Inspection on 07/06/06 for Fitzroy Lodge

This inspection was carried out on 7th June 2006.

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 29/08/08

Fitzroy Lodge 16/08/07

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 Mr D Bannier Key Unannounced Inspection 7th June 2006 9:30 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.V297944.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.V297944.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 01903 233798 Mr Ramprakash Beeharry Mr Rajkumarsingh Gunowa Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: Fitzroy Lodge is a care home, which is registered to accommodate up to twenty-four residents in the category (OP) old age, not falling within any other category. It provides personal care only. Fitzroy Lodge is a detached twostorey property, which provides accommodation in twenty-four single bedrooms located on the ground and first floors, two of which have en-suite facilities. A vertical passenger lift provides access to all floors. A dining room and lounge are located on the ground floor. The property is located in a residential area of Worthing close to the seafront and approximately half a mile from the town centre. The registered provider of this service is Mr Ramprakash Beeharry. The registered manager, who is responsible for the day-to-day running of the care home, is Mr Rajkumarsingh Gunowa. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been written using new methods introduced on 1st April 2006. Some evidence used to assess standards has been gathered before this visit took place. For example, information has been used from the registered provider’s action plan that sets out how the requirements from the last inspection will be met. This visit was unannounced and started at 9.30am. It took place over approximately eight hours and was conducted by Mr David Bannier. The inspector looked at those standards that are about how new residents are admitted to the care home; how residents are cared for; the daily life and social activities provided for residents; how the care home deals with complaints and how they protect residents from abuse; the environment in which residents live; how staff are recruited and trained; and how the care home is managed. Several residents were spoken to, along with a relative who was visiting the care home in order to gain a sense of how it is to live at Fitzroy Lodge. Inspectors also spoke to five staff that were on duty in order to gain a sense of how it is to work at the care home. The communal areas were viewed along with a number of residents’ bedrooms. The inspector also saw the kitchen, and laundry rooms. A selection of records was also seen. Mr and Mrs Beeharry and Mr Gunowa, were also present and kindly assisted the inspector with his enquiries. What the service does well: This is a care home where older people are well looked after. The residents who were spoken to said they liked living in the care home. Staff are very caring and considerate and the atmosphere was very homely. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There was no evidence to confirm that before admission, residents had been consulted during the assessment of their care needs and had been notified in writing that the care home could meet them. There was no evidence that residents had been consulted when individual care plans have been drawn up and reviewed. This means that resident’s individual wishes about how they want to be cared for have not been taken into account. Some work is required to the premises, internally and externally, to ensure residents live in a safe and well-maintained environment. Recruitment practices need to be improved to ensure appropriate criminal records checks have been obtained on all new staff before they start work in the care home. This will ensure residents are protected from the possible risk of abuse. The registered manager needs to ensure the staff rota clearly shows the hours he works at the care home. This will mean that staff, residents and their families will know when Mr Gunowa is available to them. Mr Beeharry needs to conduct monthly visits to the care home and prepare reports of these visits in accordance with regulations. This will ensure he can demonstrate he is monitoring the day to day running of the home to ensure the care home is being run in the best interests of residents. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fitzroy Lodge DS0000063807.V297944.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.V297944.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 A suitably trained person has assessed the care needs of prospective residents before they are admitted. The registered provider has been unable to confirm that residents have been consulted as part of the assessment process and that they have been assured their care needs will be met. Fitzroy Lodge does not provide intermediate care. Quality in this outcome area is good. EVIDENCE: The inspector examined the files of three residents. They had been admitted since the last inspection. There was evidence that confirmed pre admission assessments had been carried out. This means that the registered manager is able to gather information about the needs of prospective residents in order to determine if the care home can meet them. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 10 There was no evidence to confirm that residents had been consulted during the assessment process. This means that resident’s individual wishes about how they want to be cared for have not been taken into account. Nor was their evidence to confirm that the registered person had written to each prospective resident, or their representative, to confirm that the care home is able to meet assessed needs. This means that the registered person has not provided residents with information about how it proposed to meet identified needs before they decide to move in. The inspector expressed some concern that one resident has been admitted whose needs are not within the category for which this care home is registered. The current registration of the care home and its statement of purpose indicates the care home is registered to provide care and accommodation to residents in the category of old age, not falling within any other category. The assessment record and subsequent review notes indicate the resident has been admitted with dementia. This was discussed with the manager and Mr Beeharry. It was clear from evidence available that the resident is inappropriately placed and it is also having a detrimental affect on other residents in the care home. Fitzroy Lodge DS0000063807.V297944.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Residents’ health, personal and social care needs have been set out in an individual plan of care. The manager should ensure residents and their relatives are consulted when care plans are drawn up and revised. Residents’ health care needs have been fully met. Where possible residents are encouraged to look after their own medication. Some work is needed to ensure policies and procedures for dealing with medication protect residents. Residents feel they are treated with respect and their right to privacy has been upheld. Quality in this outcome area is good. EVIDENCE: According to records seen care plans have been drawn up as a result of the assessment process. The manager has also reviewed care plans on a monthly Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 12 basis to ensure they are up to date and accurately reflect the current needs of each resident. However, there was no evidence to confirm that the resident or their relatives have been consulted during this process. This means the specific wishes of residents, regarding how they want their care to be provided, has not been taken into account. Residents spoke very highly of the manager and of his staff and told the inspector they felt very well cared for. However, they have not been able to confirm they have been consulted regarding individual care plans and how they would like care to be provided. Records seen also included information regarding visits by residents’ GP’s and District Nurses to provide treatment to residents when required. A resident explained to the inspector that everybody had recently been allocated a key worker. “This person is responsible for making sure I’m okay, that my clothes are tidy and my bed linen is changed regularly. The staff are very good, however it is sometimes difficult to understand them. But, on the whole we manage!” From direct observation of care practices, it was evident staff knew about the needs of each resident and they were able to meet their needs. The inspector examined medication records. They had been appropriately kept and included a record of all medication received. The inspector noted that, where possible residents can chose to take responsibility for their medication. Residents who have done so have been provided with a secure place to store medication. However, there was no record of this in care plans or in medication records. The manager was advised to ensure some amendments are made to ensure systems for enabling residents to look after their own medication is safe. From direct observations care practices ensure that residents’ dignity has been maintained and their right to privacy has been upheld. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The registered provider has ensured a range of activities is provided for residents to enjoy. However, it was not clear if they match residents’ expectations and meet their individual needs. Residents are able to maintain contact with the family and friends. It is not clear if residents are helped to exercise choice and control over their lives. Residents have been provided with a varied, wholesome and nutritious diet in pleasing surroundings. It was not clear if mealtimes have been set by the routine of the care home or at the convenience of residents. Quality in this outcome area is good. EVIDENCE: The inspector noted that several of the residents were enjoying a musical duo in the front lounge, made up of a guitarist and a saxophonist. The duo was playing and singing hits from Broadway shows and swings standards from the ‘40’s and ‘50’s. Afterwards several residents told the inspector that they had enjoyed the session, especially as song sheets are given to them and they had been encouraged to sing along! According to information on a residents’ notice board, the duo visit the home on a monthly basis. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 14 The inspector also took part in a birthday celebration in the dining room just before dinner was served. The resident was presented with a cake, birthday cards and flowers. Mr Beeharry made a brief speech before the residents sang Happy Birthday. Some residents enjoyed a glass of sherry with their meal to toast the occasion. The residents, and especially the resident whose birthday it was, clearly enjoyed the occasion. Residents told the inspector that a visiting hairdresser calls regularly to attend to their needs. Some residents also had their fingernails polished and manicured. They told the inspector that a member of staff helps them with this. The notice board indicated an activity programme was in place. This included board games, gentle exercise, movies and church. There were also pictures of residents engaged in activities and also photographs of residents’ birthdays. Whilst a range of activities has been provided, there was no evidence to confirm that they meet the needs of individual residents. It is recommended that assessment and reviews of residents’ needs also include information about residents’ previous interests and hobbies to ensure, where possible, they can continue to enjoy them. The inspector spoke to the relative of one resident who said, “The staff are lovely, I get such a warm welcome when I come in. Mr and Mrs Beeharry are very nice people. Nothing is too much trouble. The manager is very good. If I mention anything to him, it gets done.” The inspector was also told that visitors are welcome at any time. “As a visitor, I always feel welcome. I get asked if I want a tea or coffee when I arrive.” Mr Beeharry had arranged a meeting last month and residents’ relatives were invited to attend. The relative said, “It was a very informative meeting. Mr Beeharry told us that safety of the residents is of paramount importance to him. That is why the doors to the home are alarmed. He also told us he is concerned about the hygiene in the home. He also told us about the key worker system.” As mentioned previously, there was no evidence to confirm residents have been consulted when individual care plans have been drawn up and reviewed. This would mean that residents’ choices and wishes will be taken into account, and staff should provide personal care in accordance with them. Some residents have chosen to remain in the rooms during the day. However, this was not clear if this has been as a result of an informed or active choice, or if the resident has simply withdrawn. It is therefore, not clear if residents have made active choices regarding the lifestyle experienced or if this has been driven by the routines of the care home. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 15 The inspector observed the main meal of the day being served. This consisted of a choice of chicken casserole, peas, cauliflower, and mashed potatoes or quiche with salad. This was followed by apple strudel with custard. The food was attractively served and presented. Some residents chose to have sherry with their meal whilst others had fruit cordial. The meal was taken in the dining room. Tables were attractively laid out with clean table clothes. Residents were afforded plenty of time to eat and enjoy their meal. One resident told the inspector “I enjoyed my lunch, it was very nice.” Fitzroy Lodge DS0000063807.V297944.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and their relatives know that their complaints will be listened to by the manager, taken seriously and, where necessary, acted upon. The manager has ensured that residents are protected from abuse. Quality in this outcome area is good. EVIDENCE: A written complaint procedure was on display in the front hallway of the care home. This is also included in the home’s Statement of Purpose and has been given to every resident. Residents and one visitor confirmed they knew who to speak to if they needed to complain. A visitor said, “They (Mr and Mrs Beeharry) have told us to tell them if anything goes wrong.” The manager was able to demonstrate he had kept a record of complaints that had been received. The inspector noted that details of a recent complaint that had been investigated by Mr Beeharry were not with the record of complaints. Whilst it was confirmed that Mr Beeharry does have the necessary paperwork the inspector advised him to ensure the complaint file includes details of all complaints received. The manager informed the inspector that most of the staff had watched a video entitled “What is Abuse”, however, there was no record of who has seen the video and of any further work the manager has undertaken to ensure they understand what they seen. The manager was advised to ensure all training Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 17 provided to staff is appropriately recorded. Three staff, including the manager, have received certificates from the Care Training Consortium confirming they have attended a session regarding identifying different forms of abuse and what to do if they witness abuse. Three more staff will be attending another session due to take place in the near future. Staff who were spoken to confirmed they knew how to identify different forms of abuse and they know what to do if such an incident occurred. Fitzroy Lodge DS0000063807.V297944.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Some work is required to the outside of the premises to ensure residents live in a safe well-maintained environment. Some work is required to the laundry room. Apart from this the home is clean, pleasant and hygienic. Quality in this outcome area is adequate. EVIDENCE: The inspector viewed the communal areas, including the lounge and the dining room, a number of residents’ bedrooms. These areas appeared to be safe and well maintained. Residents and relatives who were spoken to told inspector they were satisfied with the state of the environment. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 19 Internally, some small areas of concern were identified. For example the decoration in some rooms had been affected by water penetration. This had resulted in unsightly staining to paintwork and peeling wallpaper. Externally, there were additional concerns regarding the maintenance and decoration of the premises. Whilst the front of the building had been recently decorated, the sides and rear of the building had not; these areas were in a poor state of repair. Paintwork to fascias and window frames had peeled and exposed bare woodwork beneath. The frames to some windows were now rotting, as they had not been treated for some time. The garden shed had blown down and broken glass was present on the lawn. A handrail to the rear of the premises was loose and in a dangerous condition. Some pathways had begun to crack and crumble and were in a dangerous condition. Old radiators and filled black refuse sacks had been left near the fire escape. Mr Beeharry was advised to prepare and provide the Commission with a maintenance programme regarding his intentions to ensure the premises, particularly the outside, is safe and well maintained. The standards of cleanliness in the laundry room required attention to ensure the risk of cross infections to residents and staff is reduced. Wall coverings in the laundry were not readily cleanable. Plasterwork had become exposed to an area of a wall near to the outside door. Again the maintenance programme should include timescales when Mr Beeharry expects the repair to the damaged wall will be completed. Fitzroy Lodge DS0000063807.V297944.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The registered provider has ensured there are adequate staffing levels to ensure residents’ needs are met by the numbers and skills mix of staff. The registered provider has not ensured residents are in safe hands at all times. This is due to the fact that the registered provider has not ensured residents are supported and protected by the home’s recruitment policy and practices. The registered provider has ensured staff are trained and competent to do their jobs. Quality in this outcome area is adequate. EVIDENCE: At the last inspection, there was evidence that confirmed Fitzroy Lodge was staffed with employees in sufficient numbers to meet the needs of the older people who were accommodated at the care home. At the time of this visit there were 17 residents accommodated at Fitzroy Lodge. The rota confirmed from 8am to 2pm there were three care staff on duty. From 2pm to 8pm there were two care staff on duty. In addition, a cook and a cleaner were also working in the care home from 9am to 2pm. The inspector either spoke to or saw each of these staff. From direct observations, examining care records and after speaking to residents, the Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 21 inspector concluded there was enough staff on duty to meet the current needs of residents accommodated. Six members of staff had been appointed since the last inspection. Records seen confirmed that staff had started work at Fitzroy Lodge before all the necessary checks, particularly criminal record checks, had been obtained. The inspector advised Mr Beeharry that this is of concern as this has been made a requirement during the previous inspection. In addition, Mr Beeharry could not confirm that, until a clear check had been returned he had taken the necessary steps to protect residents from possible abuse. For example, according to the rota members of staff without appropriate checks were working with residents without appropriate supervision. Following discussion, Mr Beeharry was reminded of his responsibilities to ensure the safety and wellbeing of residents living at the care home. Records seen confirmed all new staff have received comprehensive induction training. Areas covered include job description, duties and responsibilities, health and safety, residents’ care, hygiene and safety, and also training and development. Staff spoken to confirmed the training they had received. Fitzroy Lodge DS0000063807.V297944.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 A person who is fit to be in charge is managing the home. However it is not clear if Mr Gunowa spends enough time in the care home in order to discharge his responsibilities fully. Mr Beeharry has taken appropriate action to ensure the home is being run in the best interests of the residents. This will be improved once Mr Beeherry commences making visits to the care home in accordance with current regulations. An appropriate secure facility has been provided for residents to deposit money and valuables for safekeeping. The registered provider has not taken appropriate action to ensure the health, safety and welfare of residents and of staff. Quality in this outcome area is adequate. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mr Rajkumarsingh (known as Vikash) Gunowa is the registered manager. He has demonstrated through the process the registration that he is fit to be in charge of Fitzroy Lodge. When the inspector arrived Mr Gunowa was not present at the care home. He arrived 15-20 minutes after a member of staff working at the care home telephoned him. The inspector looked at the staff rota. It did not show the hours Mr Gunowa worked at the care home, it stated “Supernumary” against his name. When he was asked about this Mr Gunowa told the inspector that this means he comes and goes as he sees fit. It was not clear where Mr Gunowa would go to if he should leave the care home. Mr Gunowa and Mr Beeharry were advised that this is not acceptable. The staff should know when Mr Gunowa would be working at the care home. Residents and their families should also be confident when he is available to speak to, should it be necessary. The Commission would also need to know that Mr Gunowa works in the care home for the majority of the week (at least 30 hours). As mentioned previously, Mr Beeharry had arranged to meet with residents and their relatives during the last month. One visitor told the inspector, “It was a very informative meeting. Mr Beeharry said that residents’ safety was of paramount importance. He is also concerned about the hygiene in the home. Mr Beeharry also explained about the key worker system he will be introducing. I asked him if staff could wear name badges. He said he thought that would be a good idea. But they haven’t materialised yet”. The inspector also examined minutes of meetings with staff and with residents. They confirmed that Mr Beeharry uses meetings to communicate with staff and residents to ensure the home is being run effectively and in the best interests of residents. Mr Beeharry was unable to confirm that he had been visiting the care home in accordance with regulation 26. Following discussion, the inspector advised him of that the purpose of such visits was to enable a provider, such as himself, who was not in day to day control of the care home, to monitor the day to day running of the home. He should also write reports following such visits in order to demonstrate what he has found and any action he has needed to take to address any areas of concern. Mr Gunowa confirmed that it is not the policy of this care home for the manager or staff to be involved with residents’ finances. It is expected that relatives or an independent agent, such as a solicitor, deal with finances on Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 24 behalf of residents. One resident said that a solicitor, who helps them to deal with their affairs and pays the fees or other necessary bills, visits them regularly. Mr Gunowa also confirmed that a secure facility is available if residents wish to deposit money or valuables with the manager for safekeeping. He also confirmed that a record of such items is kept. At present, no one is making use of this facility. Following a tour of the premises, the inspector noted that, following a maintenance visit by the manufacturers, the hoist in one bathroom had a label instructing staff not to use it as it was out of action. Mr Beeharry appeared to be unaware of this; he was unable to confirm when work required to repair it would be completed. It was not clear if this meant residents needing such equipment were unable to take a bath, or if staff were lifting residents manually, and putting themselves at risk. Mr Beeharry was advised to include this on the maintenance programme. The inspector also expressed concern about the state of the premises outside. It has already been noted that filled black sacks and old disused radiators had been left outside near to the fire escape. The shed has blown down in recent windy weather and broken windowpanes were on the lawn. Pathways and handrails leading to the garden were also seen to be in a dangerous condition. Mr Beeharry was advised he should take appropriate action to ensure the health and safety of residents and staff is being promoted. Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 25 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 3 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 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Fitzroy Lodge DS0000063807.V297944.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? 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 OP29 Regulation 19(1)(b) (i) as amen Requirement Timescale for action 21/07/06 2 OP3 14(1)(c ) 3 OP3 14(1)(d) The registered person shall not employ a person to work at the care home unless subject to paragraphs (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2 particularly the obtaining of current criminal record checks at an enhanced level. (Previous timescale of 17/10/05 has not been met.) The registered person shall not 21/07/06 provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, there has been appropriate consultation regarding the assessment with the service user or a representative of the service user. The registered person shall not 21/07/06 provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, the registered person has confirmed in writing to the service user that DS0000063807.V297944.R01.S.doc Version 5.2 Fitzroy Lodge Page 27 4 OP7 15(2)(c) and (d) 5 OP19 23(2)(b) having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall 21/07/06 where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative, revise the service user plan; and notify the service user of any such revision. The registered person shall 21/07/06 having regard to the number and needs of the service users ensure that the premises are kept in a good state of repair externally and internally. 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.V297944.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fitzroy Lodge DS0000063807.V297944.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. 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. 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