CARE HOMES FOR OLDER PEOPLE
The Franklyn (Fezdene Ltd) 25 Easby Drive Ilkley LS29 9AZ Lead Inspector
Nadia Jejna Unannounced Inspection 3rd February 2006 11:30 X10015.doc Version 1.40 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 The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 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 Older People. 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. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Franklyn (Fezdene Ltd) Address 25 Easby Drive Ilkley LS29 9AZ 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) 0207 232 2768 Fezdene Limited Mrs Kathleen Fenech-Soler Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (1) of places The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: The Franklyn is a converted, extended property situated in the residential area of Ilkley. The home is within walking distance of the town centre and shops. It is close to local bus routes and is within easy reach of a railway station and the main roads to Leeds, Bradford and Skipton. The home provides personal care with nursing for up to twenty-four elderly service users of both sexes. Accommodation is provided in a combination of twenty single and two double bedrooms, none of these rooms having en-suite facilities. The registered provider has said that one of the double rooms will be used as a single room. Service users have a choice of three lounges. There is a dining room on the lower ground floor. There is an attractive and easily accessible garden area. This has been equipped with garden furniture. Views of the surrounding areas can be enjoyed from the gardens as well as some of the lounges and bedrooms. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. The last inspection was unannounced and took place on the 2nd September 2005. This inspection was unannounced and carried out over two days. It started at 11:30am and ended at 6:00pm on 3rd February 2006. It was completed on 15th February with a visit lasting four hours when feedback was given to the deputy manager and the responsible individual. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress and to assess whether the care given to residents meets minimum standards. The responsible individual had completed a pre inspection questionnaire (PIQ), which provided information about the home including maintenance schedules, staff details, training given and policies and procedures. During the inspection records were looked at and care staff were seen carrying out their work. Discussions were held with staff, residents and visitors. Comment cards/questionnaires were left for residents and visitors so that they can share their views of the home with the CSCI. None had been returned when this report was written. What the service does well: What has improved since the last inspection?
The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 6 Residents and visitors said that standards of care provided in the home continued to be of a good standard. The manager is taking extended compassionate leave and it is not clear when she will return. It was positive to see that the responsible individual has given the deputy manager supernumerary time in order to manage the home and providing support and advice as needed. There has been some work on the care plans to make them individual and person centred. Arrangements are in place to make sure that unused medications are disposed of safely. A new cook has been employed. New menus have been put in place and these will be changed taking residents views into consideration. Residents said that they had noticed an improvement with the meals and that the food was good. 50 of the care assistants are now qualified to NVQ (National Vocational Qualification) 2. All staff in the home are being provided with formal supervision at least six times a year and records are kept. 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 Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 Resident’s needs are met, they are treated with dignity and their privacy is maintained. Staff are aware of the residents’ needs but the care plans need to be more detailed and individual in order to fully inform staff. EVIDENCE: Three care plans were looked at. It was clear that some of the nurses were moving towards individual person centred care plans. But others were not and still followed the nursing medical models, which do not provide clear detail about how to meet resident’s needs. The acting manager and responsible individual said that plans were in place to make sure that nurses received training around care planning. A key worker system is used in the home where carers are allocated to particular residents. One of the carers had a good insight into their allocated residents needs, strengths and abilities. They said that they would look at the care plans but were not involved with the care planning process. The acting manager and responsible individual said that there were plans for all staff to become involved with it. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 10 The responsible individual had arranged for unused medication in the home to be disposed of safely in line with changes in legislation. Medication administration records seen were up to date and fully completed. Residents said that staff treated them with respect and did all they could to maintain privacy and dignity. Examples given included knocking on doors and closing curtains when providing care. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 and 15 Residents’ choices are respected and contact with family and friends is encouraged. Residents said that they enjoyed the meals provided. EVIDENCE: A recent environmental health inspection of the kitchen was satisfactory. New equipment has been bought for the kitchen including a hot trolley to keep meals warm for those who do not come into the dining room, and a freezer. A new cook had been in post for four weeks and was still getting to know the home and the residents. New menus have been put in place. The cook said that she would meet and talk to the residents over the next few weeks to find out what they think of the new menus and ask them for their suggestions. Two choices of main course are provided at lunchtime and either a hot meal or sandwiches at tea time. A system of ordering meals the day before is going to be introduced. Residents said they had noticed a change for the better with the meals provided and that they enjoyed the food given to them. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 12 The care plans seen contained life and social histories, which gave a picture of the residents and what they liked to do. Some of these had been completed by the relatives. This information was then used in the social care plans to provide staff with information around how residents preferred to occupy their time. Various social activities are provided, including external entertainers and craft sessions. One of the residents was listening to a ‘talking book’. Others said that they were happy joining in with planned activities or watching television. Visitors said that they could visit the home at any time and were always made to feel welcome. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents feel safe living in the home. EVIDENCE: A complaints procedure is in place and the PIQ indicated that none have been received since the last inspection. Adult protection policies and procedures are in place along with a copy of the local authority adult protection procedures. Records seen showed that some staff had attended training sessions about adult protection that had been provided by the local authority adult protection unit. The deputy manager said that plans were in place to make sure that all staff received appropriate training about abuse awareness. Residents said that they felt safe in the home and that the staff were kind. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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 The home is well maintained. EVIDENCE: Major works on the exterior of the building are due to start in February. Bedrooms are being redecorated as they become empty. Large items of equipment have been purchased including three pressure relieving mattresses, a height adjustable bed and new armchairs for the lounge areas. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. Appropriate training programmes are in place but not all staff are willing to attend planned sessions. There is a risk that not all staff will be competent to do their job. EVIDENCE: No care staff or nurses have appointed since the last inspection. But steps have been taken to make sure that all required checks and information is in place for existing employees. The application forms seen did not request a full employment history. The responsible individual said that this would be rectified and that they were considering asking for copies of the persons CV to be provided. Training records are kept. These showed that some aspects of training had been provided and updated as required to some of the staff. This included training around maintaining the health, safety and well being of staff and residents as well as specialist needs of residents such as dementia. The responsible individual and the deputy manager said that plans are in place to make sure that all staff received required training but there have been problems in past when training sessions have been booked and staff have failed to attend. They said that appropriate action will be taken to remedy this. The PIQ indicated that of the ten care assistants employed five have achieved NVQ 2. One of the carers said that they were working toward this qualification and they enjoyed learning new things.
The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 16 The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The home is being well managed and run in the best interests of residents. EVIDENCE: The manager is taking extended compassionate leave and it is not clear when she will return. The responsible individual has notified the Commission and the deputy manager is acting as the manager and been given supernumerary time to do so. The responsible individual is providing support and advice as needed. Survey forms have been sent out to residents and their relatives. The deputy manager will collate the results and make them available to all interested parties when enough have been returned. The home does not act as agent or appointee for any of the residents. They will hold money in safekeeping for residents and appropriate records are kept.
The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 18 The training records showed that formal supervision has been given to staff at least six times a year. Staff confirmed this. The deputy manager has received training in order to provide supervision. It is recommended that this be made available to other staff who provide supervision. The PIQ showed that the health and safety executive had recently carried out an inspection of the home and that no requirements had been made. It also showed that regular maintenance and servicing checks are carried out on all gas and electrical appliances and installations. Accident records were seen. These showed that they would benefit from additional information, including the time the accident victim was last seen and by whom, details of the accident, any treatment given and the outcomes of the accident. The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 Requirement Work towards making sure that the care plans provide clear detailed information on how to meet individual residents needs must continue. Staff records must show that a full employment history was obtained as part of the application process. Steps must be taken to make sure that all staff receive training in order to maintain the health, safety and well being of themselves and residents and to meet the needs of residents living in the home. The manager must achieve a management qualification equivalent to NVQ 4. The results of the quality assurance survey must be made available to interested parties when ready. Timescale for action 30/07/06 2 OP29 19 30/05/06 3 OP30 18 30/08/06 4 5 OP31 OP33 9 24 01/04/07 30/07/06 The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 21 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 OP7 Good Practice Recommendations Staff should receive training in writing care plans and appropriate systems put in place to ensure this. (This recommendation was first made in the inspection report dated 29.7.04.) The following details should be documented in either the accident record or in individual service users care plan following an accident: a)The time the accident victim was last seen before the accident and by whom. b)Clear and concise details of the circumstances surrounding the accident. c)Details of any treatment given and observations made. If head injury is suspected neurological observations should be carried out. d)Details of any outcomes of the accident. 2 OP38 The Franklyn (Fezdene Ltd) DS0000064293.V281889.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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