Inspection on 26/09/05 for Friern Residential Care Home

This inspection was carried out on 26th September 2005.

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 15 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 12/06/07

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 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 Anthony Lewis Unannounced Inspection 09:00 26 & 29 September 2005 th th Friern Residential Care Home DS0000010441.V249426.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 Friern Residential Care Home DS0000010441.V249426.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. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Friern Residential Care Home Address 26-30 Stanford Road Friern Barnet London N11 3HX 020 8368 6033 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.V249426.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One exception for over 65 years Date of last inspection 7th January 2005 Brief Description of the Service: Friern Residential Care Home is a private care home, which opened in 1998 and is registered to provide care to eighteen adult men and women who have mental health problems. Mr & Mrs Vevegananthan Thambirajah are the registered providers and jointly own the home. Mrs Bijaye 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 are two kitchens, one of which is the main kitchen and the other for snacks. 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. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday 26th September 2005 at 9.10am and was completed at 2.55pm. A second visit was made on Thursday 29th September 2005 at 14.15pm and was completed at 17.25pm to gain access to confidential files and provide feedback from the inspection. The registered provider and registered manager were not available to assist with the inspection on 26th September and instead the senior support worker assisted with the inspection and was very helpful and understanding. The registered providers and the senior support worker were all available on 29th September. In order to gather evidence for this inspection, six residents, two relatives, one Community Psychiatric Nurse (CPN) and three members of the staff team were spoken to in private. Five residents and five staff files were viewed along with various records, safety certificates and other files and documents. One service user’s comment card was received. The pre-inspection questionnaire, which was completed by the registered manager and returned to the Commission, provided further information. An extensive tour of the home was conducted with the senior support worker. What the service does well: What has improved since the last inspection? What they could do better: Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 6 Sixteen requirements were made at this inspection, eight of them have been restated one of which was made an immediate requirement. To ensure that prospective and current residents receive correct information, the statement of purpose must be reviewed and updated. The registered providers must also produce a service users guide. The staff team must explore initiatives with residents, to motivate and empower residents to take control of their own lives and be more independent. To ensure that residents are not being overlooked and taken for granted, the staff must ensure that residents are involved in the day-to-day running of the home and are consulted about affairs within the home, especially financial affairs. To comply with health and safety rules, an alternative smoking room must be found within the home. In order to ensure that residents are receiving wholesome, nourishing and varied meals, the menu and meals prepared by the home must be reviewed, taking into account the resident’s choices and suggestions. Restrictions to residents must be agreed with the residents and recorded in their care plan. Staff must find strategies to motivate residents to access their local community. The recording on the medication sheets of the administration of medicines, or the annotation as to why the medication was not administered, needs to be improved to ensure that all the medication administered can be accounted for. In order to best meet the needs of residents and ensure their safety, all staff working in the home must receive adult protection training. The TV aerial must be replaced to ensure that residents can watch the TV properly. Most areas of the home need to be redecorated and re-furbished and repairs must be attended to once identified, to ensure that the residents live in a safe, homely and well maintained environment. To ensure the safety of residents, staff and visitors, all staff must have a Criminal Records Bureau (CRB) check and two authentic references in place prior to taking up employment in the home. To ensure that all staff have the necessary skills and experience to meet all of the needs of the residents, there needs to be a training and development plan in place. A suitable anonymous method of obtaining residents views regarding the quality of care they are receiving must be established. 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. Friern Residential Care Home DS0000010441.V249426.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 Friern Residential Care Home DS0000010441.V249426.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): 1, 2, 3, 4 and 5. Although assessments are carried out on prospective and existing residents to the home, the registered providers are not ensuring that prospective residents are provided with up to date and sufficient information to enable them to make an informed choice as to whether the home can meet all of their needs. EVIDENCE: The home’s statement of purpose was seen and although quite detailed, it needs to be reviewed and some updating is required, such as the name National Care Standards Commission (NCSC) to be replaced with the Commission for Social Care Inspection (CSCI) and for the Commissions address and telephone number to be included. The home’s service users guide could not be found when requested. A requirement is made that a service users guide is produced and a copy of the statement of purpose and the service users guide is forwarded to the Commission. On looking through three resident’s files, all contained initial assessments, prior to moving into the home, detailing health and personal care and domestic and social interests. A number of residents are not motivated enough or encouraged to participate in daily routines, such as attending day centres, accessing their local community, accessing religious and cultural activities and contributing more within the home. On talking to four residents, three explained that they do not do much within the home and one said that she did not want to go to her day Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 9 centre and another resident said that she does not like going out. Throughout the inspection, one resident, with slight mobility problems, spent most of the time in his bedroom. Some residents spent much of their time in the conservatory and two were observed wondering about the ground floor excessively. A requirement is made that the registered persons ensure that residents, the staff team and care professionals, where necessary and appropriate, review the resident’ care needs to agree on strategies for empowering them to be more motivated and independent within the home and the community. The home’s statement of purpose and brochure contains information on the eligibility criteria for admission to the home. The senior support worker stated that all prospective residents are supported to visit the home. The home does not take unplanned admissions. The three resident’s files viewed, each contained a contract and terms and conditions of residency, which was a requirement at the previous inspection. All were signed by the relevant resident. Friern Residential Care Home DS0000010441.V249426.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, 7, 8, 9 and 10. Although residents have adequate care plans and risk assessments are in place, the residents are being taken for granted by the staff. They are not being empowered to be involved in the day-to-day running of the home and are, at times, left to their own devices with little physical and mental stimulation. EVIDENCE: At the previous inspection a requirement was made that a daily record is kept of each residents progress. On looking through four resident’s files, each contained a brief daily record of the resident’s progress. The home has produced a policy and procedure document for the management of resident’s money and financial affairs, as was a requirement from the previous inspection. The home has in place a quality assurance questionnaire for residents however, when spoken to, a resident said that although the staff do ask what meals they would like to eat in the home, they never prepared the suggested meals. Two residents spoken to stated that they help around the house, but this appeared to be a minimal amount of help and only when asked or Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 11 prompted by staff. Many residents were observed wandering about the home or sitting in the smoking room for long periods of times, some waiting for their lunch to be prepared by the staff. Two other residents said that they do not do help out much in the house. A requirement regarding residents being involved in the day-today running of the home was made at the previous inspection and has not been fully met. This requirement is revised and restated. All of the four residents files viewed contained various risk assessments records covering various risks, such as with personal care and out and about in the community and how the risk will be managed. Resident’s personal details are kept in the office, which is kept locked when not in use. The home has a policy on confidentiality and when it may be broken. It also states that confidential information is divulged only on a need to know basis. Friern Residential Care Home DS0000010441.V249426.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, 16 and 17. Residents are confident that the staff team will support them in accessing various local community activities and to keep in touch with family and friends. The staff team are not ensuring that residents receive a balanced quality diet. There is no ingenuity in menu planning and food preparation or food purchasing. Resident’s choices and suggestions are being disregarded, which does not empower the residents. EVIDENCE: The senior support worker stated that none of the residents work in paid employment, although one does part time voluntary work. The senior support worker went on to say that some residents are at college studying various courses such as computing, art and English. Resident’s care plans contained some information on resident’s daily activities. The senior support worker said that residents regularly go to the local shops to buy items such as daily papers and cigarettes. She went on to say that residents access the local pubs, cinema, restaurants and swimming baths. Two residents were spoken to regarding what leisure activities they engage in. One Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 13 said that she goes for a walk every day. Another resident said that he goes on bus rides. On the day of the inspection, residents were observed coming and going from the home independently. However, there were some residents who had minimal outdoor leisure activities. Discussions with two residents and the senior support worker revealed that some residents lack motivation, this was corroborated when the Community Psychiatric Nurse (CPN) was spoken to. Two residents spoken to said that they did not go out into the community much. A requirement is made that the registered persons ensure that a review of resident’s social and domestic care needs is undertaken. On the tour of the home, one resident was spoken to, at his request, in his bedroom. On his bedroom walls were various paintings and sketches done by him, one was a self-portrait. He said that art was his hobby and that he enjoyed painting. Another residents spoken to said that he enjoyed embroidering. Another residents said that she enjoyed music and dancing. The senior support worker produced information on a recent trip to Clacton seaside by most of the residents and some of the staff. On the day of the inspection, one resident’s sister and brother-in-law made an unannounced visit to see him. All three were spoken to regarding visits to the home. The sister said that they were able to visit the home at any reasonable time. The same resident goes to his sister’s house most Saturdays and sometimes on a Sunday. The senior support worker stated that the registered providers are still considering an alternative smoking room for residents, which was a requirement at the previous inspection. This requirement is restated. The menu for this week and the previous week was viewed. Although the current week’s menu showed a variety of meals, there is a lack of ingenuity, the breakfast menu is the same each day, cereal, toast, jam and porridge. Many of the meals are meals that are taken from a packet and warmed or cooked in the oven. There is a lack of substantial cooking taking place in the home by the staff and residents. On closer inspection of the current week’s menu, which was written by a support worker on the morning of the inspection, it was identical to the previous weeks, which showed a lack of ingenuity and no consultation or inclusion of all of the residents. One resident spoken to said that he is receiving a salad for dinner most nights of the week and does not want as many salads anymore. When spoken to his sister reiterated this. Another resident said that she did not like the foods the home prepares and wants something different. A resident indicated, on her comment card, that she did not like the food in the home. A discussion was had with the registered persons regarding the serving hatch from the kitchen to the dining room, where residents queue for their meals. The registered persons agreed that residents will, in future, sit at the table and be served by a member of staff, who will take food from the person in the kitchen through the hatch and serve to residents sitting at the table. A requirement is made that the Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 14 registered persons ensure that a review of food purchasing and food preparation takes placed and is recorded. On touring the home, there are two kitchens, a main one and a general one for preparing light snacks. The main kitchen door has a sign stating what times it is open to residents. A requirement is made that any restrictions to residents within the home are agreed upon with the residents as to the reasons and recorded in each residents care plan. The general kitchen was quite empty of foods, including snacks. Although a review has been carried out regarding menu planning and snacks, it is clearly not being followed. Residents are not being consulted regarding menu planning. A resident said that although asked, the staff never cooks what they, the residents suggest and variety and choices are not being adhered to. A requirement at the previous inspection that the meal arrangements be reviewed is restated and revised to include that the registered persons must ensure that residents are consulted and that their choices included on the menu. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 15 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, 20 and 21. Some of the resident’s wishes and their physical and emotional needs are being met however the staff team are not ensuring that resident’s medication administration is recorded correctly, this puts residents at risk. EVIDENCE: All of the residents are independently mobile, although one resident has some slight mobility difficulties. Residents independently do their own personal care, although, according to the senior support worker, some may need prompting and support from staff at times. The home’s accident book was viewed. All accidents are being recorded correctly. On looking through three resident’s files, all contained information regarding medical appointments. The Community Psychiatric Nurse visits the home regularly to administer some resident’s medication and to give emotional support where needed. He was at the home on the day of the inspection. All of the Medication Administration Records (MAR) sheets were viewed. There were some gaps in the administration sheets where the administration of medication has not been signed for or non-administration coded as to the reason for the non-administration. The gaps were found for administration at various times of the day. Resident’s medication was checked and found to have been administered. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 16 There was also “Tipp-ex”, correction fluid being used on a number of (MAR) sheets. A requirement is made that the registered providers ensure that staff follow the correct procedures when recording information on the (MAR) sheets and that “Tipp-ex” is not used on the (MAR) sheets. The home has a covert policy for medication, which is disguised. In the three residents files viewed, all contained their funeral wishes in the event of their death. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 17 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 and 23. The staff team have ensured that all complaints are taken seriously and that policies and procedures are in place to deal with complaints. However, the registered persons are not ensuring that all staff are receiving adequate training to enable them to support residents with any incidents of abuse. EVIDENCE: The home’s complaints record book was viewed and contained information on complaints, as was a requirement at the previous inspection. The complaints record book contained details on the complaint, the action taken by the staff and the outcome of the complaint. The senior support worker stated that a resident has been missing from the home since Saturday 17th September 2005. She went on to say that all of the relevant parties and authorities have been informed, including the police and the Commission. Later in the day the senior support worker received a call to say that the resident was found and was safe. The registered persons have ensured that the home’s policy and procedure regarding adult protection contains information regarding the local authority and the Department of Health’s guidance, “No Secrets” as was a requirement at the previous inspection. However, not all of the staff team have received adult protection training, as was part of a requirement at the previous inspection. A requirement is made that all staff working in the home receive adult protection training. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 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 and 30. The registered providers are not ensuring that residents live in a tidy, comfortable and homely environment. They have allowed the décor of the home in most areas, especially resident’s bedrooms, to become worn drab and dated and are not ensuring that old or dated furniture is replaced. Which gives a negative image of the home. EVIDENCE: While touring the home, many areas were found to be in need of redecorating and refurbishing. For instance, some of the walls in the hallways were a little worse for wear. They were worn and drab looking. Many of the resident’s bedrooms contained the bare minimum, which were old and worn. One resident was sleeping on two mattresses, one of which was quite stained. The kitchens were bare and dull and the lounge and conservatory are basic. The lino in the kitchen was loose and part of it was missing, making it possible for a person to trip on it. The senior support worker stated that the lino had been identified to be replaced or repaired. The carpet in the lounge was badly stained from spillages. At the previous inspection, a requirement was made that a timetabled programme of redecoration of the home be submitted to the Commission. Although the home has a record of maintenance and decorating, which shows some work has taken place to re-decorate areas of the home, many areas have been neglected, with no timetable of if and when the work Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 19 will take place. This requirement is restated. Four identified areas for repair were identified at the previous inspection. Three of the four areas have been repaired and one, the TV aerial in the lounge/conservatory, is still not repaired. This requirement is revised and restated. On the tour of the home, it was found to be reasonably clean with adequate facilities for residents and staff to wash their hands. The laundry room has a washing machine with a sluicing programme. The home has a cleaner and according to the home’s legionnaires disease policy and procedure. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 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, 34, 35 and 36. Although staff working in the home are receiving regular supervision and are reasonably qualified, robust recruitment practices are not taking place and residents, staff and visitors are being put at risk. EVIDENCE: Three members of the staff team were spoken to individually in private in the office. One said that she is doing the National Vocational Qualification (NVQ) level 3 and the other has said that she has completed the (NVQ) level 2 and has begun the (NVQ) level 3. Two staff said that they have not undertaken the protection of vulnerable adults training as yet. Three staff files were viewed, all but one member of staff had a copy of their Criminal Records Bureau (CRB) check in place. This was a requirement at the previous inspection. An immediate requirement was made that the registered persons ensure that all staff working in the home has a CRB. Also of the three files viewed, one member of staff did not have two appropriate references in place. One of the references was dating back to 1977, even though the member of staff did not work in the home until 1990. A requirement is made that the registered persons ensure that the identified member of staff obtains an appropriate reference. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 21 The deputy manager’s file was viewed and although he has undertaken many training courses and the certificates were on file, on closer inspection, some of the certificates dated back to the early 1990s and were out of date. The registered persons were required, at the previous inspection, to draw up a staff training and development plan. This has not been completed and is restated. The registered persons have now begun ensuring that staff receive regular recorded supervision, although this has only begun quite recently. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 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): 39, 40, 42 and 43. Although the registered providers and the staff team have the skills and experiences to manage the home, residents do not have an appropriate method of giving their views as to the quality of care that they are receiving, which does not ensure that the quality of care is continually monitored and improved. EVIDENCE: The registered providers have produced a quality management policy and procedure, as was a requirement at the previous inspection. They have also produced a quality management questionnaire. The questionnaire covers most areas of resident’s social and domestic care needs. However, the registered persons are not using a suitable method of obtaining anonymous feedback and independent support to complete the quality management questionnaire. A requirement is made that the registered persons a method of obtaining residents views is established, with support from an independent individual where possible. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 23 The home has a number of policies and procedures, which are kept in the office. Policies relating to resident’s finances and quality assurance are now in place, as was a requirement at the previous inspection. The registered providers have produced a premises risk assessment and management as was a requirement at the previous inspection. The homes safety certificates and other files and documents were viewed. The London Fire and Planning Authority LFEPA visited the home on 28th August 2004 and identified three contraventions. The registered persons have met all three of the contraventions. All other certificates and documents such as fire safety tests, portable appliances test, gas certificate, water tests, heating and employee’s liabilities were in order and up to date. The home has adequate insurance cover in place and the registered providers have produced a business plan, as was a requirement at the previous inspection. The business plan contains information on location and assets, operational costs, marketing strategies consultants and professional advisors and the market and the future, although there are no actual financial figures available. The registered manager said that the home is financially viable. Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 1 3 3 Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 1 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 1 17 Standard No 31 32 33 34 35 36 Score X 3 X 1 1 3 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Friern Residential Care Home Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score x x 2 3 X 3 3 DS0000010441.V249426.R01.S.doc Version 5.0 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 YA1 Regulation 5 (1)(a-c) (2 6(a-b) Requirement The registered persons must ensure that the home produces a service users guide and that a copy is forwarded to the Commission. The registered persons must ensure that a review of resident’s social and domestic care needs is undertaken. The registered persons must ensure that residents are consulted with regards to the day-to-day running of the home and a record kept of any such consultation. (Timescale of 01/04/05 not met). This requirement is amended and restated. The registered persons must ensure that residents are motivated to participate in activities in their local community and in all other aspects of their lives. The registered persons must ensure that an alternative smoking room is found and that residents are consulted about the arrangements. Timescale for action 28/10/05 2 YA3 (16)(2) (m)(n) 27/01/06 3 YA8 24 25/11/05 4 YA13 12(3)24 (1)(a,b) 27/01/06 5 YA16 23(2a) 27/01/06 Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 26 6 YA17 16(2h,i) 7 YA17 16(h,i) 8 YA20 13(2) 9 YA23 13(6) 10 YA24 23(2,c) 11 YA24 23(2,d) (Timescale of 01/05/05 not met). This requirement is restated. The registered persons must ensure that a review of food and meal provisions is carried out and that the residents are consulted and suggestions and choices included on the menu. (Timescale of 01/03/05 not met). This requirement is revised and restated. The registered persons must ensure that any restrictions to residents within the home are agreed upon with the residents as to the reasons and recorded in each residents care plan. The registered persons must ensure that the administration of all medicines is signed for on the (MAR) sheets and any nonadministration coded as to the reason why the medication was not administered. “Tipp-ex” must not be used on the (MAR) sheets. The registered persons must ensure that all staff receive adult protection training. (Timescale of 01/03/05 not met). This requirement is revised and restated. The registered persons must ensure that the TV aerial in the lounge/conservatory is repaired. (Timescale of 01/03/05 not met). This requirement is revised and restated. The registered persons must ensure that a timetabled plan for the redecorating and refurbishing of the premises DS0000010441.V249426.R01.S.doc 25/11/05 25/11/05 07/10/05 27/01/06 23/12/05 27/01/06 Friern Residential Care Home Version 5.0 Page 27 12 YA34 13 YA34 14 YA35 15 YA39 is drawn up and a copy forwarded to the Commission. (Timescale of 01/03/05 not met). This requirement is revised and restated. 19(1,b,i)Sch The registered persons must 2(7) ensure that all staff working in the home have a CRB. (Timescale of 10/01/05 not met). This requirement is restated as an immediate requirement. 19(1,b,i)Sch(5) The registered persons must ensure that the identified member of staff has two up to date and appropriate references and a copy is forwarded to the Commission. 18(1)(c)(i) The registered persons must ensure that a training and development programme covering all staff training needs is compiled. (Timescale of 01/03/05 not met). This requirement is restated. 24(1)(a) The registered persons must (b)(2)(3) ensure that a suitable method of obtaining residents views is established, with support from an independent individual where possible. 30/09/05 07/10/05 27/01/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Friern Residential Care Home DS0000010441.V249426.R01.S.doc Version 5.0 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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