Inspection on 24/04/06 for Sycamore Lodge Care Home

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore Lodge Care Home 24/07/07

Sycamore Lodge Care Home 27/09/05

Sycamore Lodge Care Home 20/06/05

Sycamore Lodge Care Home 04/02/05

Sycamore Lodge Care Home 17/06/04

Sycamore Lodge Care Home 02/12/03

Sycamore Lodge Care Home 02/06/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Sycamore Lodge Care Home 3-5 Hardy Street Nottingham NG7 4BB Lead Inspector Rob Cooper Unannounced Inspection 24th April 2006 10:25 Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Care Home Address 3-5 Hardy Street Nottingham NG7 4BB 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) 0115 9784299 0115 9784299 Mrs Aisha Khan Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Sycamore Lodge is a converted Victorian property in its own grounds, situated in Hardy Street in Nottingham. The home is registered to provide nursing care for up to 16 residents with a learning disability. The accommodation covers two floors and there are both single and shared bedrooms available. There is a stair lift to provide access to the upper floor for residents with mobility difficulties. There is a minibus available for some of the time and at other times transport is arranged by hiring a minibus and driver. Both forms of transport incur costs for the residents using it. The home is a five minute walk from shops for a person with good mobility and there are public houses, restaurants, places of worship and access to local transport within Hyson Green itself. The fees for Sycamore Lodge vary greatly depending on the diverse needs of the residents and the levels of support they are receiving. The resident’s weekly fees range from £505 - £1,305. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place through the middle of the day with one Inspector present. A representative from Social Services (Contracting Department) was also carrying out an independent Inspection at Sycamore Lodge at the same time. The methodology used was to visually inspect the premises, talk with three residents, four members of staff, a student nurse on placement and case track three residents. Case tracking involves looking at a range of care records, and making a judgement about the quality of care that residents are receiving. Unfortunately it was not possible to speak to any relatives as none were visiting Sycamore Lodge on the day of the Inspection. Sycamore Lodge offers a service to people with learning disabilities, and within that there is a wide range of ability and disability among the residents, particularly in relation to communication – where some residents are able to vocalise their thoughts, needs and desires, others have no speech, and a behavioural approach is adopted by the staff – observing residents behaviour and gestures as a means of interaction and communication. In addition resident’s demeanour, activity and the atmosphere within Sycamore Lodge were observed to get an understanding of resident’s well being within the home. The general impression is of a care home that is moving forward, and that has seen it’s staff work very hard to achieve the requirements left at the last Inspection. Currently there is one resident vacancy, and one resident is being treated as an in-patient at the local general hospital. On the day of the Inspection the majority or residents were at home, due to no day services being available. What the service does well: What has improved since the last inspection? There have been many improvements – 21 of the 22 Requirements set at the last Inspection have been met. There is clear evidence of stronger and more direct management, and a number of improvements have been carried out to the environment, including new carpets, repairs and equipment. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1234&5 The quality outcome in this area is: Good Prospective residents at Sycamore Lodge have the information they need to make an informed choice about where to live. Prospective residents individual aspirations and needs are assessed and prospective residents know that Sycamore Lodge will meet their needs and aspirations. Prospective residents to Sycamore Lodge have the opportunity to visit and ‘test drive’ the home before they move in. Currently each resident at Sycamore Lodge does not have a copy of the Terms and Conditions of residence. EVIDENCE: The Statement of Purpose and Service User Guide were both seen. Both of these documents contained all of the information required by Care Homes Regulations. The Service User Guide contained words, signs, symbols and pictures, and was found to be user friendly. Both of these documents were seen at the Inspection in June 2005, and there has been a considerable improvement in their quality and content since then. Three resident’s files were seen, and none of them contained a community care assessment, however Social Services had visited to re-assess all residents in late 2005, and evidence was seen that these assessments had been requested, but not yet been supplied by Social Services to Sycamore Lodge. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 9 More recent in-house assessments were seen, within resident’s files covering a range of activity. The in-house assessments do meet the National Minimum Standard, although a Community Care Assessment carried out externally would add to the objectivity of the resident’s assessments. Sycamore Lodge has a well-defined category for the range of resident it can accommodate. This is identified in the Statement of Purpose, The Service User Guide and the Registration Certificate. Pre-admission visits are part of the admission procedure at Sycamore Lodge, however if a tea visit, or an over night stay would be unduly distressing for the prospective resident, then this may be omitted following consultation with that person’s current carers. In the files that were seen there was no contract or terms and conditions of residence. However the Sycamore Lodge Service User Guide had an excellent blank example, and this should be used, and issued to each resident, with a copy retained in the resident’s file for future reference. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 the following standard(s): 678&9 The quality outcome in this area is: Good Residents at Sycamore Lodge know that their assessed and changing needs and personal goals are reflected in their individual plan. Residents make decisions about their lives with assistance as needed. Residents are not consulted on all aspects of their life at Sycamore Lodge. Residents are supported at Sycamore Lodge to take risks as part of an independent lifestyle. EVIDENCE: Three resident’s files were seen, and each contained a clear and logical plan of care. There was clear evidence that the plan was being reviewed, and that senior staff were monitoring each resident’s individual plan. At the last Inspection two requirements were set around care planning. The first relating to care plans being up to date and regularly reviewed had clearly been achieved, while the second that residents, their relatives or representatives should be involved in the care planning process had not. Resident’s involvement in the care planning process was discussed with the acting manager, and there are plans in hand to achieve this, that have not yet been implemented. These plans involve signatory sheets and meetings with Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 11 relatives to discuss care plans, where particular residents are unable to be involved in the process due to their limited communication skills. This will be recorded as a recommendation and checked at the next Inspection. There was evidence that Sycamore Lodge had contacted an independent advocacy service, for people with learning disabilities, however so far no advocates have been identified, and staff at Sycamore Lodge are awaiting the advocacy service finding suitable advocates. Contact had also been made with individual Social Workers to visit and have more contact, but this has not so been possible. Two files for residents who have communication difficulties were seen, and each contained a communication care plan, which identified ways in which staff should support residents to make choices and decisions. Each of the three resident’s files that were seen contained risk assessments, and care plans relating to those risk assessments. The risk assessments related to a range of daily living activities and also in some cases medical conditions and difficult behaviours. Two residents who were able to express their views were asked about choices within Sycamore Lodge, and both said that they were asked about meals, and activities. Both residents said that they chose when to go to bed, and staff did not tell them what to do, although one resident said that the staff did wake him up in the morning if he was going out somewhere. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 the following standard(s): 12 13 15 & 17 The quality outcome in this area is: Good Residents at Sycamore Lodge take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents have appropriate personal and family relationships at Sycamore Lodge. Residents are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Each of the resident’s files that were seen contained a care plan relating to social activities. There was evidence that residents were taking part in valued, and valuable social activities. There was also a timetable on display outlining what activities were available. Two residents were asked about their experiences and both said that there was plenty to do, and gave examples of some of the activities they had been involved in. This included days out, visits, art and craft activities, and going to the pub for a meal. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 13 On the day of the Inspection staff were seen to engaging in a range of meaningful activities with residents, from foot spas, to hand massages. There was also photographic evidence on display of activities in and around Sycamore Lodge, and these photographs were noted as being ‘new’/different to the ones on display at the previous Inspection. Sycamore Lodge is situated quite close to the city centre, and two residents talked about going into ‘town’ shopping, and going to the local pub. Family contact for residents varies with some having regular contact, while some do not. The age, distance living from Sycamore Lodge, and infirmity all contributing to why some relatives do not visit too often. Family contact was well documented in each of the three files that were seen, and there was evidence that staff at Sycamore Lodge had been supporting relationships with family members. On the day of the Inspection the cook was off sick, and a take away lunch was brought in instead. The kitchen was seen to be clean, tidy and well organised, and there was a good selection of fresh vegetables available. The minutes of the last resident’s meeting showed that the residents were making suggestions around food choice and menu selection. Two residents were asked about the food, and both said that they liked it, and that there was a choice. At the last Inspection it was set as a requirement that a full record of resident’s dietary intake is maintained. Each of the three resident’s files contained full and complete information relating to food eaten and choices made. Sycamore Lodge has a four week repeating rota, and this was seen, it showed a good variety and well balanced diet on offer. The records relating to food temperature probes and refrigerator and freezer temperatures were seen, and found to be complete and correct. Each resident’s file contained a nutritional assessment and a risk assessment relating to eating and drinking. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 the following standard(s): 18 19 & 20 The quality outcome in this area is: Good Residents receive personal support in the way that they prefer and require. Resident’s physical and emotional health needs are met at Sycamore Lodge. Residents do not self-medicate, however the policies and procedures in place around medication are protecting residents. EVIDENCE: Within each of the three resident’s files that were case tracked, there were resident’s objectives within their care plan, which identified their needs and preferences in relation to personal care. One resident said that they preferred a bath to a shower, and that staff knew this, and helped to “get the bath ready in the morning.” Two residents were asked about seeing the doctor, and both said that they would tell the staff if they were unwell, and the staff would make an appointment to see a doctor – either at ‘home’ of at the doctor’s surgery. The three files contained a section relating to health needs, and documentation was well presented in a user-friendly manner. Monitoring charts relating to epilepsy corresponded with care plans, and cross referenced with information held elsewhere within the files. Running records Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 15 showed that ongoing monitoring of resident’s health was taking place. The storage of medication was seen, and the procedure for ordering and delivery of medication was discussed. Sycamore Lodge use the Boots (the Chemist) Monitored Dosage System, and Boots carried out a pharmacy inspection in January 2006. Everything was found to be in order and correct both by the pharmacy inspector from Boots, and by the Inspector on the day of the Inspection. Recording charts were seen, and these were found to have no omissions, and each individual sheet had a photograph of the resident to aid identification. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 the following standard(s): 22 & 23 The quality outcome in this area is: Good Residents at Sycamore Lodge feel that their views are listened to and acted upon. Residents are protected from abuse, neglect and self-harm at Sycamore Lodge. EVIDENCE: At the last Inspection a requirement was made regarding setting up a complaints file, and containing details of the complaints made, their investigation and the outcome. This has been achieved. A new complaints file has been set up, with information filed in a logical and methodical manner. Records showed that the last complaint was received in February 2006, and this had been passed on to Social Services to investigate. A member of staff was also identified in the last Inspection report as having attitude and performance issues that needed to be investigated. This member of staff has now left their employment at Sycamore Lodge. Three residents were asked about their experiences of living at Sycamore Lodge all three were quite positive in their comments, with one saying that: “It’s got a lot better now” exploration of this showed that the resident was talking about recent changes that had taken place at Sycamore Lodge, including changes in some of the staff. During the course of the Inspection one resident came into the office for a ‘chat’ it was fairly obvious that this was common practice, and the resident made a number of comments about activities at Sycamore Lodge, and also passed comment on the quality of the food for dinner (“It was very nice”) Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 17 Observations of the interaction between residents and staff evidenced that residents were aware of what was happening within Sycamore Lodge, and that residents felt able to comment and express their views. It was set as a requirement that a Protection of Vulnerable Adults investigation should be instigated following an allegation by a resident. This has taken place, and the documentation relating to this allegation and the investigation was seen. Staff training records show that all staff are now receiving training and support in relation to supporting vulnerable adults. The contracts officer from Social Services undertook an audit of resident’s finances, and all of the requirements set at the last Inspection relating to resident’s finances have been satisfied. Receipts were available to substantiate all expenditure, and there was a clear audit trail in place relating resident’s expenditure. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The quality outcome in this area is: Good Residents live in a homely, comfortable and safe environment at Sycamore Lodge. Sycamore Lodge is clean and hygienic. EVIDENCE: At the last Inspection three requirements were set – relating to carpets, repairs to fixtures and fittings, and the repair or replacement of the television in the main lounge. All of these requirements have been met, with new carpet having been laid in the small lounge, a new television set having been purchased and a light fitting in the bathroom repaired. During the Inspection a tour of the entire building, showed a number of improvements, including the stair lift having been replaced with a new one. The building was clean, bright and there were no obvious health and safety risks identified. There are two domestic/cleaners employed at Sycamore Lodge. Cleaning regimes were discussed with both members of staff, and during the course of the Inspection both were seen to be cleaning throughout the building. Toilets and bathrooms were seen to be clean and all areas were found to be tidy. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 19 Two residents were asked about their bedrooms, and particularly who cleaned them. The cleaning staff clean the bedrooms, and residents ‘sometimes’ help by tidying up. Both residents said that they were happy with these arrangements. One of the residents showed me the new carpet in the small lounge (which had been replaced following a requirement at the last Inspection) and told me that it was “a new one, nice ‘aint it”. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 & 36 The quality outcome in this area is: Good Competent qualified staff support the residents at Sycamore Lodge. Residents are supported and protected by the Sycamore Lodge recruitment policy & procedure. Appropriately trained staff at Sycamore Lodge are meeting Resident’s individual and joint needs. Residents do benefit from well supported and supervised staff. EVIDENCE: At the last Inspection it was set as a requirement that all staff should undertake Learning Disability Award Framework training (LDAF). Staff training records show that nine staff have undertaken this training since the last Inspection, with the training having been facilitated through Social Services. A requirement was also set that the Registered Provider should ensure that all staff should treat residents with respect, with confirmation that instructions had been given. Two staff files were seen and each contained a signed declaration that respect and dignity had been discussed in a staff meeting and that the staff member was ‘signing up’ to the principals discussed in that staff meeting. In addition the resident’s files contained detailed instructions on treating profoundly learning disabled adults with respect and dignity, these too had Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 21 been signed by members of staff. Staff training records were seen, and these showed that a range of training relevant and specific to staff roles at Sycamore Lodge had been delivered. Both of the staff files seen contained all of the information required by Care Homes Regulations. Four requirements were set at the last Inspection relating to National Minimum Standard 34, and all four were found to have been met. Discussions with staff about recruitment policies showed indicated that there had been a tightening up, and that staff were not starting work at Sycamore Lodge until they had received Criminal Records Bureau clearance, and until 2 written references had been received. Staff training records showed that staff are having an induction when they start working at Sycamore Lodge, and this was reinforced by talking to two members of staff. Further training including the Learning Disability Awards Framework (LDAF), First Aid and Food Hygiene has been offered, and further training has been identified, and is due for delivery in the coming months. Staff records showed that formal supervision is taking place at Sycamore Lodge. Three staff members when asked said that they were receiving support and regular formal supervision, and one commented that: “It’s much better now.” At the last Inspection a requirement was set that staff should receive appropriate supervision, this having been first set at the Inspection before that in June 2005. The evidence in the staff files and collected by talking to staff indicates that this requirement has been met. One resident was asked about the staffing, and they said that it was better – some staff had left, and this included some staff that the resident did not like, so they were quite happy now. The resident was also asked about staff support and they said it was fine, “staff help me a lot, and if I need anything I ask.” Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 41 42 & 43 The quality outcome in this area is: Good Residents at Sycamore Lodge benefit from living in a well run home. Residents are confident that their views underpin all self-monitoring review and development in the home. Resident’s rights and best interests are safeguarded by Sycamore Lodge’s record keeping procedures. Resident’s health, safety and welfare is promoted and protected at Sycamore Lodge. Residents benefit from competent and accountable management of the service at Sycamore Lodge. EVIDENCE: The Manager’s position at Sycamore Lodge is currently vacant; although the acting manager is due to undertake an interview with the Commission for Social Care Inspection shortly. The acting manager is suitably qualified and experienced and all aspects of the National Minimum Standards in relation to running a residential care home have so far been met. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 23 Many of the residents at Sycamore Lodge have profound communication difficulties, which makes getting their views extremely difficult. Irrespective of this resident’s meetings have been held (the last one was in January 2006). The Social Services contracts officer audited the Quality Assurance systems at Sycamore Lodge, and found them to be sound. Sycamore Lodge has seen a major review of it’s record keeping protocol, and this has produced a wide range of records that are more accurate, complete, up-to-date and comprehensive. Evidence to support this was seen in the resident’s files, the staff files, the complaints records and the health and safety monitoring records. A range of Health & Safety records were seen, including fire, Control of Substances Hazardous to Health (COSHH) and Water temperature monitoring. These were all found to be complete and correct. The fire extinguishers were serviced in April 2006. It was set as a requirement at the last Inspection that Regulation 26 visits should be carried out monthly, and copies sent to the Commission for Social Care Inspection. This has been happening on a monthly basis. There is also evidence of monies being spent at Sycamore Lodge on new carpets, and a new stair lift, which indicate a commitment to improving the quality of the service. Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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 4 2 3 3 3 4 3 5 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 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 3 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 3 Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 25 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 YA5 Regulation Requirement Timescale for action 30/06/06 2. YA8 Regulation The Registered Person must use 5 the standard Terms and Conditions form (an example of which is in the Service User Guide) and issue one to each resident, having filled in the necessary details. A copy must also be retained in the Resident’s profile for information. 24/04/06 Regulation The Registered Person must 15 ensure that the involvement of residents, their relatives, or representatives (as appropriate) in the development of care plans and their review are evidenced within resident’s files. This is outstanding from the last Inspection and must be addressed immediately. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sycamore Lodge Care Home DS0000026475.V290909.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000026475.V290909.R01.S.doc Version 5.1 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. 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