Inspection on 16/08/07 for Fitzroy Lodge

This inspection was carried out on 16th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fitzroy Lodge 26/08/09

Fitzroy Lodge 29/08/08

Fitzroy Lodge 07/06/06

Fitzroy Lodge 13/09/05

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 Ian Craig Unannounced Inspection 10:00 16 August 2007 th 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 Fitzroy Lodge DS0000063807.V342848.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. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fitzroy Lodge Address 4 Windsor Road Worthing West Sussex BN11 2LX 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) 01903 233798 Mr Ramprakash Beeharry vacant post Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (PC) to service users of the following gender: Either Whose primary needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) 2. Dementia (DE(E)) The maximum number of service users to be accommodated is 24. Date of last inspection 7th June 2006 Brief Description of the Service: Fitzroy Lodge is a care home, which is registered to accommodate and provide personal care for up to twenty-four residents in the category (OP) old age and dementia (DE). Fitzroy Lodge is a detached two-storey property, which provides accommodation in twenty-four single bedrooms two of which have en-suite facilities. A 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. At the time of the inspection the home did not have a registered manager. The weekly fees for the home range from £325.00 to £400.00. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the building, examination of records, documents and policies and procedures. Discussions were held with 2 staff and the deputy manager. Several residents were spoken to during the visit and 3 residents were interviewed together about their life at the home. Survey forms were sent to a selection of residents and their relatives, and to professionals involved in the care of the residents. The responses in these forms have also been used as part of this inspection. Care services registered with the Commission are required to submit an Annual Quality Assurance Assessment. Information contained in this document has also been used as evidence for the inspection. What the service does well: Residents and their relatives describe the home’s staff as kind, helpful and attentive to care needs. One relative said that the staff listen and act on what the residents say. Another relative stated, “They treat the residents as individuals with various needs.” Residents and relatives are provided with information about the home entitled the Statement of Purpose and Service Users’ Guide. These contain information about the care provided by the home, the staff and the complaints procedure. Each person has an assessment of need and a care plan although these do not cover all the care needs of the residents. Activities are provided for the residents on a regular basis, although a relative contradicted this. Staff have access to a variety of training courses including moving and handling, care of those with dementia and other mental disorders, medication, food hygiene and adult protection. The home was found to be clean and there was an absence of any unpleasant odours. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 6 The home seeks the views of the residents and their relatives about the service provided. What has improved since the last inspection? What they could do better: The home’s management is unclear about the categories of residents it can provide care for. The home has admitted a resident with a mental disorder when it is not registered to accommodate people with a mental disorder. The deputy manager understood that the current registration allows the home to admit people whose primary need is a mental disorder. At the previous inspection the home was found to have admitted a resident with dementia when it did not have registration to admit someone with these needs. The assessments of need and risk assessments need to be improved so that all relevant mental health, neurological conditions and moving and handling needs are covered. Assessments of risk for activities such as going out from the home independently need to be in greater detail by including reference to health and psychological needs. Confirmation in writing needs to be obtained from medical practitioners who make changes to prescribed medication by telephone conversation. Improvements are needed to the home’s physical environment. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 7 Staffing levels need to be increased during the period when only 2 staff are on duty providing care and catering at the time of the early evening meal. Recruitment checks on newly appointed staff need to improve to ensure that two written references are obtained. The home should revise its system of recording any transactions involving individual resident’s finances, including those occasions when the home purchases chiropody for residents and then invoices the resident or their relative. The home has not confirmed the management arrangements and a relative also stated that he/she finds communication with the home unclear and is unsure if there is a manager. The system of quality assurance needs to be developed to show that a more thorough audit takes place and that there is an annual development plan. 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. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 8 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 Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 9 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, 3, 4 and 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst residents and their representatives are provided with information about the home, the management are not taking steps to ensure that it accommodates those whose needs can be met. EVIDENCE: The home has a Statement of Purpose and a Service Users’ Guide, which give information about the service including the complaints procedure. These documents are available in the entrance hall of the home and the home provides each person with an information sheet stating that the Statement of Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 10 Purpose, Service Users’ Guide and inspection reports are available upon request. Residents and relatives confirmed they receive information about the service. The home has updated these documents to include the fact that the home can now admit people with dementia. The process of assessing and admitting people to the home was examined for 3 residents. The home has an assessment pro forma for the purposes of assessing and recording the following needs: • Mobility • Personal hygiene • Incontinence • Toilet needs • Bathing • Difficulties/disabilities • Diet/eating habits • Eyesight • Hearing • Medication • Allergies • Mental state including, confusion/disorientation. Thinking, mood/feelings, personality, temperament/behaviour and communication • Interest and activities The home also uses other assessment pro formas. These documents have been completed satisfactorily for two of the three residents and the documents have been signed and dated by the person completing them. For a third person, the mental state section is absent. It was also noted that the home had accommodated this person whose main need is of a mental disorder for which the home is not registered. This was discussed with the deputy manager who thought that the dementia category, for which the home is registered, allows the home to admit people with a mental disorder. Records fail to show that the home has obtained copies of the social services’ care manager’s assessment and care plan, prior to the person being admitted. There was evidence that the person was consulted about choosing to live at Fitzroy Lodge, but the home has not fully assessed the person’s mental and physical health needs. The residents records contain evidence that residents are invited to visit the home before making a decision about whether or not to move in. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessments of need and care plans do not show that individual needs are being addressed which has the potential for care needs not being met. Sufficient safeguards are not taken to protect residents when promoting independence. Residents are treated with respect and their privacy is promoted. EVIDENCE: Assessment and care plans were examined for 4 residents. Details of the assessment pro formas are outlined in the Choice of Home section of this Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 12 report. These contain numerous details of individual residents needs and how staff should provide care on a daily basis. Records show that health care needs are reviewed and updated by the home, and that the home obtains copies of social services’ review documents. Staff described changes in need for specific residents, and records have been amended to show how staff should deal with these. Risk assessments have been completed for any identified hazards in the home such as in the resident’s bedroom and en suite facility, as well as for activities such as going out alone, which allows the resident to maintain his or her independence. It was noted, however, that the risk assessment for these type of activities needs to be expanded as it does not include the person’s health care needs and how this may affect the resident’s safety. Care plans need to be reviewed so that the following are addressed: • Lack of detail about the procedures being followed by staff for the moving and handling of individual residents • Details of mental disorder have not been assessed nor care plans devised of how these needs are to be met, including details from health and social services personnel involved with the person • Details of neurological conditions have not been assessed and the home has not obtained relevant information from medical professionals about this. Care records show that residents are sometimes consulted or involved in agreeing to their care plan by recording a signature of acknowledgement. This is inconsistent and should be improved by ensuring each resident and/or their relative is consulted, and a record maintined. Discussions with staff, and examination of records, showed that the home liaises with the district nursing service regarding specific health care needs and follows the advice of health professionals in implementing programmes of care. Records show that residents have access to eyesight tests by an optician. Medication procedures were assessed. The home has its own policies and procedures for the storage, handling, administration and recording of medication. Training records and discussion with staff confirmed that staff who handle medication attend a training course in medication procedures. Examination of the medication administration recording sheets and the blister packs showed that medication is administered as prescribed. Staff sign a record each time medication is administered. The home maintains a list of specimen signatures of those staff that handle medication. A visiting medial practitioner changed the amount of medication to be taken, and signed the medication records to reflect this. A further change was made via a telephone conversation with the doctor, and the home recorded this in the daily records and on the medication records. The inspector highlighted the need to obtain written confirmation from medical practitioners following changes made to prescribed quantities via telephone conversations. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 13 For medication that is stored as a controlled drug, records show that two staff are involved in its administration. A record is not kept of the remaining balance of medication following each administration. Feedback from residents and relatives of residents includes comments that the staff are kind and helpful. A relative stated that his/her next of kin’s health has greatly improved since moving into the home. Other comments include the following: • “Helpful staff. The doctor is always called fairly quickly when necessary.” • “They treat the residents as individuals with their various needs.” • “We are generally very satisfied with the overall care given to our relative.” Each resident has his or her own room which helps promote privacy. Residents were seen to be able to choose to spend time either in their room or in one of the two lounges. One resident stated that he liked to spend his time in his room. Residents are offered a key to their room if they have been assessed as capable of handling a key. Staff were observed to treat the residents with respect and kindness. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 14 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 benefit from a variety of activities and stimulation. Wholesome and varied meals are provided. EVIDENCE: There was some inconsistency in the evidence regarding the provision of activities for the residents. One relative stated that the activities are only provided at Christmas time and several of the residents stated that they had not had opportunities to go out. On the other hand, the home maintains a daily record of activities showing regular exercise classes, games and musical entertainment. A relative stated that the provision of activities has recently improved. Residents stated how they enjoy the dancing classes. Posters in the hallways give details of when musical entertainers will be next visiting the Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 15 home. Photograph displays in communal areas show residents enjoying dancing classes. Opportunities for going out from the home are available. This may involve families taking out their next of kin/residents or residents going out independently. Two residents stated that they have not been out for several months. Staff described taking individual residents out on a regular basis. It was not possible to judge with accuracy the frequency of outings for individuals. The home’s menu plan is displayed in the home. Each of the residents spoken to described the food as good. The midday meal consisted of chicken in sauce with mashed potato and vegetables. Residents chose the amount of gravy they preferred with their meal. One resident has his/her food pureed to help him/her eat it. The whole meal was pureed together which made it look unattractive and prevented the resident from experiencing the different tastes of the individual food items. This was discussed with the staff and the deputy manager, with the inspector highlighting the benefits of pureeing the food items individually. Residents also had a dessert. Dining tables were set with napkins. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 16 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. The home takes steps to ensure that residents are protected from possible harm, although sufficient assessments of risk are not in place to ensure the safety of those going out independently. The home has a complaints procedure and listens to the views of the residents and their representatives. EVIDENCE: The home has a complaints procedure contained in the Service Users’ Guide and in the Statement of Purpose. Residents’ relatives stated that they know what to do if they have a complaint and confirmed that the home’s staff act on any concern that is raised. Residents stated that there are meetings where they can raise any matters about the home. The home has a copy of the local authority adult protection procedures. Staff receive training in adult protection procedures, which was confirmed from training records and from the staff themselves. The Health and Personal Care Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 17 section of this report highlights the need to carry out risk assessments that include all of the relevant health and psychological needs of the relevant resident. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 18 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, 21, 22, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home is clean it is not being maintained to a standard that upholds the dignity of the residents. EVIDENCE: Two residents’ relatives stated that the home’s environment is need of attention and included the following: • “Although improvements have been made in the short time the care home has been managed I feel that a proper maintenance programme Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 19 • should be implemented to update the property and furnishings and décor so it keeps to the standard expected.” “Our relative’s bedroom needs some attention to décor and furniture.” The home does not have a plan for redecoration and refurbishment, but does have a system where faults are recorded which need to be repaired. A tour of the premises showed many areas of the home as needing attention including the following: • Stained carpets in bedrooms, stairs and halls • A rucked carpet in one bedroom posing a tripping hazard • Damaged wallpaper in the main lounge and in several bedrooms • Water stains on ceiling paintwork caused by a water leak which has been repaired • Curtains had become partially detached from the tracks in two rooms • Loose paving slabs in the front garden posing a tripping hazard, which is due to be attended to. Maintenance of the home is now an outstanding requirement from the previous inspection report. There have been a number of improvements to the home, such as recarpetting, but there is still a great deal of work needed. Each resident has his or her own bedroom, two of which have an en suite toilet. Residents stated that they like their bedrooms. Several residents were observed making use of their rooms and one person stated how he likes to spend time listening to music in his room. Residents are able to personalise their rooms with their own possessions. There is a garden at the rear of the home, which the residents can use. Residents were observed using the both the home’s lounges. The home was found to be clean with no unpleasant odours. Staff receive training in infection control. There is a laundry and residents’ clothes are labelled so that they are not misplaced or given back to the wrong person. Radiators are covered to prevent possible burns to residents. There is a procedure for staff to follow in ensuring that bath water temperatures are safe so that residents are not scalded by hot water. There is a bath hoist for those with mobility needs. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 20 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’ benefit from staff that are trained, but staffing levels need to be reviewed especially during the afternoons when there are insufficient staff . Residents are not safeguarded by the home’s recruitment procedures. EVIDENCE: The staff rota was examined and the staffing levels were discussed with the deputy manager and the staff. Three care staff are on duty each morning, which was evidenced by the rota, observations, and from discussions with the staff and deputy manager. In the afternoon there are two care staff on duty who also prepare, serve and clear away the early evening meal. Although it is acknowledged that the home’s cook prepares much of the meal in advance, the period impinges on the availability for staff to provide adequate care as well as having the potential for increasing the risk of infection due to the mix of roles. The provision of staffing during this period needs to be reviewed. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 21 Two ‘waking’ night staff are on duty. The home also employs a cook and provides cleaning staff. The home has a system of staff appraisal and supervision with each person having a performance development plan. There is an induction schedule for newly appointed staff. Staff have access to a variety of training courses, which was confirmed, from staff, the deputy manager and from training records. Training records for 3 staff show that following training has been attended: food hygiene, dementia awareness, schizophrenia and psychosis, challenging behaviour, mental health, promotion of continence, medication and adult protection. Residents and their relatives described the staff as kind and helpful. Recruitment procedures were examined for two recently appointed staff. Each person has completed an application form or has curriculum vitae. Criminal record (CRB) and protection of vulnerable adults (POVA) checks have been obtained. Two written references have been obtained for one person but there were none available for the other person. The manager stated that this was due to her overseas status. Two referees have been given by the staff member, but the home has not requested references. Work permits are held on file. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s management arrangements are unclear. The home is not effectively managed in the best interests of the residents due to requirements made in previous inspection reports not being completed, and a lack of forward planning. Procedures for safeguarding resident’s finances need to be reviewed. EVIDENCE: Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 23 The home does not have a registered manager and the Commission have not been notified of the home’s management arrangements. One of the resident’s relatives stated that he/she is uncertain of the lines of communication in the home and that they are unaware of the home’s management other than having telephone numbers. The home seeks the views of the residents and their representatives via a survey about the home. A monthly report is completed by the owner regarding the home’s operation. These are brief consisting of no more than one paragraph or a few sentences about the home. They do not show that the home’s performance and operation are being adequately audited. An annual development plan, including a maintenance schedule, are not devised. The home occasionally handles residents’ finances. There was a lack of clarity regarding the home having a £20.00 note for one resident, sent by the next of kin. Staff had differing views on what this was for and it took the deputy manager almost one hour to find a record that supported his statements regarding the money. This record did not have a signature of a staff member who completed it. He explained that the home pays for residents’ chiropody and hairdressing and then invoices the next of kin for the amount. Records for this are not held individually for each resident but are included with the home’s petty cash records. The inspector highlighted the need to maintain a record for each person each time the home spends an amount on behalf of a resident which is later invoiced to the next of kin. Staff receive training in infection control, first aid, moving and handling and food hygiene. The home’s appliances have been serviced by suitably qualified persons. Fitzroy Lodge DS0000063807.V342848.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 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 X 1 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 3 X 2 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 3 Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement The home must not admit any person until an assessment of the needs of that person has been carried out which includes the person’s mental health and physical health. The home must only admit those persons whose needs can be met and for whom the home is registered to admit. This is a repeat of the requirement for the inspection of 07/06/06. 2 OP7 15 Assessments of need and care plans must include the following: • Mental health • Neurological conditions • Details of moving and handling for individual residents Risk assessments for individual residents must include all of the relevant person’s needs such as mental health and neurological conditions. DS0000063807.V342848.R01.S.doc Timescale for action 16/08/07 16/09/07 3 OP7 13 16/09/07 Fitzroy Lodge Version 5.2 Page 26 4 OP9 13 Written confirmation must be obtained from any medical practitioner who changes the dosage of medication. 16/09/07 5 OP19 23 Those areas of the home in need 16/11/07 of repair and refurbishment must be completed, including the areas identified at this inspection. A maintenance refurbishment plan must be completed. This is outstanding from the inspection of 07/06/06. 6 OP27 18 The home must review the level of care staff cover during the period when the early evening meal is prepared, served and cleared away to ensure that there are adequate numbers of staff on duty and that the risk of infection is minimised. 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 two written references. This is a partial repeat of the requirement made in the reports of 13/09/05 and 07/06/06. Confirmation must be sent to the Commission clarifying the arrangements for the management of the home. A system of quality assurance must be implemented which includes an annual development DS0000063807.V342848.R01.S.doc 16/10/07 7 OP29 19 16/10/07 8 OP31 38 30/09/07 9 OP33 24 16/11/07 Fitzroy Lodge Version 5.2 Page 27 plan and audit of the home. 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 OP9 Good Practice Recommendations Each time staff administer medication that must be stored as a controlled drug a record should be maintained of the remaining amount. Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Fitzroy Lodge DS0000063807.V342848.R01.S.doc Version 5.2 Page 29 - 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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