Inspection on 23/01/07 for Sycamore Lodge

This inspection was carried out on 23rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore Lodge 29/01/08

Sycamore Lodge 07/02/06

Sycamore Lodge 13/09/05

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 West Midlands B23 7JG Lead Inspector Nancy Johnson Key Unannounced Inspection 23rd January 2007 09:30 Sycamore Lodge DS0000016876.V324694.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 Sycamore Lodge DS0000016876.V324694.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. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Address 501 Slade Road Erdington Birmingham West Midlands B23 7JG 0121 377 6280 0121 377 6280 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) Mind in Birmingham Valerie Parker Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That five named people, who are over 65 years of age can be accommodated and cared for in this Home. 7th February 2006 Date of last inspection 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 DS0000016876.V324694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day and was the seco inspection for the home for 2006 - 2007. During the visit a full tour of the premises was carried out, five residents’ files, three staff files (one volunteer) were sampled along with other training, care and health and safety records. The inspector joined a couple of the residents and a staff member for lunch and spoke with three residents. The inspector spoke with the manager, three care officers, observed administration and recording of medication, the afternoon shift ‘hand over’ and various staff and service users interactions during the course of the day. What the service does well: The residents spoken with stated that they were happy with the care and support they received. It was clear from the inspector’s observation that residents related well with staff and that they felt able to approach staff if and when they needed to do so. It was evident from observations and records seen that residents were encouraged to make decisions about their lives within remit of their risk assessments. Residents were encouraged by the manager and staff to maintain links with families and friends. In the case of family breakdown, residents were encouraged and supported to re-establish links subject to relevant risk assessment. There were good documented evidence of the health care needs of the residents being met both in terms of their mental and physical health. Staff were able to demonstrate a good understanding of the mental and physical health needs of the residents and how to manage residents who were unwell. Where residents mental health had relapse, there was good documentation of the involvement of other professionals and how it was being monitored. The home is well managed with a stable staff team and continuity of care for residents. Residents have a plan of care that details their support needs and how these are to be met. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 6 The organisation is committed to having a well trained staff group, with the majority of the staff having NVQ Levels 2 and 3 in accordance with Standards 32.1 and 33.1. The premises provided residents with a comfortable and spacious home within easy reach of various amenities. The health and safety of the residents and staff was well managed and no requirements were made in relation to this at the last inspection or as result of this inspection. What has improved since the last inspection? The improvement noted in the environment at the last inspection has been maintained. All the bathrooms, toilets and shower rooms had been redecorated and had new flooring. One of the lounges had been redecorated, had all new furnishings and new flooring and the dining room had also been repainted. This had made the home much brighter and more comfortable for the residents. There was adequate ventilation for the residents in any designated smoking areas. All staff (including bank workers) have attended Health and Safety Training and Distance Learning Medication Training. Copies of the monthly visit reports made by the representative of the home were made available for the inspection to evidence that the conduct of the home was being overseen. Copy of reports were also sent to CSCI. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 7 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. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 8 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 Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 two new residents admitted to the home since the last inspection. One resident has their own accommodation and a period of rehabilitation is in place to facilitate their likely return. Records seen and residents spoken with confirmed they were able to visit the home prior to their move and ensure it was what they wanted. Files sampled evidenced that a thorough assessment of prospective residents were undertaken that involved other professionals. Discussions with residents evidenced that their needs were being met and that they were happy with the care they received. Staff were very much aware of any residents whose mental and physical health were causing concern and of the strategies in place to manage these. There was evidence on daily records Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 10 of the support being obtained in terms of both mental and physical health needs, for example attendance at hospital appointments, meetings with consultants and changes in medication. Files sampled were organised and included well formulated care plans with risk assessments and management plans. These were reviewed on a monthly basis and in most instances there were six monthly statutory reviews. Files sampled contained signed Licence Agreement for residents accommodation. It was evident from records, observations and discussions during the course of the inspection that residents were encouraged to make decisions about their lives, with approprate risk assessments in place where necessary. All the residents managed their own finances, had keys to the front door of the home and bedrooms. Residents were seen to come and go as they wished during the course of the inspection. In ther words of one resident “I have plenty of freedom, to come and go and make my own choices”. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 11 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): 6, 7, 8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning system was good with support needs being based on identified needs, and appropriate risk assessments and management plans in place. EVIDENCE: Five residents’ files were sampled, all included an Essential Lifestyle Plan (ELP) and two including self assessments. Records indicate that residents were involved in drawing up their ELP and it was written from their perspective and included their short and long term goals, what they enjoyed/preferred/disliked and a section that included what other people needed to know to be successful in supporting them. There was also a section for unresolved issues or issues of disagreement between staff and the resident. things like ‘I need support when I go out’, ‘I need support with tidying my room’ . According to the records there has been improvement in the section detailing the type of support staff were to offer. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 12 Residents were encouraged to undertake self assessments that asked about their mental and emotional state, what has helped their recovery, what has not helped, the skills they have and the skills they want to develop. Of the five files sampled, two residents carried out self assessments. Residents were involved in drawing up their care plans and risk assessments, including self harm, self neglect, and aggression and were aware of the management plans. These plans were detailed, clearly outlining type of support and areas of responsibilities. The ELPs clearly reflected what the residents thought were their support needs but it was evident from the daily records, discussions with the manager and the monthly evaluation sheets that the residents were receiving a lot more support than was documented. The manager confirmed that quantifying support care needs with clearly defined management plans have been an area of focus especially since the last inspection. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home demonstrate that by working with local agencies and community organisations it is better able to facilitiate more opportunities for residents’ personal development. Residents rights were respected, they were involved in formulation of menus and had the opportunity to develop and maintain life skills. EVIDENCE: Records and discussion with residents confirmed that menus were regularly reviewed, residents had a choice of meals daily including fresh fruits. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 14 There was documented evidence that staff encouraged and welcomed appropriate family involvement in the lives of the residents. Some of the residents regularly went out to see relatives and several had visits at the home. One of the residents commented about going to church every week with a relative and another commented about her weekends staying with relatives on a regular basis. Some of the residents had personal friendships and spoke of their friends being able to visit the home. The manager discussed with the inspector how the staff at the home were trying to re-establish family contact for one of the residents as there had been some issues. Arrangements were now in hand for contact to take place. Residents were supported by staff in developing and maintaining independent living skills in doing their own laundry, cleaning their own rooms, preparing their own breakfast and on occasions cooking for themselves. At the time of the inspection one resident was supported to self cater and managing their own budget using the facilities provided on the top floor of the home. Another resident was supervised in cooking three evening meals. All the residents had Sunday meal together. All residents were encouraged to pursue some activities, ranging from knitting, tapestry, pottery, cooking and other courses at the local college. There were examples of resident having a full programme of activities, Monday to Saturday. Residents were able to make decisions about internal activities including hair and beauty treatment, bingo sessions, monthly take-away and video night. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 15 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): 18, 19, 20, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal and health care needs were being met whilst maximising their independence. There was a robust medication system in place, ensuring appropriate receipt, administration and recording of residents’ medication. EVIDENCE: There was good documentation on the daily records and monthly evaluation sheets of all the health care appointments that the residents had attended including, G.Ps, dentists, chiropody and optician. Discussions with the manager and staff evidenced that they were well aware of when any of the residents’ mental health was relapsing. There was documented evidence that when this occurred the appropriate professional help was sought and if necessary residents were admitted to hospital for a while. One of the residents at the home had been admitted to hospital for an ongoing illness and had died the day before the last inspection. Another resident died since the last inspection. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 16 All the residents had been told and staff were very aware of how this might affect the mental health of some of the residents particularly those the service user was closer to and staff were monitoring the situation closely. The manager was aware of the individual’s wishes and was ensuring these were carried out. The manager made arrangements for bereavement counselling for residents and staff group. There was protocol covering Standard 21 files sampled contained signed consent forms in terms of the resident’s wishes. The ‘Have Your Say’ survey analysis suggests that service users were confident that their wishes would be respected. Files sampled showed that residents had a plan of care detailing their support needs and how these were to be met; with appropriate risk assessments and management plans in place. These outstanding requirements from previous inspections were now met. Documented evidence highlight that the health care needs of the residents were being met both in respect of the mental and physical health. The inspector’s general observation was that staff demonstrated a good understanding of the mental and physical health needs of the residents and how to manage residents who were unwell. Record showed that where residents’ mental health had deteriorated there was clear documentation of the involvement of other professionals and how it was bing monitored. Medication was being administered through a monitored dosage system and the residents were encouraged to take part in this as much as possible. The inspector was able to observe residents come into the office for their medication. Most casettes included the resident’s photograh, the resident would then check it with staff and take out of the cassettes. The inspector was informed that even with such precaution, staff were doubly careful as there were residents, if shown another resident’s identity cassette, would agree that it was their medication. One resident was self administering insulin and this was done in the presence of staff who checked the amount with her. Staff administering medication have had accredited training. In-house information sessions have been provided by the Diabetic Nurse for all staff. There were also literature on diabetes and sugar free products had also been introduced in meals. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 17 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. The home has robust complaints procedures, residents have received copies and are fully aware of how to make a complain. EVIDENCE: Records showed that residents were aware of the complaints procedures and had no difficulties raising any issues with the manager. An analysis of the service users survey forms ‘Have Your Say’ recently received at CSCI with the Pre-Inspection Questionnaire gave weight to the above. The undermentioned are a few quotes from ‘Have Your Say’ from residents. “There are complaint forms in the office which I have already been shown” “I would ask my care worker to support me” “I would talk to the Manager or a member of staff” “I would speak to the Manager, if she was not available for any reason I would speak to other members of staff”. The home has had no complaints since the last inspection. No complaints had been received by CSCI. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 18 Staff have had training in Adult Protection. At previous inspection there was a requirement that the responsible individual for the organisation must ensure that the Adult Protection Procedure is in line with the Multi Agency Guidelines. This requirement has been met and the appropriate amendment made. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 19 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): 24, 25, 27, 28, 29 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service and a tour of the premises. The home provided residents with a comfortable and homely place to live that was well maintained. EVIDENCE: The office had been moved from a large to a smaller room between the entrance hall and the lounge in order to facilitiate a resident who could no longer manage the stairs and needed a ground floor room. The resident who occupied this room was very happy with it. The home had two lounges one smoking and one non-smoking and a large dining room. Most of the areas had been redecorated and the non-smoking lounge had had all new furniture. All the rooms were comfortable and appeared to meet the needs of the residents. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 20 The home has one occupied bedroom that was not fit for purpose in relation to its size, and therefore continued to be a requirement. However, an agreement has been reached between CSCI and the Provider that when the room is vacated, it will no longer be used for a resident. It is worth noting that the room met the needs of the resident occupying this room, the resident is happy and does not wish to move. Other residents spoken to are happy living at the home is generally reflected in ‘Have Your Say’ survey. There were sufficient toilets, bathrooms and showers in the home that met with the needs of the residents. The home had also had intruder alarms fitted to all external doors since the last inspection as there had been an incident with an intruder. The alarms were used at night to alert staff who were sleeping in and would also alert them to any residents who go out at inappropriate times. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 21 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. Appropriate staffing level were being maintained by a well trained and stable staff group. EVIDENCE: The staff team at the home was very stable and some of the staff had worked there for a considerable amount of time. 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 any vacant posts. The home also employed a cook and domestic assistant. Residents spoken with were very positive in their comments about the staff and the support they were offered. Throughout the inspection it was clear that the residents were very comfortable in the presence of the staff and that staff were aware of their needs. A staff member had stayed on at the end of shift to accompany a resident on an external activity. From the resident staff Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 22 interactions it was very obvious that there was a good relationship and that the resident was appreciative of the opportunity. Equally, it seemed that the staff was longing forward to the outing. Two new staff had been employed at the home; a care officer and a cook. The cook has since left ands the post is being advertised. A volunteer has also joined the staff team. The inspector looked at the employment records for the new recruits and also sampled a existing file. The organisation’s recruitment procedure was followed and all relevant documentation in place including current CRBs. The organisation is committed to staff development and the majority of staff had completed NVQ Levels 2 and 3; the new recruit had undertaken robust induction traing and is due to commence NVQ Level 2 /3 in March 2007. This also complied with outstanding requirement in accordance with Regulation 18(1)©. Files sampled and other documentation indicate that staff receive regular supervision and the Staff Appraisal System was being reviewed. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 23 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): 37, 39, 40, 41, 42, 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is competently managed and the manager demonstrated a good knowledge of the needs of the residents in her care throughout the inspection. She has successfully completed the management component and was undertaking the care component of the NVQ level 4. The inspector was informed by the manager that she is due to complete the care component in June 07. The manager had very good relationships with the residents and they were very comfortable in her presence. The inspector observed a number of Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 24 residents approached the manager on varying matters. Analysis of the ‘Have Your Say’ Survey also demonstrates the good and valued staff / residents relationships. No issues were raised during this inspection in relation to health and safety. The fire book evidenced all the appropriate in house checks were being carried out and there was evidence that the fire alarms and extinguishers had been serviced. And visitor’s record maintained; however this needs amending to include time of arrival and departure. A recent fire drill had taken place. All staff received health and safety training in November 2006. A training matrix for the home has been received by CSCI. The manager received regular support and supervision from her line manager and copies of the Regulation 26 visit reports made by her were available for inspection. The home accommodated four residents over the age of 65 however the manager had informed CSCI and the registration of the home had been varied to allow this. The residents themselves were well and appeared to be receiving all the support they needed. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 x 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 3 3 3 3 Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 26 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. Standard YA37 Regulation 9(2)(b)(i) Requirement The manager must be qualified to NVQ level 4 in care and management by 2005. (Previous time scale of 31/12/05 not met.) Timescale for action 01/06/07 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. Refer to Standard YA37 YA7 YA35 Good Practice Recommendations The manager must ensure that the visitor’s is amended to include times of arrival and departure. The manager, in consultation with residents, should explore the need for alternative advocacy service The manager must ensure that staff receive training on diabetes care to supplement ‘inhouse-‘ information session. Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Sycamore Lodge DS0000016876.V324694.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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