Inspection on 23/11/05 for Sydenham

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Sydenham 07/06/06

Sydenham 07/12/04

Sydenham 15/06/04

Sydenham 13/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Sydenham High Street Blakeney Glos GL15 4EB Lead Inspector Gill Goldfinch Unannounced Inspection 23rd November 2005 3.00pm X10015.doc Version 1.40 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 Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 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 Older People. 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. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sydenham Address High Street Blakeney Glos GL15 4EB 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) 01594 517015 Mrs Lyn Nussey Mrs Tina Jane Gibson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Sydenham House is situated on the western edge of Blakeney village on the A48 in Gloucestershire. The house is Victorian and has been adapted to accommodate 19 elderly people who require personal care. Much has been done over the years to improve the physical standards in and around the home. A large comfortable conservatory has been added in recent years, which offers residents an additional communal area to the large lounge/dining room that is also available. The majority of rooms have en suite facilities, although there is an assisted bath on each floor for those frailer residents. With the exception of two shared rooms, the home offers all single accommodation. Each room is very tastefully and individually decorated and many are furnished with items of residents’ own furniture and personal items creating a very ‘homely’ atmosphere. The home has a shaft lift that serves all floors in the home. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately 4 hours of one day in November 2005. Opportunity was taken to talk to the Provider and staff, observe activities and talk to residents. Care records and staff recruitment files were examined. Four of the seven requirements issued at the last inspection had not been met. These have been repeated in this report with new timescales. What the service does well: What has improved since the last inspection? What they could do better: Respond more promptly to requirements made at inspections. Some of the outstanding requirements date back to May 2004. Involve residents or their representatives in the planning of their care. Introduce a system of staff appraisal and supervision. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 6 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. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The homes Statement of Purpose and Service User Guide provide residents’ and their representatives with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: Each service user is provided with a service users guide, which is kept in their room. The last inspection highlighted a need for improved recording of prospective residents care needs prior to admission. The Provider stated that admission procedures had become more robust since the last inspection. Documentation was seen to support this. A comprehensive pre-admission assessment form was seen. No admissions had taken place since the last inspection, as the home had remained fully occupied. It was therefore not possible to assess how the form was being used in practice. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 9 and 10 Care planning systems in the home ensure that resident’s needs are understood and met. The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: Documentation that was seen during the visit indicated that residents’ needs were known and understood by the care staff. Residents spoken to were confident that their needs were being met. One resident said “I am happy with the care offered to me”. Risk assessments were in place and daily records were being maintained. Reviews of the care provided were being held. However, these did not include the resident or their representative, as they should wherever possible. Daily records showed that the primary health care team were consulted and called in as necessary and residents had access to community health facilities such as chiropody and physiotherapy. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 10 Observations made during the inspection showed the staff were respectful and promoted residents dignity. Residents were able to confirm that staff respected their privacy and one resident staff would always knock, and wait for an answer before entering her bedroom. Requirement made at the last two inspections relating to completion of accredited training on drug administration for staff had not been met. Evidence that this training had been booked for the near future was seen. However, staff had not yet completed this. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Activities provided in the home cater to individual needs of the residents providing them with meaningful ways of spending their time. Residents were able to choose their daily routine. Visitors are encouraged and links with the community are maintained. EVIDENCE: Residents and staff confirmed that residents have the opportunity to exercise choice in relation to daily routines. They can choose whether to join in with social activities, where to sit and who to talk with. Those residents spoken to were strongly of the view that they were encouraged and enabled to make their own decisions about aspects of daily living. Activities coming into the home are accessed via an agency. These include musicians and singers. On the day of inspection there was a visiting musician playing electric piano in the lounge area. This session was well attended by residents with much audience participation taking place. The pianist was a regular feature and new the residents by name. Since the last inspection an extra shift has been added to the care staff rota in the evenings. This shift is specifically for the purpose of providing activity for residents. This could be in the form of a group activity such as flower arranging or for one to one time with individual residents. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 12 There was opportunity for exercise through a music and movement class provided in the home on a weekly basis. Monthly communion is held and the hairdresser visits twice weekly. There was information on residents files about their individual interests. Leisure and recreational activities were focussed on an individual basis to suit their preferences and needs. The inspector did not see any visitors during this inspection. Information about the home indicated that visitors were welcome to visit. Residents confirmed that their visitors were always made most welcome and were offered refreshments. Residents spoken to were satisfied with the food provided. Choices are made daily by residents for each meal. All staff were involved in the preparation of and cooking of meals. Residents stated they had input into planning of the menus. Meal times were said to be flexible to suit individual need and meals could be eaten in bedrooms if residents so wished. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a complaints procedure and there are procedures in place for the protection of vulnerable adults. EVIDENCE: There was a complaints procedure and all residents spoken to felt that staff were approachable and all stated they were confident to discuss any concerns, knowing that they would be taken seriously. However, there was no record of any complaints or concerns received by the home. The requirement for this record to be kept was discussed with the Provider at the last inspection. The requirement had not been met. There were adult protection policies and procedures in place. The Provider reported that staff were told about these during their induction training but that formal training had not been given. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home provides a homely environment for the residents to live in. EVIDENCE: Sydenham is a large old building that has been adapted to meet the needs of older people in a comfortable and homely manner. There is an ongoing programme of refurbishment and maintenance to ensure that the quality of the environment is maintained at a good standard. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Appropriate recruitment procedures were in place. Staff were trained and competent to do their jobs. EVIDENCE: There had been no staff appointed since the last inspection. Requirement made at the last inspection for staff recruitment files to contain all necessary documentation had been met. Three staff files were seen and contained all required documentation. All staff in the home were working towards NVQ level 2, including the registered manager. The Provider stated that the registered manager would be commencing NVQ 4 and the Registered Managers Award on completion of her NVQ 2. There had been staff training continuing in the home in relation to health and safety. All staff had received training in the following areas: • • • • • Infection Control First Aid – Appointed Persons Basic food hygiene Health and safety Fire Safety DS0000016596.V271339.R01.S.doc Version 5.0 Page 16 Sydenham A training course had been booked for 5/12/05 in safe moving and handling techniques. Medication training was also booked. It was difficult to assess staff induction since there had been no staff appointments. Documentary evidence of training related to care practice issues was limited but input is being provided in this area via NVQ training. The Provider has a City and Guilds qualification in management and is an NVQ Assessor. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 35 and 36 The registered manager was not on duty on the day of the inspection. There were some elements of a quality monitoring systems in place. These need to be developed. Residents’ financial interests are safeguarded. EVIDENCE: The provider stated the registered manager was competent and experienced to run the home. She is working towards achieving NVQ level 4 in management and care. There was some discussion during the inspection about quality monitoring systems within Sydenham. Currently the home seeks the views of residents, their representatives and stakeholders in the community, which is good Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 18 practice. The process needs to be further developed to fully meet this standard. The Provider stated the home does not have involvement in any aspect of residents’ finances. Should residents be unable to control their own finances the Provider would contact Age Concern for advocacy support. Secure facilities are provided for each resident for the safe keeping of valuables. The provider reported that no staff supervision had been completed as yet. This has been an outstanding requirement at the last three inspections and must be introduced within the new timescale given. The Provider stated that requirement made at the last inspection relating to the fitting of window restrictors had been met. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 x x Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Care plan reviews to be completed with the service user/their representative wherever possible. (Previous timescales of 7/1/04 and 23/07/05 not met) All staff who administer medications must receive accredited training on drug administration (Previous timescales of 7/6/05 and 23/08/05 not met) A record of all complaints made by service users, or relatives or representatives of service users, or persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint, must be recorded (Previous timescales of 23/07/05 not met). A staff appraisal and supervision programme to be in place (Timescale of 9/9/04 and 23/08/05 not met). The registered person should set up an effective quality assurance and quality monitoring system DS0000016596.V271339.R01.S.doc Timescale for action 31/03/06 2 OP9 13 (2) 01/01/06 3 OP16 17 (2) 20/12/05 4 OP36 18 (2) 31/03/06 5 OP33 24 31/03/06 Sydenham Version 5.0 Page 21 for the home. 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 OP18 OP28 OP31 Good Practice Recommendations Suitable policies and procedures were in place for adult protection. It is recommended that these would be further reinforced if staff were to receive training in this area. The provider should continue working towards ensuring that a minimum ratio of 50 trained members of care staff is achieved by 2005. The registered manager should continue working towards attaining NVQ level 4 in management and care or equivalent. Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Sydenham DS0000016596.V271339.R01.S.doc Version 5.0 Page 23 - 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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