individual NVQ training above NVQ level 2. A grant was obtained from the local authority in respect to training for NVQ level 2. The home’s recruitment policy and practice was scrutinised and this showed that improvement is required. Examination of a sample of staff files demonstrated that verbal references were obtained in some cases. The home must ensure that written references are obtained for potential employees and that work permits allow individuals the right to work are validated. In addition, the equal opportunities policy needs to be brought up to date in line with new legislation. As stated earlier, the majority of the staff have achieved NVQ qualifications and some are in the process of achieving this. A grant from the local authority is given for NVQ 2 qualifications but for higher NVQs staff are required to finance these training courses themselves. Approximately five staff members are undertaking a distant learning course associated with the College of North East London related with medication. The organisation is financing this. The training profiles for some staff need to be brought up to date and refresher courses undertaken where necessary. Supervision appeared satisfactory. Friern Residential Care Home DS0000010441.V342905.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a home that is managed well though leadership and management approaches are unclear presently. Systems are in place that ensures the protection of the health and safety of people who use the service EVIDENCE: The registered manager is appropriately qualified and knowledgeable to run the home in an effective manner. It emanated throughout this inspection that the newly appointed assistant manager is assigned responsibility to run the home for a majority of the time. This individual undertakes administrative and other managerial duties such as supervision and drawing up the staff rota in absence of the registered and deputy managers. To this end, the ethos, leadership and day to day management for the home is unclear and the structure and clarification should be forwarded to the Commission Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 23 The home does not as yet have computerised equipment installed and relies upon the use of the assistant manager’s personal laptop to draw up any necessary documents associated with the business. This is not satisfactory and could potentially be in contravention of the DATA Protection Act 1998 in respect to confidentiality. To this end it is recommended that the home invest in the installation of a computerized system for the business, which would benefit staff members as it would develop their individual IT skills and make their administrative workload easier to manager and in a more effective and efficient manner. A quality assurance system is in place Staff do make attempts to ensure that the necessary health and safety are carried out regularly. It was noted that the assistant manager works from a cupboard when using her computer to produce written documentation. The use of this cupboard space to undertake administrative duties contravenes the Health and Safety at Work etc Act 1984. Friern Residential Care Home DS0000010441.V342905.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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 2 27 X 28 X 29 x 30 1 STAFFING Standard No Score 31 3 32 3 33 1 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 2 12 3 13 2 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 3 x x 3 x Friern Residential Care Home DS0000010441.V342905.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4 and 5 Requirement The registered person must review the statement of purpose and service users guide in respect to the name, experience and qualification of the registered manager and range of staff qualifications and refer to requirement (7) regarding the complaints process The registered person must ensure that set goals are drawn up for individual services users and that systems are put in place to measure the achievements. The registered person must also provide opportunities for service users to develop and maintain social, emotional, communication and independent living skills The registered person must ensure that staff are more proactive and encourage service users to integrate and make more use of local, social and community activities. The registered persons must review menu planning and general food arrangements to DS0000010441.V342905.R01.S.doc Timescale for action 20/09/07 2 YA6 15 (1) and 14 (2) 20/09/07 3 YA11 12 (1)(b) 20/10/07 4 YA13 16 (2)(m) 20/09/07 5 YA17 16 (g) (h) 26/08/07 Friern Residential Care Home Version 5.2 Page 26 ensure that service users requirements are included on a weekly basis instead of two weekly. 6. YA20 13(2) The registered person must ensure that services users medication are properly managed in respect to administration, storage and disposal The registered person must ensure that the complaints policy and procedure are reviewed and consistent The registered persons must ensure that the home has a planned maintenance and renewal programme for the conversion and decoration of the premises The registered persons must ensure that all damaged furniture are replaced. The registered person must ensure that the room of an individual is decorated in accordance with his choice and wishes The registered persons must ensure that the home is kept clean and hygienic throughout and systems are in place to control the spread of infection and to consult an officer of the local Environmental Health Department This is repeated from 28/11/06 The registered person must ensure that prospective staff references are appropriately validated and approved to work The registered person must employ domestic staff to clean DS0000010441.V342905.R01.S.doc 20/09/07 7 YA22 22 20/08/07 8. YA24 23 (2abc) 20/10/07 9. YA24 23 (2abc) 20/10/07 10 YA26 23(2)(d) 20/10/07 11. YA30 23 (2d) (5) and 16 (j)(k) 26/10/07 12 YA34 19 20/09/07 13 YA33 18 (1)(a) 20/09/07 Page 27 Friern Residential Care Home Version 5.2 the home and to review the number of staff on each shift so that an adequate of staff are employed to work in the home and they are appropriately deployed to undertake their caring roles and responsibilities. Staff on duty must reflect the cultural/gender of service users 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 YA10 Good Practice Recommendations It is recommended that the home invest in computerised systems for the home to prevent the use of a staff member using their own personal computer to develop the homes systems associated with running the business, so that the potential for breaching confidentiality in respect to staff and the people who use services are not compromised under the DATA Protection Act 1998 It is recommended that a structure of the business organisation is forwarded to the Commission to provide clarity in respect to the ethos, leadership and management of the home. The use of a cupboard as an office is not acceptable under the Health & Safety at Work etc Act 1984 2 YA38 Friern Residential Care Home DS0000010441.V342905.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Friern Residential Care Home DS0000010441.V342905.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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