Inspection on 13/09/05 for Fitzroy Lodge

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fitzroy Lodge 26/08/09

Fitzroy Lodge 29/08/08

Fitzroy Lodge 16/08/07

Fitzroy Lodge 07/06/06

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Fitzroy Lodge 4 Windsor Road Worthing West Sussex BN11 2LX Lead Inspector David Bannier Announced 13th September 2005, 9:00am 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 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. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fitzroy Lodge Address 4 Windsor Road, Worthing, West Sussex, BN11 2LX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01903 233798 Ramprakash Beeharry Post vacant Care Home (CRH) only (PC) 24 Category(ies) of Old age, not falling within any other category registration, with number (OP), (24) of places Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable Brief Description of the Service: Fitzroy Lodge is a care home which is registered to accommodate up to twenty four residents in the category (OP) old age, not falling within any other category. It provides personal care only. Fitzroy Lodge is a detached two storey property which provides accommodation in twenty four single bedrooms located on the ground and first floors, two of which have ensuite facilities. A vertical passenger lift provides access to all floors. A dining room and lounge are located on the ground floor. The property is located in a residential area of Worthing close to the seafront and approximately half a mile from the town centre. The registered provider of this service is Mr Ramprakash Beeharry. The post of registered manager is currently vacant. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Fitzroy Lodge has recently changed hands. The new provider was registered on 9th May 2005. This is the first inspection since that date. The inspection was announced and started at 9am. It took place over seven hours. The inspector spoke separately to six of the seventeen residents accommodated at Fitzroy Lodge. The inspector also spoke to four staff who were on duty. The deputy manager showed the inspector around the care home. Some records were also examined. The inspector also received written comments from five relatives or visitors to Fitzroy Lodge and from one resident. What the service does well: What has improved since the last inspection? What they could do better: Since becoming the registered provider Mr Beeharry has worked hard to make improvements to the care provided to residents at Fitzroy Lodge. This is an area he has identified himself as needing to be improved. As a result he has had to recruit several new staff to carry out the changes he wanted to make. The inspector does recognise the hard work Mr Beeharry has done. However, the inspection has identified areas where improvements can be made. They are important as they directly affect the safety and wellbeing of residents. Mr Beeharry needs to ensure he conducts criminal record checks on all staff before they are employed. This will ensure residents are safeguarded from the risk of abuse. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 6 Mr Beeharry needs to ensure all staff attend regular fire drills and fire lectures. This will mean that staff will know what to do in the event of fire. 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. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 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 standard(s) Fitzroy Lodge does not provide intermediate care. No standards in this section were assessed on this occasion. EVIDENCE: Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The needs of each resident have been set out in individual care plans. Care plans include information for staff to follow to ensure each resident’s needs have been met. Whilst care plans have been reviewed on a regular it is not clear what method has been used to reassess them. Residents who wish to can look after their own medication. Otherwise experienced staff take responsibility for the administration of prescribed medicines. From the comments made by residents it would appear that the staff members respect their privacy and dignity. The inspector saw that, when helping residents, staff are mindful of being respectful. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 10 EVIDENCE: A section of care plans were seen. They included clear information for staff to follow to ensure residents’ needs are met as agreed with each individual. Records seen indicated that care plans have also been reviewed regularly to ensure the information is up to date and in accordance with residents’ current care needs. However, it was not clear what method has been used to carry out reviews. Mr Beeharry was advised to use the same assessment tool as he would use to carry out the initial assessment of prospective residents. This would mean that Mrs Beeharry could demonstrate that residents’ care needs had been fully reassessed. Records seen also included visits made to the care home by their GP or the District Nurse to provide treatment to meet residents’ individual health care needs. From direct observations of care practices, staff on duty made sure the dignity and privacy of residents have been upheld whilst providing personal care. Residents who were spoken to said that they felt well cared for. Residents said that they were aware that there had been a change of ownership of the care home. One resident said, “ It is different.” Residents described the staff and the new owners as very kind, considerate and caring. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 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 standard(s) No standards in this section were assessed on this occasion. EVIDENCE: Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 12 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 standard(s) No standards in this section were assessed on this occasion. EVIDENCE: Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 13 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 standard(s) No standards in this section were assessed on this occasion. EVIDENCE: Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Fitzroy Lodge is staffed with employees in sufficient numbers to meet the needs of the older people who are accommodated at the care home. Staff who have been employed by Mr Beeharry have brought with them criminal records checks from previous employers. Mr Beeharry has ensured that all new staff have been afforded “in house” induction training. Since becoming the provider Mr Beeharry has yet to provide training to staff. He has relied on the skills and experience staff have already obtained. However, it was clear from information provided that he has plans in the near future to provide a comprehensive training programme to meet the needs of all care staff. EVIDENCE: Rotas were seen which showed that staffing levels, care staff, catering and domestic staff were sufficient to ensure residents are well cared for. Residents said that staff are very friendly and helpful. One resident told the inspector that staff are “marvellous” and “very kind” “You only have to ask and it is done for you”. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 15 Records seen showed that Mr Beeharry has appointed staff on the basis of criminal records checks which have been carried out by previous employers. Mr Beeharry has been advised that such checks are not transferable. He has also been advised to carry out new checks on the staff he has employed without delay. In future, no new staff should start work at Fitzroy Lodge, until such checks have been undertaken. This will ensure all residents are protected from possible abuse. Mr Beeharry provided the inspector with information regarding his plans to develop a training and skills development programme in the near future. This will mean that all staff will have the necessary skills that will help them understand how they should provide care to older people. Records seen showed that all newly appointed staff have been provided with an “in house training programme”. Following discussion, it is recommended that Mr Beeharry ensures all staff have received induction training as prescribed by the Skills for Care Training Consortium. This will mean that all new staff will receive appropriate training in accordance with the National Minimum Standards (NMC). This training will ensure staff provide care to residents in accordance with the basic principles of care including maintaining the privacy, dignity, independence, individuality and respect of each resident. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36 and 38 The post of registered manager is currently vacant. Since becoming the registered provider Mr Beeharry has taken steps to ensure residents and staff are clear about how he intends to run Fitzroy Lodge. Mr Beeharry has made sure all staff have been appropriately supervised. Mr Beeharry has yet to ensure fire drills and fire training has taken place to ensure all staff are aware of procedures in the event of fire. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 17 EVIDENCE: Mr Beeharry was given three months from the date of his registration to appoint a suitably qualified manager. Mr Beeharry informed the inspector that such a person has been appointed and an application to register the manager has been given to the Commission. Records seen showed that Mr Beeharry has held regular meetings with residents and with staff. Minutes have been taken of each meeting, which have taken place on a monthly basis. The minutes showed that the meetings have provided Mr Beeharry with an opportunity to communicate with residents and staff alike with regard to how he intends to run the care home. Minutes seen also showed that Mr Beeharry has used meetings to enable residents and staff to raise any issues and concerns they may have. Mr Beeharry clearly wants to ensure the care home is being run in the best interests of the residents. Records seen showed that Mr Beeharry has set up a system to ensure all staff employed in the care home have been supervised on a regular basis. This will mean that all staff are clear about what is expected of them with regard to the care of residents and the day to day running of the care home. Such sessions will also provide an opportunity to identify staff training needs. Prior to the inspection, Mr Beeharry provide the inspector with information that confirmed that the care home has been appropriately maintained. It also confirmed that he has taken appropriate action to ensure the health and safety of residents and staff. However, there is one exception to this. Mr Beeharry was unable to confirm that he has provided staff with fire training, fire lectures and fire drills to ensure they know what action to take in the event of fire. Following discussion, Mr Beeharry was advised to ensure he takes appropriate action on this matter without delay. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x 3 x 2 Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? NA 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 29 Regulation 19(1)(b) (i) as amended Requirement The registered person shall not employ a person to work at the care home unless subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2 particularly the obtaining of current criminal record checks at an enhanced level The registered person shall maintain in the care home the records specified in Schedule 4; particularly a record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the care home and of any action taken to remedy defects in the fire equipment The registered person shall after consultation with the fire authority make arrangements for the persons working at the care home to receive suitable training in fire prevention; and to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as Timescale for action 17th October 2005 2. 37 17(2) 17th October 2005 3. 38 23(4)(d) and (e) 17th October 2005 Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 20 practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. 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 7 Good Practice Recommendations It is recommended that the assessment tool, used to assess prospective residents, is also used to review individual service user plans as required. Fitzroy Lodge H60-H11 S63807 Fitzroy Lodge V240467 130905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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