Inspection on 17/05/05 for St Andrews Lodge

This inspection was carried out on 17th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Andrews Lodge 07/02/07

St Andrews Lodge 27/09/05

St Andrews Lodge 25/11/04

St Andrews Lodge 03/06/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Andrews Lodge St Andrews Lodge Burgess Hill West Sussex RH15 0PJ Lead Inspector Linda Riddle Announced Tuesday, 17 May 2005 V220475 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Andrews Lodge Address 39 St Andrews Road Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01444 236805 Mr Mohammad Feizal Ruhomally Mrs Beebee Zareenah Ruhomally Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 6 of places Dementia - over 65 years of age (DE(E)) 1 St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2004 Brief Description of the Service: St Andrews Lodge service number 0000014727 is a care home registered to provide accommodation and personal care for seven residents with mental disorders who are between the ages of eighteen and sixty five years. The registration includes provision for one service user over the age of sixty five. The registered providers are Mr M F Ruhomally and Mrs B Z Ruhomally who have owned the service since February 2002. Mrs Ruhomally is also the registered manager responsible for the day to day running of the home. St Andrews is a two storey detached house situated in a residential area within easy access of the town of Burgess Hill. Residents are accommodated in five single and one double room. There are two communal lounges one of which is designated as a smoking room. There is a large garden for residents use at the rear of the property. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This annual announced inspection was carried out over six hours by one inspector. Prior to the inspection the inspector looked at information held on file for the last six months. She read information provided by the owner/manager in a pre-inspection questionnaire and the last inspection report. The home had one vacancy at the time of inspection. All six residents were spoken with and they were very satisfied with the way they are looked after and with the home in general. Information was provided during discussion with the manager and for a shorter period, with Mr Ruhomally the co-owner. Care plans for three residents were read along with a number of other records and documents. Observations were made and a tour of the entire home was undertaken. Some areas of the building were in need of attention to the decorative condition. The overall quality of care was found to be good. Records were well maintained and the home was found to be efficiently managed. What the service does well: What has improved since the last inspection? The owner/manager has put in place a training programme which includes training specific to care of people with mental illness. This was a requirement resulting from the previous inspection. It will help to ensure that the changing needs of service users continue to be met and enable staff to have a better understanding of those they care for. Recruitment procedures have been tightened which should contribute to the safety of residents. This was also a requirement of the previous inspection but is still not completely addressed. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 6 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. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The needs of residents are fully assessed prior to admission to the home both by outside professionals and the owner manager. This process ensures that the home is the right place for each individual. That it can provide suitable accommodation and has staff who are suitably trained to care for each person in the way they need. That the home can help them to achieve their personal aims and goals. EVIDENCE: Pre-admission assessments were seen to be in the three files examined. One resident said ‘’yes I remember someone asked me about what I needed and wanted before I came here, a social worker I think’’. He had been in the home for several years as had most residents. A prospective resident had spent some short stays in the home and was due to be coming again before a decision is reached by him, his social worker and the manager about his moving in. Documentation was available to show the monitoring of these short stays as part of the assessment process. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8 The needs and wishes of residents are discussed with them. Residents then know that as changes happen in their lives they will be assisted by staff in appropriate ways to meet those needs. Staff will know how to care for a person based on the information provided in the Plan of care. Residents are consulted about what happens in the home and can take an active part in home life if they wish. In this way they are encouraged to view the home as ‘theirs’ and to be involved in the decisions that determine how it is run. EVIDENCE: Three individual Plans were read. They identified the physical, mental, emotional and social needs and showed how staff could help meet those and to adhere to resident’s specific wishes. One resident said “Zareena asks me what I need and what I would like to do, we talk about my problems and how she can help me’. Care plan reviews undertaken in the home were seen but copies of resource centre reviews for those who attend had not been obtained. This is a recommendation of the report. The owners meet with the residents approximately three monthly to discuss any issues about the home that arise or that residents raise. Minutes of these were seen to be signed by those who attended. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 10 Residents made comments such as “we have meetings and talk about everything in the home’’ We choose food for the menus’’ “I was asked what colour paint I wanted for the walls in my room and I think we were asked about the lounge decoration too’’. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 16, 17 Residents have opportunities to undertake jobs, training and skills that suit their lifestyles and accord with their wishes. As a result those who wish are able to go out into the community, to mix with people other than those they live with and to find fulfilment in doing what they like to do. There are few house rules and residents have the freedom to come and go much as they please within reason. With appropriate support, they are encouraged to have control over their own lives. Residents are helped to be as independent as possible which results in greater self-confidence. They are provided with a varied diet and quantities of food are sufficient for resident’s needs. The dining room was not very welcoming. EVIDENCE: Care plans included details of resident’s interests and arrangements for meeting their occupational needs. Three residents attend day centres for varying periods of time during the week. One said about the Stead Resource Centre, “I really like going there we do lots of different things and I have friends”. Another talked about several small jobs that he does in the local community and said “I’m retired but I like to keep busy”. Two residents preferred to remain at home carrying out some household tasks. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 12 Residents said there are few house rules “we can come and go as we please within reason as long as we let them know, that’s only fair”. One said there are rules about smoking “where we do it and about being careful”. Residents have their own bank accounts and mainly manage their own finances as they confirmed. Records of finances were seen. Menus showed that meals are varied and provide a balanced diet. Comments from residents included “it’s good food and we have plenty”, “I’m on a diet so I’m having lots of salads which I like” and in relation to alternatives one said “yes, we just say if we want something else”. The dining room is rather Spartan with bland walls and worn carpet and would benefit by being made more attractive which is a recommendation of this report. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Residents have a choice of GPs, dentists and other practitioners in the area to whom they can call upon for help and advice with or without the help of the manager. If a resident wishes to keep control of his/her own medication, a decision is made based on the outcome of risk assessment which determines if it is safe to do so. Medications in the control of the home were being safely stored, recorded and administered to ensure their security and the safety of residents. EVIDENCE: Information about resident’s GPs and social workers was detailed in their files. A resident commented “I haven’t needed to see my doctor for a long time but Zareenah would take me if I did”. Extra support for residents was seen to be provided by the Community Mental Health Team. Visits to dentists and opticians were recorded in the daily notes and a recommendation in relation to this has been made. Residents use hairdressers of their choice in the community. One said “Zareenah takes me to the hairdressers as I don’t like going on my own, I get nervous.” The manager made a chiropody appointment for one resident on request during the inspection. Records examined showed that medicines were being handled and recorded correctly. Residents said that they received their medications at the set times and as prescribed by their doctors. Records of medication training were seen. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has a complaints procedure which includes timescales. Residents were not very aware of the full procedure. They did think that they would know who to go to if they had a complaint. EVIDENCE: A complaints procedure is included in the Service User Guide but residents said they hadn’t really read them as they already knew about the home. The complaint procedure displayed in the home was not easy to read and needed a little updating which is a recommendation of this report. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Arrangements are in place to make the home as safe as possible for residents who live there. It is generally homely and residents have comfortable private and communal space. Parts of the building are in poor decorative order which need to be improved so that residents live in well maintained accommodation. The home is clean and hygienic thereby contributing to resident dignity, health and welfare. EVIDENCE: Reports seen indicated that the home met fire and environmental health standards. Furnishings were observed to be suitable for residents and in good condition. Private rooms are a good size and there is ample communal space for seven residents. Residents said they were happy with their rooms and the facilities in general. Some areas of wall, ceiling and skirting were seen to be in poor condition which appeared to have been caused by water damage. It is a requirement of the report that this be attended to. All areas including toilets, hand basins, and kitchen area were seen to be clean and fresh. The laundry is small but adequate and the policies and procedures for controlling infection were seen to be in place. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 The arrangements for staff cover are sufficient to meet the needs of current residents. Residents have confidence in their carers. The recruitment procedure is still not as thorough as it needs to be to fully safeguard residents. Suitable staff training is being provided by an external organisation. This is helping to ensure that the needs of residents are recognised, understood and met. EVIDENCE: Duty rotas examined showed that at least one person is always on duty and Mrs Ruhomally said that this is often two. Four residents are out at other venues on some weekdays. A resident said “yes, I think there’s enough of them to look after us well”. Other comments received indicated that the manager spends one to one time talking to residents and takes them to appointments. Most, but not all records and documentation was seen to be in place for those working in the home. A requirement has been made in respect of these matters. Training records were examined. A suitable induction training programme is now in place for any new staff recruited. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41, 42, 43 Residents know that their views and best interests are an essential part of any review of the home’s performance. Their rights are safeguarded by the home’s record keeping and policies. The home protects the welfare, health and safety of residents and staff. Residents benefit from living in a well run home. EVIDENCE: Annual questionnaires are used to obtain the views of residents and others. Results of these were published and on display in the home. All policies were seen to be in place. Records are securely held and were up to date and in good order. There were records of training in health and safety topics. Comments from residents included aspects of safety. Records showed they are involved in fire drills. A facility was available to record accidents. Documentation showed that equipment and installations such as the fire warning system, gas and electrics are tested regularly by approved contractors. A current insurance certificate was on display and a business and financial plan was seen. St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x 3 3 3 H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 19 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. 2. Standard 24 34 Regulation 23(2) (b) (d) 19 (1)(b) Requirement All parts of the care home are kept in good repair and are reasonably decorated. The registered person shall not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1 to 7 of Schedule 2.(Previous timescale of 31st January 2005 not met) Timescale for action 17/07/05 30/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 6 17 19 22 Good Practice Recommendations External care plan reviews should be obtained and held on file. The dining room should be made more welcoming Appointments/visits to/by healthcare practitioners should be recorded on a separate sheet in each individual file for ease of reference. The complaints procdure should be updated and be easier to read St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Andrews Lodge H60 H11 S14727 St Andrews Lodge V220475 170505 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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