Care Home: The Franklyn (Fezdene Ltd)

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What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE The Franklyn (Fezdene Ltd) 25 Easby Drive Ilkley LS29 9AZ Lead Inspector Nadia Jejna Unannounced Inspection 8th November 2007 10:45 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.V354544.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 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.V354544.R01.S.doc Version 5.2 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) 01943 816161 01943 816165 Fezdene Limited vacant post 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.V354544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 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. Information about the home and the services provided is available in the Statement of Purpose and Service User Guide. Copies are kept in the managers office along with a copy of the most recent inspection report. Copies will be given to enquirers on request and when they visit the home. Fees charged by the home range from £ to £ per week. This information was provided in November 2007. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit started on 6th November 2007. The manager did not know that this was going to happen. A second visit was made on 16th November 2007. The purpose of this visit was to make sure that the home was being managed for the benefit and well being of the people using the service. During the visit residents, their visitors and staff were spoken to. Records were looked at such as staff files, complaints and accidents records. Before the visit was planned the provider was asked to carry out a quality assessment of the service stating what they did well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. This document is called the Annual Quality Assurance Assessment and will be referred to in the report as the AQAA. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. Questionnaires were sent to people living in the home, their relatives and healthcare professionals before the visit took place. These people were selected using information provided in the AQAA. When the visit took place surveys had been returned by one person living in the home and five relatives/visitors. The information from these was used to inform the visit and is referred to throughout the report. What the service does well: Care is provided in a clean, tidy and well maintained home. Two of the lounge areas have lovely views of the gardens and areas beyond. The grounds are attractively planted, equipped with garden furniture and provide a pleasant place to sit when the weather allows. Information from surveys, people and visitors said that: • They had been given enough information about the home. • The relative of somebody who had been at the home about six months said they were delighted with the way they had settled into the home. • The staff were kind, caring and understanding. • Visitors could call at any time and were made to feel welcome. • They were kept up to date about changes in their relative’s condition. • They said it was homely, friendly and had a lovely atmosphere. • People’s privacy and dignity was respected. • People said that the food was good and enjoyed their meals. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 6 Some 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. The home made links with the community matron who visits each week and helps staff look after people’s minor medical problems. Their own doctor is called in as and when needed for more serious illnesses. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 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.V354544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have enough information about the home to decide whether or not it will be suitable for them. The home makes sure that it can meet people’s needs before agreeing to admit them. EVIDENCE: The manager is going to revise the Statement of Purpose and Service User Guide to make sure people have got all the information they need about services provided. She said she would look at guidance available on the CSCI web site when doing this. The information for the most recent person admitted to the home showed that a pre admission assessment had been done while they were still in hospital. Their relatives had been to look round and chosen the home on their behalf. The information was detailed enough for the manager to be sure that their needs could be met by the skill mix of the staff team. Two more care plans looked at also contained pre admission assessment information. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 9 The AQAA said that eight people living in the home have some from of dementia. The manager said that this was not their main reason for needing twenty-four nursing care. She knows that the home is not a specialist dementia care home and takes this into consideration when assessing people’s needs. She has arranged training for staff about dementia so that they will be better equipped to understand and meet the needs of people in the home who have it. Information from surveys, people and visitors said that: • They had contracts for services provided, either direct with the home if they paid privately or with the local authority/health authority if fees were paid by them. • They had been given enough information about the home. • The relative of somebody who had been at the home about six months said they were delighted with the way they had settled into the home. The staff were very caring and understanding. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are met. They are treated with dignity and respect and their right to privacy upheld. EVIDENCE: The format for the care plans has changed since the last inspection. The manager said that all people have a new style care plan but that it is still a ‘work in progress’. She has given staff guidance on how to use them but it is some time since she did any training around care planning. Three care plans were looked at. It is clear that a lot of work has gone into making sure people have individual care plans. There is more work to be done to make sure they are individual to peoples needs and that all identified needs have a plan telling staff how they can the help the person. Information from healthcare risk assessments should be linked into the care plans so staff know what the risk is and what action should be followed to reduce it. For example: • The falls risk assessment for somebody showed that they were at high risk of falling but there was no care plan in plan telling staff how to reduce the risk. The manager said that the GP and district nurses had The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 11 • been involved in the persons care. She said she would contact the falls prevention team for support, advice and training for staff. The information in the care plan for an insulin dependant diabetic did not set out what the acceptable lowest and high blood sugar levels were, how to monitor which injection sites had been used and how often they were being seen by diabetes specialist nurse or doctor. The manager said that she would look at contacting a diabetic nurse specialist for advice and training for staff. She said she would nominate one of the staff as ‘link’ with the specialist nurse to get up date information for staff regularly. The community matron comes to the home each week to hold a clinic, carry out health checks and deal with minor ailments. They work closely with a local GP practice. This has been running since the last inspection and the manager said it is working very well. The deputy manager is the ‘link’ nurse for pressure area and wound care and continence. This means that she attends meetings about these subjects and brings up to date information and good practice guidance in to the home. The manager is going to talk to the nursing staff and nominate them to act as ‘link’ nurses for end of life care, falls and diabetes. ‘End of life’ care plans are being put in place for each person in the home. Staff are talking to the person and or their relatives about their wishes and preferences. Part of this includes asking if they would want to be resuscitated. One survey said that this had not been done in a ‘sensitive’ manner. The plans looked at did not show that the GP had been involved in the decision-making process or if they were aware of the outcome. The manager said that the home does not have a policy about resuscitation. She was advised to look at professional guidance available and put one in place. She must consider The Mental Capacity Act 2005 when doing this. Nursing staff deal with medication. Most of them have had training updates and it is planned for those who haven’t. The medication charts seen had been completed correctly, including the dates and amounts of stocks received. The practise seen when medications where being given to people safe. Information from surveys returned, people in the home and visitors said that: • Staff are very kind and people are looked with respect and a caring attitude. • Privacy and dignity is respected. • They received the medical support they needed. • Staff are very caring and understanding. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ choices are respected and contact with family and friends is encouraged. EVIDENCE: The atmosphere in the home is warm, welcoming and friendly. Visitors said that they could call in at any time and were always made to feel welcome. People said that they could go out with their family and/or friends if they wanted to. One person goes out most days, either for a walk locally, or by taxi to a friend’s house. Some of the survey responses said that there was not enough to do. The manager and staff know that the social activity programme in the home needs to be improved. They are looking at ways of increasing the range and types of leisure and social activities offered. One of the care staff has done some training about activities and will be involved with the project. At present the aim is to make sure that activity sessions take place every afternoon and staff will ask people what they want to do. The home has gone through a period of being short staffed and this had been difficult to keep up to but it is now fully staffed and there should be the time for staff to lead activity sessions as The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 13 planned. The manager said that a weekly programme of planned sessions would be put together and it would be discussed at a residents meeting. Other planned activities in the home include a guitarist who comes once a fortnight to play and sing and every week there is a craft session. One resident enjoys listening to talking books and the manager has arranged for audio newspapers to be delivered to the home. People can choose how and where to spend their time, either in their own room or one of the communal lounges. They said that they choose when to get up, go to bed, if they join in with any activities and where to eat their meals. The manager said that she does encourage people to use the dining room for meals to make it more of a social occasion. A new chef has started working at the home since the last inspection. The last environmental health inspection awarded the kitchen five out five stars on the ‘scores on the doors’ system. The menus have been changed and there always two choices at every mealtime. The chef talks to people about what they want to eat and will provide alternatives to the main menu or change the menu. The meal served at lunchtime looked and smelled appetising. People who needed help to eat were given it discreetly. People said that they enjoyed their meals and that the food was good. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected from abuse because staff are receiving appropriate training. They can be confident that their concerns will be listened to and acted upon. EVIDENCE: The organisation has introduced a new complaints procedure. This was displayed in the main entrance and has been added to the Statement of Purpose. It includes CSCI as part of the homes complaints process and the manager was advised to alter this to say that people can contact CSCI at any time if they wish to. Contact details for the local authority complaints department should be added for people who are funded by them can take their concerns about the home to them if they want to. Not all the people responding to the surveys were aware of the homes complaints procedure. But they all said they knew who to speak to if they were unhappy with anything. When completing the AQAA the manager said that there have been no complaints since the last inspection. During discussions with somebody living in the home and their visitor it was clear that they had raised a concern about an accident that had happened at night. The manager and the deputy manager had investigated and dealt with the concern. Agreements were made with the person about how care and support would be provided at night and they were satisfied with this. Records were kept, but it had not been looked at as a The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 15 complaint. The manager added this information to the homes complaints file and said that all concerns would be logged in the complaints records in future. This will be helpful to her as part of the homes quality assurance processes and identify if there are any areas where changes need to be made. Adult protection policies and procedures are in place along with copies of the local authority adult protection procedures. Staff are in the process of receiving abuse and adult protection training as part of the induction training package they are all doing. Staff said they would report suspected abuse to the person in charge or the manager. The manager has completed a ‘train the trainer’ course in this subject and can provide training updates to staff when they need it. She said she would contact the local authority adult protection unit to attend their two day training course for social care managers. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, tidy, safe and well-maintained home, which is suitable for their needs. EVIDENCE: The home was clean and tidy. The manager said that a new housekeeper has been employed since the last inspection. Information from people said that some times there were ‘smells’ in the home. The manager said that at times this can happen because of some individuals health problems and that all that could be done was done to reduce and eliminate odours. There were no odours on the days of the visits. Accommodation is provided in mainly single rooms, none of which are en suite. There are enough communal toilets and assisted bathrooms. People said that their rooms were clean. Some of the residents had brought their own furnishings and pictures in order to make the room ‘theirs’. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 17 There are three communal lounge areas. They have been comfortably furnished and give people a nice place to sit. Two of the lounges have lovely views of the gardens and areas beyond. The grounds are attractively planted, equipped with garden furniture and are easily accessible to people. Since the last inspection a walk/wheel in shower and hairdressers room has been provided. The provider has bought: • A new hoist and equipment to use when moving people. • New beds. But they are divan type beds that are not height adjustable and do not have castors with brakes so they can be held in place. • New bedroom furniture for some of the bedrooms. The manager said plans are in place to: • Redecorate the corridors, bathrooms and communal toilets. • Make some repairs to the exterior of the building. • Make some changes to the garden areas. • Repaint the laundry floor. The last fire safety officer’s visit was in August 2006. The manager said that the home has got a fire safety risk assessment in place. When the laundry was looked at it was clean, tidy and appeared well organised and the clothes nicely laundered. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents could be placed at risk because the recruitment procedures are not thorough or robust. EVIDENCE: On the first day of the visit there were twenty people living in the home and there five staff on duty, plus the manager and ancillary staff. In the afternoon/evenings there would be four and at night two staff. The manager said that these staffing levels were satisfactory for needs and numbers of people in the home. There had been staffing problems over the last few months but new staff had been recruited and the shifts were always fully covered now. Information from people said that staff were usually available when they needed them. One person said ‘more staff would be beneficial to people but the staff do very well and we are satisfied with the care and services provided.’ The atmosphere in the home was calm and unhurried and people were not waiting long for staff to attend to them. Call bells were answered promptly. Records for two staff who have been employed since the last inspection were looked at. A requirement was made at the last inspection about pre employment checks being in place before offering jobs to people. Both files showed that they had started to work in the home without satisfactory POVA (Protection of Vulnerable Adults) and enhanced CRB (Criminal Records Bureau) The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 19 disclosures being in place. One person only had one reference returned when they started. Records to show that the manager had checked to make sure nursing staff were registered with the Nursing and Midwifery Council and able to work as nurses was seen in their files. The manager has arranged training courses for all staff that will make sure they have completed induction training that is equivalent to the Skills for Care common induction standards and will include certificated training about: • Moving and handling • First aid • Infection control • Health and safety • Abuse/adult protection • Care values • Fire safety Most staff have done it and it is intended that they will all have done it by the end of April 2008. She has also arranged for a dementia training course to be held in the home in January 2008. A McMillan nurse has been to the home and provided training about palliative and end of life care, and a specialist Parkinson’s disease nurse has spoken to staff. The nursing staff have done training sessions about wound care, catheter care and looking after syringe drivers. The manager said that she is looking at adding training around the Mental Capacity Act 2005 to the list of future sessions. Staff said that they appreciated the increase in training provided since the manager started working at the home. They were pleased with what had already been done and enthusiastic about what was planned. Many of them have completed NVQ (National Vocational Qualification) training and the home now has 38 staff qualified to at least level 2. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of people living there. EVIDENCE: The manager has been at the home nearly a year. She is an experienced nurse who has worked at another home in the group as the deputy manager and she has already achieved the registered managers award. She has not yet applied to become registered with CSCI. Information from surveys, people living in the home, their visitors and staff said that the manager was open, approachable and supportive. Staff that team working had improved and that they all worked well together to provide a good standard of care to people. The manager is holding regular staff meetings to discuss issues and records are kept. The last one was nearly two months ago. The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 21 Visitors said that the office door was open and they could talk to the manager when she was on duty. The manager said she has a system of quality monitoring audits that looks at the building – maintenance and safety issues – bedrail safety checks, medication audits and what equipment is being used in the home. People living in the home had completed quality assurance surveys with help from staff earlier in the year. The manager said she had looked at them and taken appropriate action where it was needed. The results had not been collated and made available to people. When the next survey is done the manager should look at involving relatives, visitors and healthcare professionals as it will give her an all round view of different stakeholders views. The provider’s representative visits the home at least once a month to provide support to the manager and monitor what is happening. Reports of these visits should be made and a copy kept in the home. The manager said that nobody working at the home acts as agent or appointee for anybody living in the home. She said that small amounts of money are held in safekeeping for some people so that they can get it when they need it. Appropriate records of monies received and returned to people were seen. Information from the AQAA said that all maintenance and safety checks were up to date. Accident records are kept but 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.V354544.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X X 3 The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 19 Requirement To make sure that the recruitment procedures are safe and protect people living in the home, the manager must make sure that: * Two satisfactory written references are obtained. * Satisfactory POVA checks are in place, before offering employment to staff. In these instances employment must be subject to receiving satisfactory enhanced CRB disclosures. The timescale of 21/2/07 was not met. The manager must make application to become registered With the CSCI so that people know somebody who is safe and competent to do so is managing the home. To show that the provider is monitoring the quality of services provided by the home a written report of the outcomes of visits must be made each month by their nominated DS0000064293.V354544.R01.S.doc Timescale for action 30/11/07 2. OP31 9 30/12/07 3. OP33 26 31/12/07 The Franklyn (Fezdene Ltd) Version 5.2 Page 24 representative. Copies must be kept in the home and made available to interested parties. 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.) In order to make sure that the care plans provide clear detailed information on how to meet individuals needs work started on making the care plans more person centred should continue. 2. OP11 The manager should look at producing policies and guidance for staff around resuscitation that takes into account current legislation and good practice guidelines. This will help to make sure that all relevant people are involved in any decisions made about ‘end of life’ care. The manager should look at putting together a regular programme of planned activities that takes into account peoples preferences and abilities. To protect people living in the home the manager should make sure that all staff receive training around abuse and adult protection. The manager should make sure that at least 50 of care staff are qualified to NVQ level 2. In order to make sure that people who need to be cared for when in bed can be attended to safely, the provider should consider buying height adjustable beds when beds are being replaced. So that staff are equipped to meet peoples needs, DS0000064293.V354544.R01.S.doc Version 5.2 Page 25 3. OP12 4. OP18 5. 6. OP28 OP22 7. OP30 The Franklyn (Fezdene Ltd) including specialist healthcare needs, the manager should make sure that the training programme is continued and extended to all staff. 8. OP33 In order to get the views of all people who are stakeholders of the home the manager should look at involving relatives, visitors and healthcare professionals, as well as people living in the home, when the next quality assurance survey is carried out. The outcomes of the survey should be and any action to be taken as a result should be made available to all interested parties. 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. 9. OP38 The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Franklyn (Fezdene Ltd) DS0000064293.V354544.R01.S.doc Version 5.2 Page 27 - 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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