Inspection on 26/08/09 for Fitzroy Lodge

This inspection was carried out on 26th August 2009.

CQC 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 CQC 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 29/08/08

Fitzroy Lodge 16/08/07

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Fitzroy Lodge 4 Windsor Road Worthing West Sussex BN11 2LX Lead Inspector Lesley Webb Key Unannounced Inspection 26th August 2009 10:50 DS0000063807.V375750.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Fitzroy Lodge DS0000063807.V375750.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 Manager post vacant Care Home 24 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 24. Date of last inspection 5th June 2008 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 £419.00 to £450.00. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people that use this service experience adequate quality outcomes. We visited this home on Wednesday 26th August 2009, arriving at 9.50 am and staying until 4 pm. The purpose of this inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The acting manager was present during our visit and offered assistance throughout. During our visit to the home we had conversations with nine residents and two relatives. We examined the care records of three residents and recruitment records of two staff. We also looked at other documentation maintained in the home such as health and safety records, staff training records, medication and complaints. In addition to this we looked around the home and indirectly observed interactions between residents and staff. Prior to our visit the home supplied us with a copy of its Annual Quality Assurance Assessment (AQAA). We also received completed questionnaires from six residents, some of which had been completed with assistance from relatives. Information from all of the above sources was assessed and used to help us form judgments on the quality of service provided to residents. What the service does well: The home assesses the needs of potential new residents before they move into the home so that staff understand what areas individuals require support. Residents who completed questionnaires expressed satisfaction with the support they receive. Five state they always receive the care and support they need and one that they usually. Staff treat residents with respect. Generally residents that we spoke with expressed satisfaction with activities offered. As one person explained, “Occasionally they get entertainers in, wouldn’t say all the time, some might come twice a month, mainly singing. And voluntary exercise with staff, this not regular and you do not have to join in if you do not want to”. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 6 Visitors are made welcome. Two relatives spoken with during our visit said that there are no restrictions about visiting. They informed us, “We visit three times a week at different times, always made to feel welcome, staff make nice atmosphere, tranquil, homely atmosphere”. A variety of meals are offered. All residents that completed questionnaires state there is always someone available to speak to informally if they are not happy. What has improved since the last inspection? What they could do better: The health needs of residents at risk of dehydration or malnutrition are not always monitored safely and consistently. The registered person must be able to demonstrate through records maintained in the home that residents receive the care they require with regard to nutritional needs. The registered person must review the homes medication practices to ensure that people in the home receive their medication as prescribed, that the temperature is monitored in any facility that medication is stored and all Controlled Drugs must be stored in a cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. Improvements in these areas must happen to ensure all medication practices are safe and comply with the law. Some staff are working excessive hours without a day off. The registered person must be able to demonstrate through risk assessment that staff do not pose a risk to residents. The registered person must not allow any person to commence work at the home until the required recruitment documentation, including obtaining two references, one of which must be from the most recent employer have been Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 7 obtained. If staff commence working at the home without a full enhanced CRB having been obtained CQC and Department of Health guidance must be followed. This must happen in order that the homes recruitment practices safeguard residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Fitzroy Lodge DS0000063807.V375750.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.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have their needs assessed so that staff understand what areas individuals require support. EVIDENCE: Prior to our inspection the home sent us it’s Annual Quality Assurance Assessment (AQAA). With regard to assessment processes it states ‘Assessments are carried out by highly skilled, trained and seasoned staff members before admission. Assessments are aimed to be holistic in identifying every need of the potential resident including physical, mental, and emotional, sexual, psychological, spiritual and cultural needs, so as to ascertain that the Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 10 Home is fit to cater for the all the needs of the potential resident. Moreover, all documents relevant to care management arrangements, including the care plan are thoroughly studied to ensure the capability of the Home to meet all needs of the potential resident. The residents’ views are registered through support and encouragement. Information gathering is also extended to incorporate data, views, commitment and advice as and when provided, through consultations, from professionals involved in the caring for the potential resident. The assessment is meant to ensure the capability of the Home to adequately and fully provide a person-centered care which includes the diverse needs, incorporating race, religion, belief, physical and mental health, age and sexual orientation’. During our visit to the home we looked at the pre admission documentation for three residents, including the newest person to move into the home, spoke with the acting manager and relatives of one resident. Evidence from these sources supports the contents of the homes AQAA. For example the homes admission documentation for the newest resident had been completed in full and copies of the placing authorities needs assessment and care plan had also been obtained. The relative of one resident informed us, “The social worker gave us the names of three homes who take people with dementia. This was second we visited, didn’t bother looking at third, was impressed and are very happy with the care he receives. The staff are lovely, always welcoming, dad smiles when they come in the room, big difference from place he was living before”. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. Five state they received enough information about home to help decide if it was right for them and one person did not respond to this question. Fitzroy Lodge does not offer intermediate care. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in place for all identified needs. The health needs of residents at risk of dehydration or malnutrition are not always monitored safely and consistently. Generally medication practices safeguard residents. Residents are treated with respect and their rights to privacy are upheld. EVIDENCE: We sampled three residents care records and found that in the main these demonstrate that the home is meeting individuals’ needs safely. For example all contained care plans that give instructions to staff how they should support individuals. In addition to this risk assessments for areas including falls and moving and handling were on file. We did note that none of the care plans that we viewed had been signed either by the resident or his or her representative. All had been reviewed on a monthly basis. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 12 One residents file included a nutritional assessment that was not dated and gave a score of nine. The form states that for any individual scoring under twelve a further assessment should be undertaken. We could find no evidence of this. The same individual has a monthly weight chart in place that details a loss of 1.5 stone over an eight month period. They also have a statement of need by the placing authority that states ‘will require full support and supervision of one carer with all aspects of meal preparation in order to maintain his nutritional status and the prompting of fluid to prevent possible dehydration’. We discussed the resident’s loss of weight, lack of further assessment and the contents of the placing authorities’ statement of need with the acting manager. She confirmed that no nutritional or fluid monitoring is undertaken by the home and that medical advice had not been sought regarding the loss of weight. We informed the acting manager that action must be taken by the home to ensure the above resident’s needs are being met safely and that a requirement would be made regarding this. She informed us that she would contact the general practitioner as a matter of priority. As at the previous inspection records show that residents have access to community based health professionals as required. For example visits by professionals such as a general practitioner and chiropodist are noted and any advice or treatment recorded. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. Five state they always receive the care and support they need and one that they usually. Five state they ‘always’ get the medical care they need and one person did not respond to this question. An additional comment was also recorded of ‘this home has nursed me back to good health and that to me is everything’. We sampled a number of residents’ medication administration records, all of which were in good order and up to date. We did note that for one person they were being administered a medication at 9pm when instructions on the dispensing label state this should be administered at 6pm. We informed the acting manager that the prescriber’s written approval must be sought if medication is being administered at a time that differs from instruction. She agreed to contact the general practitioner regarding this. On the day of our visit the temperate within the home appeared very warm. The acting manager said that the temperature within the medication trolley is not monitored. The lack of temperature monitoring for the medication trolley Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 13 means that the home cannot show that the medicines that they keep for people will be fit for use when they are given. We also examined the records and storage facilities for controlled drugs. The home does not have a controlled drugs storage facility that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 with controlled drugs medication currently being stored in a metal tin within the trolley used to store other medication. We informed the acting manager that a requirement would be made with regard to this. Records for the administration of controlled drugs were in good order and up to date. Staff were observed speaking and assisting residents with dignity and respect. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to individuals by the name they wished. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can choose how they want to spend their day and the home arranges activities they can participate in if they choose. Residents are able to maintain contact with their friends and families so that they can continue to lead a fulfilling life style for as long as they are individually able to. The home provides a choice of well balanced and nutritious meals. EVIDENCE: With regard to daily life and social activities the homes AQAA informs us ‘We provide a well diversified spectrum of activities and recreational items individually and in groups as per the choice, wishes and performances of residents’ and that these include ‘All types-physical, mental, music, exercises, short walks, outings, rememberances’. In the main evidence gained through our inspection process supports this statement. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 15 For example photos of activities and parties are displayed in the hall and residents that we spoke with generally expressed satisfaction with activities offered. As one person explained, “Occasionally they get entertainers in, wouldn’t say all the time, some might come twice a month, mainly singing. And voluntary exercise with staff, this not regular and you do not have to join in if you do not want to”. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. Four state the home always arranges activities they can participate in, one usually and one sometimes. An additional comment was also recorded of ‘more activities would be nice’. The people living at the home who we spoke with told us that their visitors could come at any time and were made to feel welcome. Two relatives spoken with during our visit said that there are no restrictions about visiting and that they are made welcome. They informed us, “We visit three times a week at different times, always made to feel welcome, staff make nice atmosphere, tranquil, homely atmosphere”. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. All state they always like the meals provided. We saw that a four week menu is in place that offers a variety of meals. During our visit we spoke with five residents, four of whom expressed satisfaction with the meals provided. Comments included “food very good” “meals not too bad” and “meals always nice, I never leave anything”. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives know how to make a complaint and have access to a formal complaints procedure. Safeguarding procedures are in place so that people are protected. EVIDENCE: With regards to complaints the homes AQAA states ‘The ethos of the home ascertains that complaints constitute elements which should be taken seriously and positively in view of upgrading the quality of service and care provision. Whistle blowing formal and informal representations and concerns expressed from all quarters are fully investigated and resolved in line with the procedures prevailing at the home’. In the main, evidence gained from our inspection process supports this information. For example, as at our previous inspection we observed that a copy of the complaints procedure is displayed in the entrance hall and there is a copy in the service user guide. Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 17 We looked at the record of complaints and saw that complaints made had been responded to in the agreed timescales. We did note that one concern raised with both CQC and the home was not recorded in the homes complaints log. It had however been acted upon in full by the home. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. All state there is always someone available to speak to informally if they are not happy. Five also state they know how to make a formal complaint and one that they do not. The home has a copy of the local authority adult protection procedures. Training documentation evidences that some staff working at the home have received training in safeguarding and in depravation of liberty. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are being made to the environment in order that it is a comfortable place for people to live in. These need to continue in order that all areas of the home are to a good standard. EVIDENCE: With regard to the environment the homes AQAA states ‘Management sees to it that the Home conforms to all requirements in respect of infection control and other regulatory norms. Residents exercise their full choice in choosing the type of room they want (all rooms in Fitzroy Lodge are singles with some having en suite facilities) and besides management providing all necessary Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 19 furniture, and amenities, residents are encouraged and free to individualize and personalize their rooms in every way they wish. Kitchen and laundry are designed to promote involvement in domestic tasks as and when possible. Risk assessment is carried in view of balancing the issue of maintaining independence, involvement and risks, as per assessment of needs of every resident. Bathrooms, bedrooms and utilities are kept attractive and functional to promote person centred delivery of care’. In the main evidence gained through our inspection process supports this statement. For example when we looked around the home we saw that people living in the home have personalised their rooms, with some bringing items of personal furniture as well as other personal affects. The homes AQAA informs us that some bedrooms have been redecorated and new carpets fitted when rooms have become vacant. We did note that some of the corridors would benefit from decoration as some areas included torn wallpaper, chipped paintwork and stained carpets. We also noted that several chairs in the main lounge were stained and the cushions appeared worn. Since our last visit a conservatory has been installed. The acting manager informed us that flooring and ramps were on order for this new facility. One toilet is currently out of use. The acting manager informed us this is being changed to a shower room. Six residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. Five state the home is always fresh and clean and one that it is usually. Training records indicate that the majority of staff have received infection control training. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from trained staff but their wellbeing may be compromised due to the excessive hours some staff work. Some recruitment practices place residents at risk. EVIDENCE: We were informed that staffing levels consist of three care staff of a morning shift and two of an afternoon and during the night. In addition to this a kitchen and domestic person is allocated to each day shift. We examined the staff rotas for 20th July 2009 to the 26th August 2009 and found that staffing levels have been maintained to the stated levels. The rota indicates that one member of staff has been working between 60 to 72 hours each week and on one occasion for this period of time worked nine consectutive shifts without a day off. Another member of staff worked ten consecutive shifts without a day off and another seven. Three members of staff also worked a night shift from 8pm to 8am and then undertook a day shift. We raised concerns regarding these practices with the acting manager as staff could become tired and pose a risk to residents’ wellbeing. The acting Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 21 manager was not aware of any risk assessments having been completed in relation to staff working excessive hours neither was she aware of anyone signing working agreements in line with the European Work Time Directives. Fifteen residents completed questionnaires and returned them to us before our inspection. Some of these had been completed with assistance from relatives. All state there are always staff available when needed. Additional comments were recorded of ‘the staff are very patient which is wonderful considering the sometimes tiresome behaviour of many of their clients’ ‘the staff are always so helpful’ and ‘well run staff, management good’. We examined the recruitment records for the two newest staff to commence working at the home. They included an enhanced criminal records bureau disclosure, completed application form and two references. However for both individuals the references have been obtained after they commenced working at the home and for one also before the full enhanced CRB had been obtained. When asked, the acting manager confirmed that a risk assessment had not been completed with regard to the above member of staff working at the home without a full enhanced CRB having been obtained. The above practices are not compliant with the Care Home Regulations 2001 or with guidance issued by the Department of Health with regard to recruitment of staff and have the potential to place residents at risk of harm. We informed the acting manager that with immediate effect no new members of staff must commence working at the home unless the required recruitment documentation have been obtained as detailed in Regulation 19 and Schedule 2 of the Care Home Regulations 2001. With regard to staff training the homes AQAA states ‘Staff members have continuously been exposed to latest skills development and new areas of knowledge by attending different training programmes. This constitutes a continuous feature of our administration which promote capacity building relating to the experience required to understand the particular needs of our residents and effective delivery of individual resident centered care. Staff are also encouraged with management support to take external qualifications beyond basic requirements. At present our staff demonstrate a minute plurality of qualification and experience including NVQ 3 and NVQ 4’. When visiting the home we sampled a number of staff training records and these indicate staff have received training in areas including food hygiene, infection control, health and safety, protection of vulnerable adults, deprivation of liberty and medication. Fitzroy Lodge DS0000063807.V375750.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and monitoring systems are not meeting all of the needs of residents safely and consistently with regards to some residents’ health care needs and recruitment practices. Health and safety monitoring ensures residents live in a safe environment. EVIDENCE: There is currently no registered manager employed at the home, with the responsible individual taking responsibility for day to day management of the home. This was also the situation at our last key inspection. A senior care has Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 23 recently been appointed as acting manager and was present during this visit. She informed us that she has worked at the home since July 2008 and is in the process of submitting an application for registration. Previously she has worked as a nurse and holds a NVQ level 3. The acting manager informed us she is currently undertaking the HNC and HND in health and social care. Evidence gained at this inspection show that improvements must be made with regard to some elements of health care monitoring, medication and recruitment practices. When giving feedback to the acting manager regarding our inspection findings she assured us action would be taken immediately to address the shortfalls. As at our previous inspection the home has a quality assurance system in place that includes a survey seeking the views of residents and relatives. A monthly report regarding the homes operation is also completed by the owner. The acting manager informed us that the home does not hold or manage any money on behalf of residents. She informed us that the home invoices residents or their representatives on a monthly basis. Records indicate that staff receive both formal one to one supervision and group supervision in the form of staff meetings. We sampled a number of health and safety records finding all to be in good order and up to date. For example water temperatures are being regularly monitored, hoisting equipment services and risk assessments reviewed. Fitzroy Lodge DS0000063807.V375750.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 2 X X X X X X 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 3 X 3 X X 3 Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. 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 OP8 Regulation 12(1) Requirement The registered person must be able to demonstrate through records maintained in the home that residents receive the care they require with regard to nutritional needs. This must happen to ensure resident health needs are met safely and consistently. The registered person must review the homes medication practices to ensure that people in the home receive their medication as prescribed. Particular attention must be paid to – * Ensuring the temperature is monitored in any facility that medication is stored. * Seeking the prescriber’s approval if medication is administered at a time that differs from those instructed. All Controlled Drugs must be stored in a cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. This must happen to ensure the DS0000063807.V375750.R01.S.doc Timescale for action 26/09/09 2. OP9 13(2) 26/09/09 3. OP9 13(2) 26/11/09 Fitzroy Lodge Version 5.2 Page 26 4. OP27 18(1)(a) 5. OP29 19 Schedule 2 home complies with the law. The registered person must be able to demonstrate through risk assessment that staff who work excessive hours without a day off do not pose a risk to residents. The registered person must not allow any person to commence work at the home until the required recruitment documentation, including obtaining two references, one of which must be from the most recent employer have been obtained. If staff commence working at the home without a full enhanced CRB having been obtained CQC and Department of Health guidance must be followed. This must happen in order that the homes recruitment practices safeguard residents. 26/09/09 27/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fitzroy Lodge DS0000063807.V375750.R01.S.doc Version 5.2 Page 27 Care Quality Commission South East The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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