Inspection on 07/02/07 for St Andrews Lodge

This inspection was carried out on 7th February 2007.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Andrews Lodge 27/09/05

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 E McLeod Unannounced Inspection 7th February 2007 09:30 St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 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.V324817.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 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.V324817.R01.S.doc Version 5.2 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) standrewslodge@tiscali.co.uk 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.V324817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27.9.05 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.V324817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to update assessments of key standards from the National Minimum Standards made at the previous inspection. The key unannounced inspection visit to the home was undertaken by one inspector on the 7th February 2007 from 12.30 p.m. until 3.20 p.m. The registered person had completed a pre-inspection questionnaire and information from this plus evidence from previous inspections has been used to inform the planning and inspection process, and this report. Evidence gained during the inspection visit also informs this report. On the day of the inspection visit, the inspector spoke with three residents, Mrs Ruhomally the registered manager, and Mr Ruhomally the joint owner and a member of the care team. A partial tour of the premises was made. The inspector sampled three sets of admission records for residents, and three sets of care plans. Two sets of staff recruitment and training records were also sampled. The inspector observed interactions between staff and residents. A number of policies, procedures, and health and safety records were also sampled. What the service does well: What has improved since the last inspection? St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 6 Improvements to the premises since the previous inspection include the refurbishment of the kitchen and a bathroom. Residents continue to develop their independence skills and increase their selfesteem. 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. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 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.V324817.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA2 New service users are admitted only on the basis of a full assessment undertaken by people competent to do so. EVIDENCE: The present scale of charges is £296.88 to £400 per week. Three sets of pre-admission reports and assessments were sampled, which indicated that prospective residents are being fully assessed to find out if the service can meet their needs before a trial placement is offered. These visits are carried out by Mrs Ruhomally or Mr Ruhomally, who are registered mental nurses. Trial placements are for a minimum of one month, and prospective residents are visited as part of the assessment process. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA6, 7, 9 Residents know their assessed and changing needs and personal goals are reflected in their individual plan. Residents make decisions about their lives with assistance as needed. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Three sets of service user plans and care records were sampled, which indicate that residents have a full care plan which guides staff on how their needs are to be met. Care plans are being regularly reviewed, including through Care Programme Approach (CPA) reviews which include the local community mental St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 10 health team. Residents participate in the writing and reviewing of their care plan, and sign these to indicate their agreement with the plan. Residents are involved in making up the menus and choosing colours when we decorate their bedrooms. Residents interviewed gave examples of how they are being assisted to make decisions about their lives and have their individual choices respected. It was the observation of the inspector that residents were being treated with respect, and no incidents which indicated that residents were being discriminated against on account of their disability, gender or race were noted. Care records sampled included risk assessments, and indicated how staff should be assisting the resident to take risks as part of an independent lifestyle. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA12, 13, 15, 16, 17 Residents are able to take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents’ rights are respected and responsibilities recognised in their daily lives. Residents have appropriate personal and family relationships. Residents are offered a healthy diet and enjoy their meals and mealtimes. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents interviewed had active lifestyles, including work projects where the can earn pay, and attendance at centres where they can meet up with their peer group. Some residents are also being supported to improve their independence skills by doing tasks such as food and drinks preparation in the home. Examples were given of how residents are supported to keep up their interests and hobbies. Interviews with residents indicated that they make use of facilities in the local community, and that there are good relations with neighbours. Residents said that staff support them to make use of local shopping facilities as well as travelling further a field when they feel able. Residents and staff gave examples to the inspector of how residents are being supported to maintain contact with family and friends. A relative has advised the Commission that he/she feels welcomes when the visit, and are kept advised and are consulted about important care issues. Residents are free to use their time as they wish, but where it has been helpful to provide structure for the resident this is included in the care plan. Residents are encouraged to develop their independence skills by the activities they take part in and support to increase their confidence and self esteem. Menus seen indicate that there is a light lunch, for example sandwiches of beans on toast, with soup as an alternative. There is a cooked evening meal, with the alternative being cooked meat and salad. Residents interviewed liked the food provided, and it was indicated that residents help plan the menus. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA18, 19, 20 Residents receive personal support in the way they prefer and require. Residents’ physical and emotional health needs are met. Residents retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Residents interviewed felt they were being cared for in a sensitive and respectful manner. Interviews with staff indicated that assistance with personal care was usually only in the form of prompts and encouragement. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 14 Care records sampled indicated that residents are accessing a range of health and mental health support services, including dentistry, chiropody, and local community health services. There was evidence that staff support is enabling residents to better cope with life situations and problems such as panic attacks. A relative who responded to a CSCI survey said that they were satisfied with the overall care provided in the home. Medication procedures and records were sampled. Health records seen indicate that the resident’s medication is being reviewed on a regular basis by the local community mental health team. One resident self administers medication, for which they have lockable storage, and a risk assessment was carried out before self administering medicines began. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA22, 23 Residents feel their views are listened to and acted on. To better protect residents from abuse, neglect and self harm the adult protection procedures should be expanded to include the referral of incidents to the local social services department and the referral of staff found to have caused harm to residents to the Protection of Vulnerable Adults register. EVIDENCE: The complaints policy was most recently updated on 15.11.06, and advises residents and others on the home’s procedure for responding to complaints. The complaints record was seen, and it was noted that no complaints have been recorded since the previous inspection. Training in adult protection is being provided for staff, and registered manager Mrs Ruhomally said that she had applied to take up training in updates to local adult protection procedures. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 16 An adult protection procedure for the home is in place, but this does not include information on the duty of the provider to make appropriate referrals to the protection of vulnerable adults register, and does not advise staff of local adult protection procedures or the need to make appropriate referrals to West Sussex County Council social services department. A copy of the Department of Health guidelines on making an application to the Protection of Vulnerable Adults register was not available in the home. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA24, 30 Residents live in a homely, comfortable and safe environment, but some redecoration and refurbishment is needed. All areas of the home visited were clean and hygienic. EVIDENCE: Improvements to the premises since the previous inspection include a new carpet in the lounge, and refurbishment of the kitchen and a bathroom. Mrs Ruhomally said that keeping the home looking nice and homely is important, and that painting and decorating was usually carried out during the summer months. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 18 A partial tour of the premises was carried out. The garden is well kept, but some damage to fences was noted. The main communal areas are the lounge, the smoking lounge, and the dining room. Some tears and other signs of wear was noted on couches in the lounges and on chairs in some bedrooms, and some carpets seen were in need of replacement. Some areas seen were in need of redecoration. There is one shared bedroom and six single bedrooms. The two residents who share a bedroom are good friends and spend social time together. All areas of the home visited were clean and hygienic. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA32, 33, 34, 35 Residents are supported by competent and qualified staff. Residents are supported by an effective staff team. Residents are supported and protected by the home’s recruitment policy and practices. Residents’ individual and joint needs are met by appropriately trained staff. EVIDENCE: There are 4 care staff, one of whom has NVQ level 2 or above, and a registered mental nurse (RMN). One new member of staff has commenced employment since the previous inspection, and has started on an approved St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 20 induction training. Formats for foundation training are also used to assist staff in developing their skills. Staff rotas sampled indicate there is one member of staff on each early, late, and night shift. It was the view of one relative responding to a CSCI survey that there are always sufficient staff on duty. Interviews with residents indicated that staff are available to accompany them on appointments and take them out. Two sets of recruitment records were sampled, which indicated that the appropriate checks and selection processes are in place to ensure residents are protected by the home’s recruitment processes. Staff training provided during the past 12 months has included first aid, fire training, and administration of medication training. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. YA37. 39, 42 Residents benefit from a well run home. More needs to be done to ensure residents views underpin all self-monitoring, reviews and development by the home. The health, safety and welfare of residents are promoted and protected. EVIDENCE: St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 22 The registered manager has continued to update her training and skills, and there were many indications during the inspection that the home is being well managed. Residents are being asked their views on the running of the service, and this is evidenced by completed questionnaires and records of service user review meetings seen. However, no summary of the views of service users has been produced, and therefore there is no indication of action planned to improve the service as a result of consultation with residents, their relatives, and stakeholders in the community. The provider has advised the Commission of the most recent service visits, checks and inspections which have taken place, and staff training in health and safety issues which has taken place. Mrs Ruhomally said that she undertakes regular safety checks of the home, but does not record these. The provider has advised that five residents handle their own financial affairs. The manager/owner acts as appointee for handling the personal allowance of one resident. St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 24 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 YA23 Regulation 23.2 Requirement Timescale for action 30/03/07 2 YA24 13.6 3 YA39 24.2 Procedures for responding to suspicion or evidence of abuse or neglect must be expanded to better protect residents The home must have a planned 27/04/07 maintenance and renewal programme for the fabric and decoration of the premises with records kept The results of service user 27/04/07 surveys are to be published and made available to service users, their representatives and other interested parties. 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 St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 St Andrews Lodge DS0000014727.V324817.R01.S.doc Version 5.2 Page 26 - 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. 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