Care Home: Franklyn Lodge 71a District Road

What the care home does well The organisation has systems in place to ensure that any prospective residents` needs are appropriately assessed before the home accepts the resident. Staff have worked in the home and for the organisation for a number of years. They are familiar with the needs of the residents and the approach to take to meet the needs of the residents. Residents have the opportunity to engage in recreational and social activities that they enjoy and want to take part in. Appropriate activities are provided and residents receive the appropriate level of support for them to have the lifestyles that they desire. The home is a small-detached bungalow and provides a homely, warm and personalised environment for the residents. They seemed relaxed and contented. One resident said that he was very happy to live in the home. The home provides staff in adequate numbers to meet the needs of the residents. Staff have been in post for some time and ensure continuity of care. Appropriate training is offered to members of staff to make sure that they are able to care for the residents. More than 50% of the staff are trained to NVQ 2 or above. What has improved since the last inspection? People who are referred to the home for admission can be confident that their needs` will be assessed comprehensively and care plans will be drawn up with their or their relatives/friends` involvement to address all their needs, including the mental health needs. Once admitted to the home residents receive a copy of the home`s contract/statement of terms and conditions to make sure that residents and their relatives/friends are aware of their rights and obligations. Care plans are on the whole kept updated every six months or when required although there may be a slight delay in this process. We found that updated care plans were not available on the second day of the inspection. These were available on the third day. Risk assessments are in place in cases where residents are being supported to develop independent living skills and independence. The risk assessments are not always reviewed six monthly or when changes occurred. Minor issues, which were noted with the environment during the last inspection, have been addressed to make the home safer and a nicer place for residents. What the care home could do better: Three requirements from past inspections are repeated in this report and there are five new requirements. The home did not have an updated service users` guide available for inspection. It was therefore not possible to confirm whether this document has been reviewed and updated. For example service users` guide must now include information about the range of fees that are charged by the home. This is required to make sure that people who are referred to the service have enough information to make a decision about moving into the home. While care plans are on the whole comprehensive and reviewed six monthly, risk assessments are not always reviewed six monthly and updated as required. Medicines management is generally good. One serious issue was noted which must be addressed. This involved changes in the doses of medicines. When these are noted, these must be confirmed with the GP to make sure that residents are not being put at risk. A duty roster must be available for inspection at all times as this is a legal requirement, to enable a person looking at this record make a judgementabout the staffing level in the home and identify the member of staff who should be on duty. The home does not have a quality management system to evaluate the quality of the service that it provides. Monthly visits as per regulation 26 of the Care Homes Regulation 2001 are also not carried out regularly. These issues must be addressed to make sure that the quality of the service is being effectively monitored. The home did not have an updated health and safety risk assessment and fire risk assessment. An emergency fire plan was also not available for inspection. These must be addressed to ensure the safety of residents. CARE HOME ADULTS 18-65 Franklyn Lodge 71a District Road Franklyn Lodge 71a District Road Wembley Middlesex HA0 2LF Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 6 , 14 and 25th February 2008 09:45 th th Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Franklyn Lodge 71a District Road Address Franklyn Lodge 71a District Road Wembley Middlesex HA0 2LF 020 8902 5205 020 8903 9860 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Residential Care Services Ltd Ms Margaret Avan-Nomayo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Franklyn Lodge belongs to Residential Care Services Ltd, a private company, based in Brent specialising in providing personal care, and accommodation for younger adults with learning disabilities in care homes. The home is located in a residential area of Sudbury. There are some shops about five minutes walk from the home. The home is accessible by public transport, which is available on the main road, a few minutes walk away from the home. There is a driveway in front of the home with parking for one to two cars. Additional parking is available on District Road, which does not have parking restrictions. The home is a detached bungalow, with most of the accommodation on the ground floor. The attic is used for storage. There are three single bedrooms (one with en-suite toilet and wash hand basin), a through lounge/dining area, a bathroom with a bath and shower and a kitchen. There is a paved area in front of the home with wheelchair access and a garden at the back and a patio, which can be reached from the lounge/dining area. At the time of the inspection there were two residents in the home, who were both funded by Local Authorities. The fees paid were therefore those that are paid by the Local Authorities. More information about fees can be obtained by contacting the manager. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This report contains the findings of the key inspection for the period 20072008. The inspection started on Wednesday 6th February from 09:45-10:05, continued on Thursday 14th February from 15:20 to 17:20 and finished on Monday 25th from 14:10-16:10. The first and the second days were unannounced and an appointment was made with the manager for the last day of the inspection. During the course of the inspection we were able to tour some of the premises, look at some of the records kept in the home and talk to the residents in the home and the manager and two members of staff. An Annual Quality Assurance Assessment (AQAA) was carried out by the service and sent to the Commission. This was used where possible in writing this report. We would like to thank the residents for a kind welcome into their home and the manager and her staff for the support and cooperation during the course of the inspection. What the service does well: The organisation has systems in place to ensure that any prospective residents’ needs are appropriately assessed before the home accepts the resident. Staff have worked in the home and for the organisation for a number of years. They are familiar with the needs of the residents and the approach to take to meet the needs of the residents. Residents have the opportunity to engage in recreational and social activities that they enjoy and want to take part in. Appropriate activities are provided and residents receive the appropriate level of support for them to have the lifestyles that they desire. The home is a small-detached bungalow and provides a homely, warm and personalised environment for the residents. They seemed relaxed and contented. One resident said that he was very happy to live in the home. The home provides staff in adequate numbers to meet the needs of the residents. Staff have been in post for some time and ensure continuity of care. Appropriate training is offered to members of staff to make sure that they are able to care for the residents. More than 50 of the staff are trained to NVQ 2 or above. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Three requirements from past inspections are repeated in this report and there are five new requirements. The home did not have an updated service users’ guide available for inspection. It was therefore not possible to confirm whether this document has been reviewed and updated. For example service users’ guide must now include information about the range of fees that are charged by the home. This is required to make sure that people who are referred to the service have enough information to make a decision about moving into the home. While care plans are on the whole comprehensive and reviewed six monthly, risk assessments are not always reviewed six monthly and updated as required. Medicines management is generally good. One serious issue was noted which must be addressed. This involved changes in the doses of medicines. When these are noted, these must be confirmed with the GP to make sure that residents are not being put at risk. A duty roster must be available for inspection at all times as this is a legal requirement, to enable a person looking at this record make a judgement Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 7 about the staffing level in the home and identify the member of staff who should be on duty. The home does not have a quality management system to evaluate the quality of the service that it provides. Monthly visits as per regulation 26 of the Care Homes Regulation 2001 are also not carried out regularly. These issues must be addressed to make sure that the quality of the service is being effectively monitored. The home did not have an updated health and safety risk assessment and fire risk assessment. An emergency fire plan was also not available for inspection. These must be addressed to ensure the safety of residents. 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. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 9 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): 1,2 and 5 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents receive enough information about the service to decide if they want to live in the home. The home makes sure that the needs of all prospective residents are assessed prior to a place being offered to them. EVIDENCE: The home has not had any new residents since the last inspection. The two residents who were in the home had copies of the service users’ guide (SUG) in their care files. An updated copy of the SUG was however not available in the home for inspection. It was therefore not possible to check whether the service users’ guide has been amended to contain information about the range of prices that the home charges. There was an admission policy in the home’s policies and procedures manual. In the past admission of new residents to the home has been carried out appropriately and there are no reasons why this should not happen in the future. Residents are normally supported through the decision process of moving into the home by the provision of appropriate information and by the home offering the opportunity to prospective residents and their relatives to visit the home. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 10 A copy of the home’s contract/statement of terms and conditions was available in each of the residents’ files and was written in an easy to read format. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plans are detailed and include the action to take to meet the needs of the residents. Risk assessments are in place for each resident but these are not always reviewed and amended as required to reflect changes in residents’ circumstances. EVIDENCE: The care plans of both residents were inspected on the second day of the inspection. These were kept in a filing cabinet. The care plans were printed and were easy to read. These were comprehensive and covered the needs of residents and the action to take to meet these. There was evidence of the involvement of residents and/or their relatives in drawing and reviewing the care plans even if they do not always sign that they have agreed to these. The care plans were discussed in external review meetings as well as in internal review meetings where residents and/or their relatives were present. Minutes were kept about these meetings. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 12 On the second day of the inspection the care plans were dated June 07 and needed to be reviewed in December 07, but had not been reviewed. On the third day of the inspection the updated care plans were in place. These could however have been more individualised. For example they addressed the management of a female issue when both of the residents are male. Care plans addressed the religion, culture and ethnic background of the residents. Plans were in place to support residents, and staff were on the whole knowledgeable about the needs of residents in regards to these aspects of the life of the residents. The manager stated in the AQAA that ‘staff will undergo more regular equal opportunity training’. Each resident had a key worker. Records were available about meetings with the key worker and residents to discuss progress with regards to implementation of the care plan. There were a number of risk assessments in the care records of residents, which dealt with the promotion of living skills, and independence of residents while maintaining their safety. For example these covered the risk of absconding, use of public transport, access to hot water, use of the bath, use of the kitchen and shopping. We however noted that the risk assessments for one resident were drawn in September 2005 and for the second resident in December 2005. These have not yet been reviewed. While some of the risks were current there were some, which needed to be reviewed such as the risk of absconding for one resident. Areas for improvement could include supporting residents to make decisions in their daily lives. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 13 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): 11-17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead a lifestyle according to their preferences and needs within a risk assessment context. EVIDENCE: Residents’ social and recreational needs are assessed and activities that they enjoy doing are identified and recorded. The residents are supported in maintaining the lifestyles that they desire. During the inspection we observed that the residents were offered the opportunity to engage in the activities that they enjoy. One normally enjoys reading the papers and the other enjoys watching TV. Both residents are supported to attend the day centres. One resident said that he enjoys going there to meet other people. They each have a key worker at the day centre, who supports them with activities and with opportunities for learning. Report about progress at the day centre is also provided to the annual review of the needs of the residents. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 14 Residents are able to engage in the local community. One resident stated that he enjoys going for drives with his friend. Members of staff said that the other resident enjoys going for walks. The residents do not go alone in the community and are accompanied by members of staff for their own safety. The home also supports residents in maintaining links with their friends and relatives. Relatives and friends can visit residents in the communal areas of the home or in the bedrooms of residents. Residents also go out with their friends and relatives. The residents have not been for holidays, but this is a matter of preferences and needs rather than the opportunity not being offered to residents. The residents seem to be quite comfortable in the home and one said that he is used to life in the home and does not like change. Meals are provided mostly on an individual basis for residents due to the different tastes of each resident. The provision of meals also takes the cultural background of the residents. One resident who spoke to us said that he was satisfied with the meals that he receives. There is a menu in place in the home. The likes and dislikes of residents are on the whole recorded in the care plans and records of meals that are provided to residents are also kept. Residents receive a meal in the day centre for lunch if they wish to. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are met to a good standard. Medicines management in the home was generally good but records must be kept about changes in the doses of medicines to make sure that this safe for residents. EVIDENCE: We noted that residents were offered support with their activities of daily living where required. Areas of support are identified in the individual care plan of the resident. Staff recognise that residents are able to manage some tasks and they therefore encourage residents to engage in these tasks/activities. We observed staff supporting a resident with mobilising to make sure that the resident was safe. Support by staff is offered to residents in a discreet manner while respecting residents’ rights for privacy and dignity. Residents are encouraged to choose their own clothes and to participate in their personal care. The manager reported how a resident was supported to make choices and buy his clothes. The care plans showed that residents are Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 16 supported with baths and shaving where required. On all the three days of the inspection residents presented as appropriately dressed and groomed. The care records of residents contain information about their healthcare needs and the input of various healthcare professionals in the care of the residents. There was evidence that staff supported residents with their out patient appointments and with their appointments with the GP and other healthcare professionals such as the optician, dentist and chiropodist. Medicines management in the home was inspected. Medicines were generally signed when received in the home except for a few medicines. These were mostly for medicines, which were prescribed to be given when required. The amounts of these medicines should also be brought forward on a new medicines chart at the end of a medicine cycle, to audit trail the amount of the medicines. On one occasion the dose of a medicine seemed to have been changed as the amount of the medicine in the dossette box was different from what should be in there, as per the instructions in the medicines chart. On the 14th February, the medicine was not in the dossette box for the morning dose even though staff have been signing for it. The medicine seemed to have been omitted for the morning dose for the rest of the week. This was pointed out to the person in charge at the time. On the 25th February when we visited the home again, there was no update regarding this matter. We were informed that the GP had contacted the chemist to alter the dose, but there was nothing in the home to evidence the change in dose. The manager stated that she has been trying to get that information from the chemist and GP. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home takes complaints and allegations of abuse seriously and there are systems in place to make sure that residents are protected from abuse. EVIDENCE: The complaint procedure was available in the foyer of the home and in the service users’ guide. It is available in an easy to read format. There were no complaints in the complaints register of the home. One resident said that he would talk to the manager if he had any concerns. Training records showed that staff have received training on safeguarding adults and prevention of abuse. One member of staff, who talked to us, appropriately described the action that she would take if she came across an allegation or suspicion of abuse. She was also aware of the Whistle Blowing policy of the home. None of the home’s staff act as an agent for the social benefits of residents. Residents either have relatives or friends who act in this capacity. The home however supports a resident with the management of his person money. Money is received by the home for the day to day expenditures of the resident. We cross referenced a number of expenditures and entries in the records and noted that records for transactions were appropriately made and that receipts were kept for all expenditures. The other resident only kept a small amount of money in the home mostly for pocket money. Franklyn Lodge 71a District Road DS0000017442.V354169.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 and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, warm and clean environment, which enhances their quality of life. EVIDENCE: The outside of the home was in keeping with the time of the year. The grounds in the front and at the back of the home were maintained. The lawn, shrubs and trees looked trimmed and tidy. The exterior of the building also looked in an appropriate condition. The home was warm and clean on all the days of the inspection. There was a slight odour on the first and third day of the inspection in the lounge area, the origin of which was unclear. Since the last inspection the bathroom has been retiled, the flooring in the kitchen has been replaced and the loose paving slabs at the back of the home have been re-pointed. The flooring in the bathroom now needs replacing, as there were holes in it. The provider should also consider having a plan to Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 19 address the long time redecoration of the home, as it is possible that the home may need redecoration soon. The communal areas were appropriately decorated and there was some pleasant furniture in the dining area. The stitching of the leather settee that is found in the lounge area was noted to be coming apart. This must be repaired or the settee must be replaced. There was a TV with SKY channels for residents’ viewing pleasure. The kitchen was appropriately equipped and was clean and tidy. The bedrooms of residents were cleaned and appropriately furnished. These were personalised with items of decoration, pictures and photos according to residents’ wishes. There were locks to the bedrooms doors but we told by staff that none of the residents wanted to use a key to keep their rooms locked. Franklyn Lodge 71a District Road DS0000017442.V354169.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): 32, 35 and 36 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides appropriately trained staff in appropriate numbers to meet the needs of the residents. EVIDENCE: The home has two residents and there is always one member of staff on duty. More staff are provided when residents have to be accompanied when they go out, such as when they go for out patient appointments. At night there is a sleep in member of staff. On the first two days of the inspection we requested current duty rosters to look at. The members of staff looked for these and could not provide them. On the first day of the inspection one member of staff found the duty rosters up to December 2007. On the third day of the inspection these were provided by the manager. However duty rosters are legal documents and must be available at all times in the home. All members of staff have worked in the home for many years and were familiar with the needs of the residents. There were no new members of staff. We noted that they communicated well with residents and that residents were also comfortable in the presence of members of staff. Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 21 As there were no new members of staff during the inspection period, we did not look at the personnel records. Each member of staff has an individual training plan. This is good practice and is commended. The training plan addresses the training needs for each member of staff. One of the areas where learning has been identified is about ‘capacity’ and the ability of residents to make decisions about their life. Training records showed that members of staff have a range of training including fire training, first aid training and abuse training. Three out of the five members of staff have at least an NVQ level 2 qualification or above in care. There was evidence of some supervision sessions between the manager and members of staff, but there was no evidence to show that staff were receiving supervision at least six times a year or once every two months. Staff confirmed that they have supervision but not always every two months. Franklyn Lodge 71a District Road DS0000017442.V354169.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager runs the home in an open and inclusive manner for the benefit of the residents. The home has a quality assurance procedure. It however does not have effective quality control systems to evaluate the quality of the service. Health and safety issues are generally addressed in a timely manner but a few issues were not addressed as required to ensure the safety of people who use the service. EVIDENCE: The manager has worked in the home prior to the inception of the Commission. She has a degree in social work and an advanced certificate in managing health and social care. On the whole she is familiar with the issues and aspects of running a care home and with the needs of residents. She runs the home in an open and inclusive manner. There are 3-4 monthly staff meetings and residents’ meetings, minutes of which were available for Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 23 inspection. Staff stated that they always make an effort to attend the staff meetings. The home has a quality assurance procedure. It says, “The system (quality management system) will be based on Total Quality Management System whereby standards will be set changes made to meet those standards and the process reviewed regularly”. On this occasion we could not see the standards that have been set and the audits/assessments to measure/assess the service against the standards. There were no audit results available for inspection. Regulation 24 of the Care Homes Regulation 2001 as amended in 2006 requires that the home have a quality management system to evaluate the quality of the service. The quality assurance procedure also mentions that the home will have an annual development plan. One was not available for inspection. The home has satisfaction questionnaires but we were informed that the residents and the relatives do not always complete these and that the response is not that good. Reports were available following the monthly monitoring visits as per regulation 26 of the Care Homes Regulations 2001 but the latest one was dated October 2007. The home completed the AQAA, which was sent in the beginning of October by the Commission. This was not completed on time and a reminder letter had to be sent. The AQAA was received at the end of November. On the whole it was completed appropriately and gave a reliable picture of the service. The home had a health and safety risk assessment, which was last reviewed in January 2006. The fire risk assessment was also not up to date and the home did not have an emergency fire plan as per the Regulatory Reform (Fire Safety) Order 2005 which came into force in October 2006. The fire and health and safety risk assessments were up to date during the last key unannounced inspection in September 2006 but these have not been reviewed since then. A gas safety certificate, portable appliances test certificate and an electrical wiring test certificate were available for inspection. There was evidence of two weekly fire detector tests when staff also performed a fire drill. There was no testing of the emergency lights by staff in the home except when the service contractor visited the home. The service contractor was also responsible for the maintenance of the fire fighting equipment and the fire detector system. It is recommended that emergency light tests be carried out monthly. Franklyn Lodge 71a District Road DS0000017442.V354169.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Franklyn Lodge 71a District Road DS0000017442.V354169.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 OP1 Regulation 5 Requirement Timescale for action 30/04/08 2 YA9 14(2) 3 YA20 13(2) 4 YA24 23(2)(b) There must be an up to date service users’ guide available for inspection. This must contain information about the fees that are charged by the home. This is required to make sure that people have enough information about the service to make an informed decision about moving into the home. Risk assessments must be 31/03/08 reviewed at least every six months or when the condition of residents changes and must be agreed with the residents/representatives (Previous requirementTimescale of 31/01/06 and 31/10/06 not met). Any changes in the medication 31/03/08 regime of residents must be confirmed by the GP as soon as possible to make sure that the correct residents’ medication regime is being adhered to for the safety of the residents. That the following, in reference 30/04/08 to the environment and building, is attended to: DS0000017442.V354169.R01.S.doc Version 5.2 Franklyn Lodge 71a District Road Page 26 • • Replace/repair flooring in the bathroom. Repair/replace the settee where the stitching is coming undone. 5 YA36 18(2) This is required to make sure that the home continues to provide a high quality environment for the residents. The registered person must ensure that members of staff have supervision six times a year or once every two months. The registered person must ensure that there is an effective quality management system in place. Satisfaction surveys must be carried out and the result/report must be produced outlining the outcome of the survey (Repeated requirement-timescale 31/12/06 not met) The home must also have an annual development plan. There must be an up to date health and safety risk assessment in the home to make sure that people who use the service are not being placed at unnecessary risks. The registered person must ensure that a Fire Emergency Plan is in place in the home (Repeated requirementtimescale 31/01/06 and 31/10/06 not met). It must also have an up to date fire risk assessment. This is required to make sure that people are safe on the premises. 30/04/08 6 YA39 24(1) 30/04/08 7 YA42 13(4) 30/04/08 8 YA42 13(4), 23(4) 30/04/08 Franklyn Lodge 71a District Road DS0000017442.V354169.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA20 Good Practice Recommendations Care plans should be individualised to make sure that these reflect the individual needs of the residents. That a record is made of the amounts of medicines received into the home, which are to be used as required, to facilitate audit of the medicines. To make sure that the emergency lights are working appropriately these should be tested monthly and records should be made about these tests. 3 YA38 Franklyn Lodge 71a District Road DS0000017442.V354169.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. 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