Inspection on 13/09/05 for Sycamore Lodge

This inspection was carried out on 13th 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

Sycamore Lodge 29/01/08

Sycamore Lodge 23/01/07

Sycamore Lodge 07/02/06

Sycamore Lodge 08/03/05

Sycamore Lodge 14/10/04

Sycamore Lodge 17/12/03

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Sycamore Lodge 501 Slade Road Erdington Birmingham B23 7JG Lead Inspector Brenda ONeill Announced 13 September 2005 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. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Address 501 Chester Road, Erdington, Birmingham B23 7JG 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) 0121 377 6280 0121 377 6280 MInd In Birmingham Val Parker Care Home 13 Category(ies) of Mental Disorder (13) registration, with number of places Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years 2. That three named people, who are over 65 years of age can be accommodated and cared for in this Home. Date of last inspection 8th March 2005 Brief Description of the Service: Sycamore Lodge is a three-storey home consisting of two semi-detached properties, which have been converted into one home. All bedrooms are single and arranged over all three levels of the home. The accommodation on the top floor of the home is in the form of flatlets, with separate kitchens, bathrooms, bedrooms and communal lounge. These flatlets are provided for residents with higher levels of independence who may be en route to more independent living. There are two large lounges on the ground floor of the home, one smoking and one non - smoking; there is also a large dining area. The home also has a main kitchen and a training kitchen for use of residents under supervision of the staff and the homes cook/trainer. There is a wellestablished side and rear garden equipped with garden furniture and a green house. The home is conveniently located for local shops, churches, and college and leisure facilities. There are several bus routes running past the home providing easy access to Erdington and the city centre. Focus Housing Association owns the building, and the care and support is provided by Mind in Birmingham. The home views itself as a rehabilitation service, although there is no pressure placed upon residents to move on until they feel they have developed the necessary skills. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over one day and was the first of the statutory inspections for the home for 2005/2006. During the visit a partial tour of the premises was carried out, three residents’ files and the training and supervision records for three staff were sampled as well as numerous other policies and procedures, other care records and health and safety records. The inspector spoke with the manager, service manager, two of the staff on duty and seven of the twelve residents. What the service does well: All the residents spoken with were very positive in their comments about the staff and there were evident friendly relationships. It was evident from the practices observed that staff were very aware of the support needs of the residents and how these were to be met. There had been four new admissions to the home in a very short space of time however this did not appear to have disrupted the existing residents in the least and everyone appeared to have settled well. All residents spoken with were satisfied that their needs were being met. Staff were very aware of any residents whose mental health was causing concern and of the strategies in place to manage this. Resident involvement was seen as high priority at the home and residents were involved in staff training, staff recruitment and quality assurance audits if they wished. There were policies, procedures and general information available for the residents at all times. Independent living skills were being maintained and developed by residents with support from staff in respect of doing their own laundry, cleaning their bedrooms, preparing their own breakfasts and on occasions cooking. There were opportunities in the home for residents, who were able with support from staff, to manage their own budget and self cater using the facilities provided on the top floor of the home. There was good documented evidence of the health care needs of the residents being met both in terms of their mental and physical health. Staff demonstrated a good understanding of the mental health needs of the residents and of how to manage residents who were unwell. Where resident’s mental health had relapsed there was good documentation of the involvement of other professionals and of how it was being monitored. There had been no staff turnover at the home, which was good for the continuity of care for the residents. Staff were well trained and almost all had Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 6 either NVQ level 2 or 3. The training programme developed by MIND for this year clearly evidenced that they were committed to having a well trained staff group. The manager was experienced in the care of people with a mental health need and demonstrated a good knowledge of the needs of the residents in her care. The residents confirmed the manager was always willing to listen to them and that they would have no hesitation in raising any issues with her. Health and safety was very well maintained at the home and no requirements were made in relation to this following the inspection. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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 Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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, 3, and 4. The assessment procedures for the home were good and took into account the individual’s aims and aspirations. Staff were aware of the support needs of the residents and how these were to be met. Prospective residents were able to visit the home prior to admission to ensure the facilities and services met their needs. EVIDENCE: There had been four new residents admitted to the home since the last inspection. All of these were from another of the organisation’s homes that had closed. Those residents spoken with confirmed they were able to visit the home prior to their move and ensure it was what they wanted and all of them had settled well. The full assessment procedure was not inspected however the inspector was aware from previous visits that a thorough assessment of prospective residents’ needs took place that involved a variety of other professionals. All the residents spoken with were satisfied their needs were being met and discussions with staff evidenced they were aware of the support needs of the residents. Staff were very aware of any residents whose mental health was causing concern and of the strategies in place to manage this. There was evidence on daily records of the appropriate support being obtained in relation to both physical and mental health needs, for example, attendance at hospital appointments, meetings with consultants and changes to medication. One Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 9 resident who had wanted a move at the last inspection as she was getting older and wanted a change, had been helped to obtain another placement. Another had moved to a home where she could live more independently reflecting the ethos of the home to enable people to develop their skills so they were able to live more independently. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 10 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, 7, 8, and 9. There were good systems in place for care planning and assessing risks that involved consultation with the residents. However there needed to be a care plan in place when residents were unwilling to take part in drawing up their care plans to ensure staff knew their support needs. Residents made decisions about their every day lives wherever possible. EVIDENCE: Three residents’ files were sampled two included an Essential Lifestyle Plan (ELP) the third did not. An essential part of the ELPs is that the residents contribute to them as they include what’s important to the person, what others need to know from the residents point of view, what they enjoy, preferences and so on. As one of the residents had been unwilling due to their mental health to undertake this there was no ELP. This was discussed with the manager, as it was important to ensure that staff knew the support needs of the resident and how these were to be met. There needed to be a system in place that ensured support needs were documented for staff to follow particularly as the home used agency staff on occasions who would not know the residents or their needs. Residents were also encouraged to undertake self assessments that asked about their mental and emotional state, what has helped in their recovery, what has not helped, the skills they have and the Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 11 skills they want to develop. There were monthly evaluation sheets included on the files that documented how residents were progressing and identified any issues and actions to be undertaken. It was noted on one that it had been agreed with the resident to set up a weekly programme to give him some structure to his day/week as this may help overcome some of the issues identified however this had not been done. The residents were able to make decisions and this was respected by staff within the bounds of their risk assessments. Residents were seen to come and go from the home, spend time in their rooms or in the lounges, they had keys to their rooms and the front door and all the residents handled their own financial affairs on a daily basis. The manager and the organisation continued to be very keen to develop ways in which the residents could participate in the running of the home. All were involved in drawing up their own care plans and risk assessments. They could be involved in staff recruitment and the quality assurance audits if they wished. Residents were also encouraged to take part in staff training courses. There were policies, procedures and general information available for the residents at all times. All the files sampled included numerous risk assessments for such things as self harm, self neglect, aggression and so on. These included specific known triggers for the risks as well as a risk management plan. The residents were involved in drawing these up and were aware of the management plans. The vast majority of these were very well detailed however some needed to be more specific, for example, one stated give support but did not state what type of support and give full explanations but did not detail what explanation. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 12 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) 12,13,14,16 and 17. Residents had the opportunity to develop and maintain life skills both within and outside the home and were able to engage in appropriate leisure activities. There were no rigid rules or routines in the home and the residents were satisfied that they could spend their time as they chose within the bounds of their risk assessments. EVIDENCE: Independent living skills were being maintained by residents with support from staff in respect of doing their own laundry, cleaning their own rooms and preparing their own breakfasts and on occasions cooking for themselves. There were opportunities in the home for residents, who were able with support from staff, to self cater managing their own budget using the facilities provided on the top floor of the home. There were no residents in employment at the time of the inspection. All residents were encouraged to pursue some activities during the week. They could attend local colleges and a day centre run by MIND that was very close to the home. One resident commented that she had started a pottery course at college the day of the inspection, another returned from a day centre during Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 13 the course of the inspection. There was a computer in the home that residents could use if they wished and the manager was keen to encourage this. All the residents were able to go out independently in the local community and many travelled on public transport. Others had the support of staff when going into the city centre. There was evidence of residents going out for meals, to the hairdressers, to the doctors, to visit families and being consulted about going to bingo, bowling and out on day trips. There did not appear to be any rigid rules or routines in the home and the residents were satisfied that they could spend their time as they chose within the bounds of their risk assessments. Where any restrictions were in place they had been agreed with the residents and were documented, for example, some bedrooms were checked on a very regular basis due to the risks of residents smoking. All the residents spoken with were happy with the catering arrangements at the home. The menus were drawn up after consultation with the residents and appeared varied and nutritious. There were no stated choices on the menu for the main evening meal but the residents confirmed that if they did not like the main meal as long as they informed the cook before midday an alternative would be discussed and prepared for them. All residents prepared their own breakfasts in a separate kitchen and had access to this for making their own drinks and snacks. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 14 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) 18, 19 and 20. Staff had a good understanding of the resident’s personal and health care needs and ensured these were met whilst maximising their independence and control over their lives. The medication system was well managed ensuring the residents received their prescribed medication appropriately. EVIDENCE: The residents were independent in terms of personal care and only needed prompting by staff. Staff did have to be more persistent with some residents however this was seen to be done in an appropriate manner. There was good documented evidence of the health care needs of the residents being met both in terms of their mental and physical health. Staff demonstrated a good understanding of the mental health needs of the residents and of how to manage residents who were unwell. Where resident’s mental health had relapsed there was good documentation of the involvement of other professionals and of how it was being monitored. Residents attended the local doctors surgery for general physical health concerns and there was also evidence of any specialised equipment being obtained, for example, shoes. Medication was being administered via a monitored dosage system and the residents were encouraged to take part in this as much as possible. They were Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 15 observed to come to the office for their medication check it with staff and take out of the cassettes. One of the residents was self administering insulin and this was done in the presence of staff who checked the amount with her. All staff that administered medication had accredited training. The manager was auditing the medication twice weekly to ensure there were no discrepancies. There was only one minor requirement made in relation to one resident not having written guidance for the administration of PRN (as and when necessary) medication for staff to ensure they knew when it should be administered. Guidelines were available for all other residents. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 16 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 and 23. The home had a robust complaints procedure that evidenced any complaints received were taken seriously and acted upon. Staff had received training in the prevention of abuse to ensure the protection of the residents. EVIDENCE: The home had a robust complaints procedure that all residents had received a copy of. Residents commented they would have no difficulties raising any issues with the manager. The home had received two complaints over the last year both from residents which were appropriately investigated, documented and resolved. No complaints had been lodged with the CSCI. Staff had received training in the issues surrounding adult protection. No issues had arisen at the home. There were policies and procedures on site both from the organisation and the most recent multi agency guidelines for adult protection. It was noted that the organisation’s procedures differed slightly from the multi agency guidelines in respect of investigations and whether to report to social care and health. This was discussed with the service manager who was to address with the procedure writers. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30. There had been extensive redecoration and some new furnishings at the home which had greatly improved the environment which now provided the residents with a comfortable, spacious and homely place to live. EVIDENCE: In the main the premises were fit for purpose, safe and accessible. There had been a considerable amount of redecoration since the last inspection and all bathrooms, toilets and shower rooms had been redecorated they had also had new flooring fitted. The smoking lounge had been redesignated to another lounge and the former smoking lounge had been redecorated had all new furniture and new flooring. The home has a decorating/refurbishment plan for the next three years and in the main this is being completed in the specified times. The grounds of the home were very well maintained and had a lawned area with garden furniture available for the use of the residents. Although not inspected during this visit it was known by the inspector that the home has one bedroom that is documented as only being 8 square metres and Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 18 as such was not fit for purpose. The room continued to be occupied and the resident concerned did not want an alternative room. Once this room is vacated it is not to be reused as a bedroom. One bedroom was seen and this met with the needs of the occupant and all other residents spoken with were happy with their bedrooms. The home had ample communal space comprising of two lounges, large dining room, small room where there was a computer for the resident’s use and a small lounge on the top floor of the home. The manager was aware that if the lounge being used as the smoking area was to remain as such then adequate extractor fans would have to be fitted. The home also had a main kitchen where the majority of the meals were cooked, a training kitchen for the use of the residents and two further small kitchens on the top floor for the use of any residents who wished to self cater. There were ample toilets, bathrooms and showers in the home that met with the needs of the residents. The home was found to be generally clean, with the exception of the carpet in the entrance hall corridor, hygienic and odour free. Domestic assistants were employed to assist with the cleaning of the communal areas. The laundry was appropriately located and equipped. There were infection control procedures on site however it was recommended that the manager obtained an updated copy of these. Protective clothing was available for staff when needed. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 36. Adequate staffing levels were being maintained by a well trained staff group that could meet the needs of the residents. EVIDENCE: Throughout the inspection staff demonstrated a very clear understanding of the needs of the residents and the support they needed. There were very positive interactions between staff and residents and without exception the resident’s comments about staff were very positive. There had been no staff turnover since the last inspection which was very good for the continuity of the care of the residents. Staffing levels appeared adequate for the needs of the residents at the time of the inspection. There were generally two care officers on shift with the manager’s hours being supernumery to this during the week. When fully staffed there were occasions when there were three care officers on shift. Staff transferring from another of the organisations homes had filled the previous vacant posts. The home also employed a cook and domestic assistant. The inspector had the opportunity to view the training programme for MIND for this year and this demonstrated they were clearly committed to having a well trained staff group. There was an induction procedure followed by other Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 20 training that encompassed all the regulatory training plus other topics, for example, essential lifestyle plans, self harm, recovery and protection from abuse. The manager did need to ensure that the induction and foundation training was carried out within the time scales specified by the Sector Skills Council as from the training programme this would be difficult to achieve as the training had prescribed dates and it would depend on when new staff commenced their employment. Six of the seven care officers were qualified to NVQ level 2 or 3 and all were receiving ongoing training in a variety of topics. Three staff supervision files were sampled and these met with the requirement of six sessions per year. There were staff handovers at the change of shifts, regular staff meetings and the manager had regular contact with the staff. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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 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) 37, 38, 39, 42 and 43. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was very well managed. EVIDENCE: The manager had several years experience in caring for people with a mental health need and demonstrated an excellent knowledge of the residents in her care. She was undertaking the care component of the NVQ level 4. She was very pro active in trying to involve the residents in the day to day running of the home and maintaining and developing their independence. Regular resident and staff meetings were held. Residents and staff were seen to have very good relationships with the manager. The residents confirmed the manager was always willing to listen to them and that they would have no hesitation in raising any issues with her. Throughout the course of the inspection residents were coming and going from the office chatting to the manager. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 22 Although not fully inspected the inspector was aware from previous inspections that MIND had a quality assurance system which incorporates internal audits of the standards of the service being carried out. Staff, residents and an executive committee member from the organisation were involved in the auditing process. Health and safety was very well maintained at the home. Staff had received training in safe working practices including, fire procedures, first aid and food hygiene and protective clothing was available as needed. There were numerous policies and procedures on site in relation to health and safety, for example, lone working, adult protection and dealing with aggression. There was evidence on site of the regular servicing and required checks of fire alarms, emergency lighting, fire extinguishers, gas appliances, portable electrical appliances and electrical wiring. Staff also carried out regular checks on residents’ bedrooms in respect of health and safety. The frequency of these was determined by the risks posed. There were adequate up to date risk assessments on site for the premises, fire prevention and in relation to the residents. The home had complied with the requirements made by the environmental health officer and the fire officer. Accident and incident recording and reporting was seen to be appropriate. There was comprehensive insurance cover for the home and evidence of this was seen during the inspection. The manager received regular support and supervision from her line manager. CSCI were receiving some copies of Regulation 26 visit reports however this was not being done on a monthly basis as required. Three of the new residents admitted to the home were over 65 years of age. As the home is registered to accommodate people between the ages of 18 and 65 an application to vary the registration to accommodate this must be forwarded to the CSCI. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 2 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 3 x x 3 2 E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 24 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 6 Regulation 15(1) Requirement All residents must have a plan of care that details their support needs and how these are to be met. Any actions agreed with residents at the monthly evaluations must be carried out. Risk assessments for the residents must detail the type of support to be given to the residents. There must be written guidance for staff to follow in respect of all PRN medication. The responsible individual for the organisation must ensure that the adult protection procedure is in line with the multi agency guidelines. When vacated the small bedroom measuring only 8 square metres must not be used as a bedroom for residents.(Ongoing requirement until room vacated.) There must be adeqaute ventilation/extractor systems in any smoking areas in the home. The entrance hall carpet must be thoroughly cleaned. Induction and foundation Timescale for action 01/11/05 2. 3. 6 9 15(1)(c) 13(4)(c) 01/11/05 01/11/05 4. 5. 20 23 13(2) 13(6) 14/10/05 01/11/05 6. 25 23(2)(a) When vacated. 7. 8. 9. 28 30 35 23(2)(p) 23(2)(d) 18(1)(c) 01/12/05 14/10/05 01/11/05 Page 25 Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 10. 37 9(2)(b)(i) 11. 43 26 12. 43 12(1)(a) (b) training must be carried out within the time scales specified by the Sector Skills Council. The manager must be qualified to NVQ level 4 in care and management by 2005. (Previous time scale given had not expired.) Copies of the monthly visit reports made by the representative of the organisation must be available for inspection. A variation application must be submitted to the CSCI in relation to the new residents over the age of 65 years. 31/12/05 01/10/05 01/11/05 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. Refer to Standard 30 Good Practice Recommendations It was recommended that the manager obtained a copy of the most recent infection control procedures. Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 56-46 Stephenson Street Birmingham B2 4UZ 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 Sycamore Lodge E54 S16876 SycamoreLodge V242919 130905 AI stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!