Inspection on 29/01/08 for Sycamore Lodge

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore Lodge 23/01/07

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 Kulwant Ghuman Unannounced Inspection 29th January 2008 09:30 Sycamore Lodge DS0000016876.V359066.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.V359066.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.V359066.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.V359066.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. 23rd January 2007 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 people 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 people 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 individuals to move on until they feel they have developed the necessary skills. The service user guide stated that the contract price was £450.54 per week for Birmingham residents, other authorities would need to be negotiated. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced inspection that was carried out over one day in January 2008 by one CSCI inspector. Lynn Crooks (expert by experience) was there for part of the inspection. As a service user Lynn had an expert opinion on what it was like to receive services for people who have a mental illness. Lynn’s comments are included throughout this report where she is referred to as ‘the expert’. The home had been asked to complete an Annual Quality Assurance Assessment which was sent to the CSCI following the fieldwork visit. During the inspection two files of the people living in the home and one person working in the home were looked at. Several other documents including health and safety, medication and maintenance documents were looked at. The inspector was able to speak with the manager, two care staff and 6 of the people living in the home. There had been no complaints or adult protection referrals made to the Commission regarding the service. What the service does well: The home provides comfortable accommodation for people to live in. The expert commented: “The home is located on a busy main road surrounded by shops and residential properties. Externally, it looks like any other house in the road so it is free of stigma for the residents and there are plenty of local amenities for them to use on foot, including a library and the Beechcroft drop in centre. It is also well serviced with public transport.” “The residents I met were quite mixed in their ability to chat. Those I spoke to were extremely articulate and spoke highly of their life in Sycamore Lodge. They were happy there and felt ‘looked after.’” The people living in the home were involved in writing up their care plans and directing their care. They were encouraged to take responsibility for daily living needs such as cleaning their bedrooms, making meals and doing their laundry. Where needed individuals were assisted with personal needs and attending medical appointments. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 6 The management of medicines in the home was good. 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. The summary of this inspection report can be made available in other formats on request. Sycamore Lodge DS0000016876.V359066.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 Sycamore Lodge DS0000016876.V359066.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): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People admitted to the home had the opportunity to visit the home before moving in and staff were aware of their needs. The people living in the home had information that told what they could expect at the home. EVIDENCE: No-one had been admitted to live in the home since the last inspection however the admission process was assessed at the last inspection and people were able to visit the home so that they could decide whether to move in or not. The completed AQAA returned by the home confirmed that people would be encouraged to carry out visits to the home before deciding whether to move in or not. A service user guide was available for the people living in the home to refer to regarding what was available in the home. Discussions with the people living in the home said they were happy with the care they received. The expert by experience spoke with some of the people living in the home and they told her ‘They were happy there and felt looked after.’ Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 9 Daily records showed that people received medical treatment Essential lifestyle plans indicated the short, medium and long-term objectives for individuals. Licence agreements were seen to be in place on the files sampled. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care were in place and the people living in the home were involved in writing them. They needed to be updated as situations arose so that they reflected individuals changing needs. EVIDENCE: The files of two people who were living in the home were looked at. Both files had an Essential Lifestyle Plan (ELP) and self-assessment in place. It was evident from the records that the individuals had been involved in writing these documents and they included information regarding their likes and dislikes, good and not so good attributes and what they thought other people should know about them. There was some good information about the individuals needs however, there was some additional information that was needed in the files. The people living in the home were growing older and the care plans needed to have more information about how the needs of these individuals were to be met. This Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 11 was particularly important where individuals were not very talkative or developing conditions such as dementia. The files did indicate what the short, medium and long term goals of the individuals were however, in one case where the individual had stated that they no longer wanted to stop smoking, a month after having decided that they wanted to try this, there did not appear to be any further discussions about why or what other goals could be set up. For example, cutting down the number of cigarettes smoked or using chewing gum as a substitute. The individual had been having some problems managing a health problem and although it was evident that the individual had had input from various sources the care plan had not been amended to indicate what steps were being taken and how the individual was to be helped in this area. The individual’s risk assessment also needed to be updated to include how this issue would be managed. For another individual it was noted that she had begun to isolate herself from another person living in the home due to some relationship difficulties. The file indicated that coping strategies were to be discussed but there was no evidence to suggest that this had taken place. This issue was discussed with the expert by some of the people living in the home and it was obviously still ongoing. There were regular meetings held in the home that enabled the people living there to decide on how celebrations were undertaken eg a meal out at Christmas, and other issues such as using the complaints procedure and accessing advocates. People living in the home were able to join in some of the training events for the staff for example, diabetes awareness and management. They were able to come and go according to any risk assessments that were in place. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home were able to live individualised lives, however, more in house activities could be arranged for people who did not go out very often. EVIDENCE: The age range of people living in the home varied considerably from early 30s to 70’s and there were only two men living in the home at the time of the inspection. The home needed to ensure that if it was to continue to have such a wide age range in the home, the varying needs were planned for in everyday life, for example, food, entertainment, activities, decor and adaptations within the home. For example, on the day of the inspection there was a beauty session organised for the evening and although the men could attend no alternative plans had been considered to meet the needs of the men in the home. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 13 The expert said: “Although Sycamore Lodge is categorised as Adult Mental Health, it did feel more geriatric because of the propensity of over 50’s.” “Apart from one young girl, all the residents I met were over 50. I wondered if the younger girl felt isolated in this environment.” “I did sense a real lack of ‘things to do.’ I saw no games anywhere or magazines or pictures on the wall showing what residents had created. This has to be taken into consideration that a lot of activities take place at the drop in centre, but only for residents capable of getting there.” “There were not too many residents about when I made my visit, but some were at the drop in centre and some in their rooms. The ladies in particular were looking forward to the evening because they were having a Beauty session by one of the carers. I learnt that this was a regular event.” People living in the home were able to access local day centres, colleges, churches, restaurants and shops. There was contact with family members according to the wishes of the people living in the home. Individuals had keys to their bedrooms and the front door and were able to come and go as they chose. Meals were prepared in the home by staff but some of the people living in the home made their own meals. One individual’s ELP identified that they cooked their own lunch one day a week. Individuals were advised about healthy eating and foods that were appropriate according to their health needs but they were able to decide what to eat. The expert said: “Each residents needs were addressed, and I particularly noticed this at lunchtime as one resident was able to come in and make her own lunch because she didn’t fancy what was on the menu. It was beans on toast. There wasn’t a choice of menu and nothing fresh was served but that was only one meal. There was no evidence of fresh fruit available.” The inspector did evidence that fresh fruit was available in the residents’ kitchen and that the people living in the home were satisfied with having only one meal prepared for them as they were able to choose to have something different. Individuals living in the home were encouraged to clean their bedrooms and undertake their own laundry as well as make some meals for themselves. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals were supported with personal and health care needs. There was one issue of the emotional needs of some of the people in the home not being met. The management of medicines in the home was good. EVIDENCE: There was ample evidence noted on the files of the people living in the home that their health care needs were being met by various health professionals including dieticians, GP’s, nurses, opticians and dentists. In general the individuals were taken to or reminded about attending clinics and appointments. When needed, services were called into the home. Some people in the home were unhappy with the behaviour of another person. This situation needed careful management as it was not good for any of these individuals. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 15 As indicated elsewhere in this report the group of people living in the home were generally becoming frailer and developing needs of an ageing population including mobility issues, continence and other health needs. The home was ensuring that the staff were developing skills in these areas by accessing training in areas such as dementia and continence however, this does mean that the time input required from the staff for day-to-day personal care has increased. The manager acknowledged that this was having an effect on the time available for staff to be involved in other activities. The expert said: “One complained that they could never get a shower, but there didn’t seem to be any overcrowding anywhere.” None of the people living in the home were looking after their own medicines. Staff were responsible for managing the administration of medicines. Only staff who had undertaken training could give out medicines. The medicines were generally administered from a monitored dosage system and the individuals came to the office for their medicines. The inspector observed individuals check the medicines with the staff before taking it. One of the people living in the home was finding it difficult to manage their diabetes. On the day of the inspection training was provided to the staff and the individual regarding management of diabetes. Staff were vigilant in observing for signs of side effects of the medicines and reporting these back to the doctors so that the amounts could be adjusted. An audit of the medicines showed that it was being well managed. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people living in the home were listened to and the policies and procedures in the home safeguarded them. EVIDENCE: The complaints folder was checked and one complaint had been logged from one person living in the home against another. It appeared that this had been addressed appropriately however, the expert did identify that two of the people living in the home had discussed this with her and there appeared to be an ongoing issue. This was discussed with the manager who was aware of the situation and trying to resolve it. There was evidence that making complaints had been discussed with the people living in the home during meetings. There was information about advocates available in the home so that they could contact them if they wished. There used to be regular meetings with the advocates and the inspector was told that these would be taking place again. It appeared that individuals were protected as far as possible. They were listened to and supported to raise issues that they wished to be aired. Staff spoke to them respectfully and recruitment procedures safeguarded them. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 17 The expert said: “Everyone I met was talked to by the staff in a very respectful way and it was obvious to me that there was a great deal of care to address each person kindly.” One of the people living in the home told the inspector they would have no worries about talking to the staff if they were unhappy. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 18 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, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The accommodation currently meets the needs of the people living there. EVIDENCE: The home had two lounges, one smoking and one non-smoking, a large dining room and all bedrooms were for single occupancy. Since the last inspection one person had moved downstairs as they had been unwell and was finding it difficult to manage the stairs. The inspector viewed only the communal areas as most of the bedrooms were locked or individuals did not answer the door if they were inside. The inspector noted that the people living in the home would benefit from some small coffee tables in the non-smoking lounge for drinks. The furniture was otherwise homely. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 19 The inspector commented to the manager that it looked a little bare and would benefit from some homely touches such as flowers and pictures. This was being pursued. The inspector was told that a new plasma television was being purchased for this lounge. There was a large dining room available however, this again looked rather empty and bland. It was pleasing to note that the people living in the home had access to a kitchen to make drinks and snacks for themselves. The bathroom on the ground floor had some support rails available however, as the needs of the people living in the home increase there may be a need for rails to be available to both sides of the bath and toilet. There were two bars of soap in the bathroom. These should be returned to individuals’ bedrooms after use to prevent cross infections. One of the toilets on the first floor had a step up to the toilet that again will become unsuitable if the mobility of individuals becomes an issue. There was a bolt on the inside of the shower room on the first floor. This should be removed to ensure that no one gets locked inside as staff would be unable to gain access in an emergency situation. On the second floor there appeared to be a facility that was suitable for use for people who were contemplating moving to more independent living however, this facility was underutilised as no-one used the kitchen facilities on a regular basis for preparing meals. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 20 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): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels currently met the needs of the people living in the home however, this needs to be kept under review as their needs increase. EVIDENCE: The inspector was informed that there were generally two support staff on duty in addition to the manager during the day. There was one sleeping in member of staff during the night. The home had domestic cover for three days a week and there was a vacancy for a cook trainer, one care staff and domestic. The staffing levels were just about able to manage all the tasks required but this situation should improve once the identified vacant posts had been filled. The manager also needed to monitor staffing levels to ensure that the identified goals for individuals did not get overlooked due to staff spending more time on assisting individuals with personal care. Staffing levels may need to be increased. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 21 The staff group were a stable staff group and there was a good rapport observed between them and the people living there. The expert said: “Sycamore Lodge is doing an excellent job looking after a mixed group of people with various mental distress diagnoses. The staff have obviously been in position for a long time and had an excellent relationship with the residents.” One of the people living in the home told the inspector “ The staff are fine”. The staff appeared to be competent at caring for the individuals but the increased needs of the people living there meant that more time was needed to assist the individuals with personal care needs. They were also trying to equip themselves more for caring for older people with enduring mental health needs. The manager needed to ensure that the staffing levels continued to meet the needs of the people living in the home. One staff member’s file was sampled and showed that there was adequate training supplied by the organisation. The individual had worked at the home in a different capacity and although they had undertaken induction training then, this could not be found and it could not be evidenced that additional training had been given for the recent change in role. The criminal bureau checks for all staff were being reviewed. Staff were being regularly supervised. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and run with the best interests of the people living there in mind. Some attention needed to be given to meeting the needs of a wide age range and ensuring that the needs of the men are not overlooked. EVIDENCE: People living in the home were comfortable and the home was run with their needs in mind. The manager had been in post for several years and had completed the RMA but the certificate was not yet available. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 23 The expert said: “Sycamore Lodge is doing an excellent job looking after a mixed group of people with various mental distress diagnoses. The staff have obviously been in position for a long time and had an excellent relationship with the residents. No one expressed any real concerns except that one person living in the home was causing some people some distress. I think the location is excellent as it allows real integration and socialising for the residents, although the manager expressed her worry that because the area provides so much, there is little incentive to explore further a field. I would explain to the manager that she could do a lot to help the exploration, not by getting residents further out in the field, but to bring some stimulation for them into the home.” The organisation needs to consider and plan for the long-term future of the home. If the home is to continue to care for an ageing population the physical environment needs to be considered and plans made for how individuals increasing needs will be met in the home and by the staff. If it is felt that the home will not be able to care for individuals as they age they need to be helped to make plans for their future care. The manager needs to look at the security of the building. The inspector was let into the building by people who were leaving and shown the office. She was then able to access all areas of the home. One person helped the inspector look for a member of staff. A member of staff came downstairs some twenty minutes later. It would have been possible to access the building by the rear door which was also open. Equipment in the home had been regularly maintained and testing of fire equipment had been carried out. The general risk assessment for the home was last updated in December 2006 although certain sections had been updated at various times. The manager needed to ensure that the risk assessment was current and accurate. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 24 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 3 Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA3 Regulation 13(1)(b) Requirement The manager needed to ensure that the emotional needs of all the people living in the home were met. Timescale for action 01/04/08 2. YA9 12(4)(c) This will ensure that good mental health is maintained for all the people living in the home. Personal risk assessments 01/04/08 needed to be updated as situations changed. This will ensure that the people living in the home are kept safe. Bathing and toilet facilities needed to be assessed for suitability and identified adaptations put in place. 3. YA18 23(2)(n) 01/08/08 4. YA42 13(4)(c) This will ensure that the needs of all the people living in the home are met. The manager must ensure that 01/03/08 the bolt on the bathroom door is removed. This will ensure that all the people living in the home are kept safe. Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations Care plans needed to have additional information on how the people living in the home would be assisted to help them attend to their personal care needs. This will ensure that individuals receive person centred care in accordance with their wishes. Staff needed to ensure that they spent time with the people living in the home to ensure that goals identified were pursued or replaced with alternatives where this was needed. This will ensure that individuals are encouraged to reach their potential. The staff in the home needed to ensure that the needs of people living in the home were planned for so that age and gender differences were accounted for. The manager needed to look at ways in which communal areas of the home could be made more homely. Staff must ensure that tablets of soap are returned to bedrooms after use in communal bathing facilities. This will ensure that good infection control procedures are followed. The manager needed to keep staffing levels under review. This will ensure that increasing needs are adequately met. The organisation needs to discuss the care to be provided in the home so that the needs of the older people living in the home can be planned for. 2. YA6 3. 4. 5 YA6 YA24 YA30 6 7 YA33 YA38 Sycamore Lodge DS0000016876.V359066.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V359066.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. Re-publishing this information is in breach of the terms of use of that website. 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