Inspection on 29/08/08 for Fitzroy Lodge

This inspection was carried out on 29th August 2008.

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 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 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 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Fitzroy Lodge 4 Windsor Road Worthing West Sussex BN11 2LX Lead Inspector Jo Hartley Unannounced Inspection 29th August 2008 10:00 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.V369142.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.V369142.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 Old age, not falling within any other category registration, with number (0) of places Fitzroy Lodge DS0000063807.V369142.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 16th August 2007 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 £335.00 to £410.00. Fitzroy Lodge DS0000063807.V369142.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 senior person on duty. Several residents were spoken with during the visit and two 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. Past inspection reports and information held on the service file was also examined prior to the site visit. 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. The quality rating for this service is 1 star. This means that the service provides adequate outcomes for service users. What the service does well: Residents and their relatives describe the home’s staff as kind and helpful. Both residents and relatives tell us that they are listened to and that the home acts on any concerns they raise. 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. 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. The home seeks the views of the residents and their relatives about the service provided. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed prior to moving into the home. The home does not provide Intermediate Care, therefore Standard Six does not apply. EVIDENCE: We looked at the pre-admission assessments for three residents and found them to include assessments on mental and physical health. This was a requirement at the last inspection. It has now been met. At the last inspection it was found that a resident had been admitted with needs that the home was not registered to admit. The current residents in the home all are within the homes current registration. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 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. 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. Individual needs are met by the home, however the home needs to ensure that every resident has a Moving and Handling assessment. Residents are treated with dignity and respect. EVIDENCE: We examined the pre-admission assessments and care plans for three residents. We found that care plans provide enough detail for staff to meet the health and personal care needs of the residents. Care plans are reviewed monthly by the home and changes are made if needed. The home also has copies of social services yearly reviews where appropriate. Risk assessments are in place for identified hazards around the home such as slips, trips and falls. Risk assessments are also in place for mental health and neurological conditions where needed. A Requirement was made at the last inspection regarding this. This has now been met. One residents records that we looked Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 10 at did not include a Manual Handling risk assessment. The resident was staying in the home for a short period of respite. At the last inspection a Requirement was made that assessments must include details of moving and handling for individual residents. This has not been met. All residents are registered with a local General Practitioner. The records we examined showed that health needs are being met by the home. Residents have access to opticians, dentists, District Nurses and other health professionals as needed. We looked at the homes policies, procedures, recording and storage of medication. The policies and procedures are followed by staff. The recording of the administration and disposal of medication were up to date, with no gaps in recording. It was also noted that the home is now obtaining written confirmation from medical practitioners who change the dosage of medications. This was a Requirement at the last inspection and has now been met. A Recommendation was made at the last inspection that a record should be kept of the quantity of controlled medication remaining following administration. This is now being done. We saw that all staff who administer medication have received training in this area. During the visit staff were observed treating residents with dignity and respect. One resident said I am treated well here, another said the staff are very helpful. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 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. 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. Wholesome and varied meals are provided. EVIDENCE: Residents told us they enjoy the activities provided by the home. One resident told us that the activities she likes to join in with include dancing, musical entertainment and exercises. Other activities provided include outings, Pat A Dog, board games and baking. Photos of activities and parties are displayed in the hall. A visitor told us that she is welcomed in the home whenever she visits her relative. The visitors signing in book shows that people are able to visit at any reasonable time. Most of the residents we spoke with told us they like the food provided for them. One resident said the food is cooked with loving care. Another resident said that she particularly enjoys the roast dinners and the Irish stew. One resident said that the food was adequate. Residents confirmed that they are a choice of meals. The menu seen at the visit was varied, nutritious and Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 12 included fresh vegetables. Food that needs to be pureed is pureed separately now to retain flavour and look more attractive when presented. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 13 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. Residents and relatives are assured that their complaints will be listened to and acted upon. Residents are protected by the homes policies, procedures and training on the Protection of Vulnerable Adults. EVIDENCE: The home has a complaints procedure that is available in the Service User Guide and Statement of Purpose given to residents. The complaints procedure is displayed in the hall of the home. A visitor told us that she raises any concerns with senior staff on duty and they are always dealt with. Residents said that they know how to make a complaint if they need to. The home has a copy of the local authority adult protection procedures. Records and discussions with staff show that all staff have received training in the Protection of Vulnerable Adults. The home also has a whistle blowing policy in place. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 14 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is still in need of improvement in certain areas EVIDENCE: A tour of the premises showed that areas of the home are in need of redecoration or repair. These include, the outside of the home has paint flaking off the windowsills and is in need of redecoration; the paintwork in the dining room needs cleaning or repainting; in one bedroom the carpet was rucked up and poses a trip hazard. Since the last inspection some redecoration has taken place including four bedrooms and the lounge. Some rooms have also been recarpeted. The home now has a development plan in place to attend to the maintenance and redecoration of the environment. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 15 The home was clean throughout. Radiators were covered for safety and restrictors are fitted on windows. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from trained staff and are safeguarded by the homes recruitment process. EVIDENCE: Staffing levels at the home are adequate to meet the needs of the residents. At the last inspection a Requirement was made that the home review the level of care staff cover during the evening meal period. We looked at the rota and found that staff cover during this period has been increased and a cook has been employed to provide this meal. Staff members stated that they felt very well supported by their colleagues and the owner of the home. They said that they are encouraged to attend training courses and that the temporary manager also passes on skills and information to staff from courses that the manager has attended. The inspector examined staff training profiles and these included a record of training attended and certificates to support this record. Records demonstrated that staff have attended mandatory training including Food Hygiene, First Aid, Health and Safety and Moving and Handling. Staff have also received training in supporting people with dementia. An induction programme is in place to Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 17 train and develop staff. There is also a system of staff appraisal and supervision in place. Residents and visitors described the staff as kind. Three staff files were examined and found to have appropriate application forms, a minimum of two written references, proof of identity and a completed Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check. The Requirement made at the last inspection regarding this has now been met. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 18 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 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 has a quality assurance system in place. There is no registered manager. This needs to be addressed as soon as possible. EVIDENCE: The home does not have a registered manager in post. We have been informed of the plans for a manager to be put in place, however we have not received an application for a registered manager yet. 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 home now has a development plan and a maintenance plan in place. Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 19 The home looks after some money for residents. Receipts and up to date records are kept for all transactions. 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.V369142.R01.S.doc Version 5.2 Page 20 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 2 8 2 9 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 3 Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15 Requirement Assessments of need and care plans must include details of moving and handling for individual residents. This is a partial repeat of the requirement made in the report of 31/8/07 and a repeat of the requirement made in the report of 16/08/07. 2. OP19 23 Those areas of the home in need 30/12/08 of repair and refurbishment must be completed, including the areas identified at this inspection. This is a partial repeat of the requirement made in the report of 16/08/07. 8. OP31 38 Confirmation must be sent to the Commission clarifying the arrangements for the management of the home. This is a repeat of the requirement made in the report Fitzroy Lodge DS0000063807.V369142.R01.S.doc Version 5.2 Page 22 Timescale for action 30/12/08 30/12/08 of 16/08/07. 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.V369142.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V369142.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!