• Care Home
  • Care home

Archived: Dr French Memorial Home Limited

Overall: Inadequate read more about inspection ratings

13 Nether Street, North Finchley, London, N12 7NN (020) 8445 4353

Provided and run by:
The Dr French Memorial Home Limited

Latest inspection summary

On this page

Background to this inspection

Updated 1 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Inspection team

The inspection was carried out by two inspectors, a specialist nurse advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience visited the service to speak with people living there, and then spoke to people’s relatives by phone to request feedback. These calls took place in the week after the inspection visit. Two inspectors carried out a second inspection day at the service and spoke with two additional relatives.

Service and service type

Dr French Memorial Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We also sought feedback from the local authority and professionals who work with the service. In addition, we reviewed recent communications and statutory notifications received by CQC from the service. We used all of this information to plan our inspection.

During the inspection

We spoke with the registered manager, the assistant manager, four care staff, the chef and the two members of the board of trustees who provide leadership to the registered manager. We also spoke with six people who lived at the service and one family member who was visiting.

We looked at nine care records. We looked at various documents relating to the management of the service which included medicine administration records, three staff recruitment records and training and supervision records for the team. We looked at staffing rotas, infection control records, accident and incident logs, behaviour logs, and quality assurance records.

After the inspection we spoke to four relatives and obtained more information from the registered manager and provider regarding staff meetings, audits, supervisions, training, infection control documents and policies. We also obtained feedback from six health and social care professionals working with the service.

Overall inspection

Inadequate

Updated 1 February 2023

The Doctor French Memorial Home Ltd is a residential care home providing accommodation and personal care for up to 27 people. By the second day of the inspection there were 23 people living at the service.

The service supports mainly older people, with mental health or physical health needs.

People’s experience of using this service and what we found

Feedback from relatives and people on the care provided at Dr French Memorial Home Ltd was positive such as kind and caring staff, clean and well-maintained environment and a responsive management team. However, we found significant concerns throughout the inspection which impacted on safety and quality of care and people's well-being.

We were concerned that despite quality issues being raised at the last two inspections, remedial action in key areas to ensure people’s safety had not been implemented. We remained concerned at the lack of care planning documentation including risk assessments. We also found continued concerns with supervision, lack of effective audits and medicines management.

At the last inspection we found people were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found the provider and registered manager did not have a comprehensive understanding of their obligations under the Mental Capacity Act 2005. We found that this remained the case at this inspection.

We found the provider and registered manager did not provide effective leadership, to support the staff to provide good quality care to all the people living at the service.

Although staff understood how to safeguard people from abuse. The registered manager could not show they had taken all remedial action to safeguard people from abuse. The registered manager and provider had not understood their obligations to notify CQC of all significant events.

There were insufficient records to evidence that extremely vulnerable people were receiving adequate food and hydration.

For people who had lived at the service for some time, long standing staff worked hard to provide person-centred care. But lack of person-centred care planning, and the lack of information in care plans meant the information was not there for new staff to follow. Also person centred information related to new people entering the service was not captured on care plans.

We found issues with recruitment of staff as not all checks had taken place in line with legal requirements prior to staff starting work. This meant the provider had not taken all reasonable steps to ensure staff were safe to work with vulnerable people. This was resolved by the time of writing this report.

Whilst we found the home was odour free and clean, we found issues with infection control and staff were not always using personal protection equipment, including masks effectively.

Rating at last inspection and update

At the last inspection we rated this service requires improvement (the final supplementary report was published on 29 October 2021).

At that inspection we identified significant concerns regarding the governance of the service and safe care and treatment of people. This resulted in two Warning Notices being issued against the provider and registered manager related to safe care and treatment, and good governance of the service.

We also found breaches of the regulations in relation to person centred care and the need for consent.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dr French Memorial Home Limited on our website at www.cqc.org.uk

Why we inspected

We undertook this inspection on 18 February and 1 March 2022 to check the provider had followed their action plan, and to confirm they now met legal requirements related to the Warning Notices and the breaches of the regulations.

We carried out a full comprehensive inspection covering all five domains, safe, effective, caring, responsive and well-led.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified four repeat breaches in relation to safe care and treatment, person centred care, consent and governance of the service at this inspection. We have identified new breaches of the regulations around meeting nutritional and hydration needs, safeguarding and notifying CQC of other events. We have also made a recommendation in relation to the way the staff training is recorded.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Follow up

For services in special measures we usually return to inspect within six months. In the coming months, we plan to meet with the provider and registered manager, and work with the local authority and local health professionals to monitor actions for improvement.

We will continue to monitor information we receive about the service until we return to visit as per our inspection programme. If we receive any concerning information, we may inspect sooner.