Inspection on 27/09/05 for St Andrews Lodge

This inspection was carried out on 27th September 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 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

St Andrews Lodge 07/02/07

St Andrews Lodge 17/05/05

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 39 St Andrews Road Burgess Hill West Sussex RH15 0PJ Lead Inspector Mr D Bannier Unannounced Inspection 27 September 2005 14:00 St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 Adults 18-65. 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. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Andrews Lodge Address 39 St Andrews Road Burgess Hill West Sussex RH15 0PJ 01444 236805 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) Mr Mohammad Feizal Ruhomally Mrs Beebee Zareenah Ruhomally Mrs Beebee Zareenah Ruhomally Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2005 Brief Description of the Service: St Andrews Lodge is a care home registered to provide accommodation and personal care for up to seven service users in the category mental disorder (MD) between the ages of eighteen and sixty five years. The registration includes provision for up to three service users over the age of sixty five years. St Andrews is a two storey detached house situated in a residential area of Burgess Hill within easy access of the town centre and its facilities. Private accommodation is provided in one double and five single bedrooms located on the ground and first floors. Communal areas include two lounges and a dining room located on the ground floor. There is also a large garden to the rear of the property. The registered providers are Mr and Mrs Ruhomally. Mrs Ruhomally is also the registered manager and is responsible for the day to running of the care home. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 2pm. It took place over two and a half hours. The inspector spoke to three residents, including one resident who had been admitted since the last inspection. Mr and Mrs Ruhomally were present at the time of the inspection and kindly helped the inspector with his enquiries. Mr Ruhomally showed the inspector around the care home. Some records were also examined. What the service does well: What has improved since the last inspection? Improvements have been made to the decorative order of the care home. The area where water damage had occurred has been repaired and redecorated. Work has commenced on improving the decoration in the dining room. Residents have been consulted with regard to how this should be done. All staff who work in the care home have now been subjected to criminal records checks to protect vulnerable residents from abuse. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 DS0000014727.V253112.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 2 A comprehensive assessment of residents’ needs is carried out by the manager prior to their being admitted. EVIDENCE: One resident has been admitted since the last inspection. Records seen showed that a comprehensive assessment has been carried out before the resident was admitted to the care home. As recommended at the last inspection, the manager has also obtained care plans drawn up by the resident’s social worker. The resident explained to the inspector that he was consulted about his assessment and has also been involved in drawing up the subsequent care plan. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 and 9 Care plans have been drawn up after consultation with individual residents. EVIDENCE: The inspector looked at the records of three residents, including those of the new resident. Records seen demonstrated that care plans have been drawn up with each resident. Residents have signed care plans to indicate they have been consulted. Residents explained to the inspector that they discuss their care plans with the manager on a regular basis. Care plans include details and guidance for staff to follow to ensure residents’ needs are met as agreed with them. Care plans seen reflected that the majority of residents require support by discussing any concerns they may have and identifying how they may be resolved. One resident is being assisted in budgeting to ensure they have enough money to purchase cigarettes and tobacco through the week. One resident likes to help out with the housework. This includes helping with polishing and dusting, and preparing and cooking meals. This care plan showed that the risks involved in working in the kitchen has been fully discussed with St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 10 the resident. The support and supervision the resident needs in order to successfully perform such tasks has also been discussed and agreed. Residents told the inspector that they are able to talk to Mr and Mrs Ruhomally about any worries they have. Residents described them as very kind and caring. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 13 and 15 The residents are encouraged to become part of the local community. Other key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: Residents told the inspector that they could go out to the local town if they want. One resident said that they had planned to go to Brighton at the weekend, but had decided not to go after all. Two residents visit friends and family on a regular basis. One resident told the inspector their friends can visit him in the care home, but he prefers to go out to visit them. The manager informed the inspector that residents are encouraged to go to and, where necessary, accompanied to go to the local shops. They are also encouraged to attend local churches. Several residents attend local rehabilitation centres. Here, they are provided with rehabilitative work for which they are paid. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 12 St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 18 The manager discusses the way each resident prefers to receive personal support with each resident regularly. Other key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: The inspector looked at the records of three residents, including those of the new resident. Records seen demonstrated that care plans have been drawn up with each resident. Residents have signed care plans to indicate they have been consulted. Residents explained to the inspector that they discuss their care plans with the manager on a regular basis. Care plans include details and guidance for staff to follow to ensure residents’ needs are met as agreed with them. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 23 The providers have taken appropriate action to ensure residents are protected from abuse. Other key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: During the course of the last inspection it was identified as a requirement that all staff that work at the care home should undertake criminal record checks. This should include Mr and Mrs Ruhomally’s family members, who help out from time to time. Records seen demonstrated that all members of staff who work in the care home have now been subjected to such checks at an enhanced level. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 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 the following standard(s): 24 The providers have made improvements to the environment to ensure residents live in a comfortable and safe environment. Other key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: During the course of the last inspection it was noted that an area in the care home had been affected by water damage. The inspector made it a requirement that the providers should repair and redecorate this area. The inspector saw that the skirting board had been replaced and the wall and ceiling had been redecorated. Mr Ruhomally informed the inspector that he had discovered that the toilet, located on the other side of the wall, had been leaking and had caused the damage. Mr Ruhomally showed the inspector that he was in the process of having this toilet replaced. It was also recommended previously that the dining room should be made more welcoming. Mr Ruhomally showed the inspector that some pictures had St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 16 been put on the walls. He also intended to replace the flooring with a covering that is more easily cleanable. Mrs Ruhomally informed the inspector that she had been talking to residents with regard to their preferences for colour in the dining room. One resident told the inspector that he liked it the colour it is already! St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Staff employed at St Andrews Lodge is considered to be competent and qualified to support the residents accommodated. The providers have taken appropriate action to ensure the home’s recruitment policy and practices are sufficiently robust to support and protect vulnerable residents. Other key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: According to the rota, the staff team is made up of Mr and Mrs Ruhomally and one other member of staff. Mr Ruhomally is a qualified Registered Mental Nurse (RMN). Mrs Ruhomally informed the inspector that she relies on her husband for guidance and advice regarding clinical issues relating to residents’ mental health needs. Mrs Ruhomally holds the Advanced Management in Care award and takes responsibility for the day-to-day running of the care home. She also has six years experience of providing care and support to people with mental illnesses. They also have a care worker who has worked at this care home since before Mr and Mrs Ruhomally have become the registered providers. This provides some continuity for residents. There are plans for this member of staff to St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 18 undertake some training with regard to improving their understanding of mental health issues. Mrs Ruhomally is responsible for supervising the member of staff. Records seen showed that, currently, supervision takes place every six months. Following discussion, the inspector advised Mrs Ruhomally that best practice dictates that such supervision should take place at least every two months. Mrs Ruhomally was also advised that supervision should include discussions related to how care is provided to meet the needs of each resident, linking care practices to the aims and objectives of the care, and identifying staff training needs. This will mean staff are clear about their role and are appropriately trained to carry this out. During the course of the last inspection it was identified as a requirement that all staff that work at the care home should undertake criminal record checks. This should include Mr and Mrs Ruhomally’s family members, who help out from time to time. Records seen demonstrated that all members of staff who work in the care home have now been subjected to such checks at an enhanced level. This will mean that vulnerable residents are protected from the possibility of abuse. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 19 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed on this occasion. Key standards in this section had been assessed as being fully met at the last inspection. EVIDENCE: St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 20 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 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Andrews Lodge Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x DS0000014727.V253112.R01.S.doc Version 5.0 Page 21 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 33 Good Practice Recommendations It is recommended that staff receive supervision at least every two months. St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 22 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 St Andrews Lodge DS0000014727.V253112.R01.S.doc Version 5.0 Page 23 - 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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