Inspection on 07/06/06 for Sydenham

This inspection was carried out on 7th June 2006.

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 23/11/05

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 Mrs Janet Griffiths Key Unannounced Inspection 7th June 2006 09:45 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.V299534.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 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.V299534.R01.S.doc Version 5.2 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.V299534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 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. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are between £350 and £400 per week. Additional charges are made for hairdressing, chiropody, newspapers and magazines and transport for social purposes. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection commenced on one day in June 2006, with the site visit that took place over 6 hours 30 minutes. During this time the inspector spoke to a number of residents, some relatives, staff working in the home, the manager and provider of the home. Four resident’s files were looked at in detail to include their medication records. Surveys were either completed during interviews with residents or their relatives, or were handed out to relatives/residents during and following the inspection and these results were later collated. A pre inspection questionnaire was sent out several weeks before the inspection but on enquiry the provider said because of the poor postal delivery this had not reached them. A second questionnaire was hand delivered at a second visit to the home the following week and has since been returned. What the service does well: What has improved since the last inspection? The care staff have undertaken safe handling of medications and infection control training and are currently undertaking health and safety training. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 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. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 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.V299534.R01.S.doc Version 5.2 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): 3 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users are well informed about the home prior to admission and a full pre-admission assessment is completed. EVIDENCE: There have been six new admissions since the last inspection. Four of these residents were spoken with in addition to two relatives. Several were seen in their rooms and a copy of their service users guide containing a copy of their contracts, were seen. One stated that she had been once to visit the home prior to admission and had seen the room she was to have. In other cases families viewed the rooms and made arrangements for admissions, or the residents had been at the home for day care or respite care prior to admission so were already used to the home. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 9 In each case the resident said that they had settled in quite well and were happy with their accommodation and the care they received, although one admitted she had not really settled and really wants to go back home and another would have preferred to have been in her home town closer to friends. One survey received said how the resident was very unhappy initially as she had to leave her home unexpectedly but now regards it as home thanks to the staff and the food. Both relatives spoken with were very happy with the home and the care received. One made particular reference to the care her mother received when she was ‘very ill’. The other said she is always made to feel very welcome, is able to come and go as she pleases and is able to contribute to her mother’s care such as bathing, which she finds very rewarding. She also said that she could visit at any time and always finds the staff calm, ‘with never a raised voice or sign of impatience’. Residents confirmed that they had been seen prior to admission and the owner and manager both confirmed that they carry out a thorough pre admission assessment and a record of this is kept and examples seen. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are set out in the individual plan of care. Service users health care needs are fully met. Service users 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. EVIDENCE: Care files of four residents were selected and examined in detail. These all had full assessments completed, from which care is planned. Although dated they were not signed, which is required. It was explained that the date is the date of review, which is when a new form is completed. Again the form must indicate that this is a review date and monthly reviews should take place. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 11 One relative’s signature was seen as an indication that some care plans are reviewed with them and one relative confirmed that her mother’s care is always discussed and she is kept fully informed. However, in general they still did not include the resident or their representative, as they should wherever possible. Daily records kept by the carer on duty are very clear, full and informative and these are always signed and dated. The care plans reflect the current needs of the service users and care staff spoken with, were all fully aware of the needs of individual service users who confirmed that their needs are met. Again records seen and conversations with service users indicated that other agencies such as doctors and district nurses make frequent visits to the home and again the outcome of these visits are all clearly recorded. All the surveys received also indicated that they always received the medical support they needed although one said the out of hours service is remote. It was noted in one record that a relative voiced some concern that his mother was losing weight and following this a weight chart was commenced and has shown a gradual increase in weight. Weight should always be recorded on admission as a baseline and subsequently as frequently as is necessary. Where nursing needs have been identified, such as someone admitted with a pressure sore, appropriate action is taken and pressure-relieving equipment is in place. One resident has also been provided with a hoist from health agencies to aid moving and handling procedures. The home has worked hard to improve their medication procedure and each resident has their medications locked in a small safe in their room where their medication chart is also kept. All medication records were well maintained. All staff have undertaken safe handling of medicines training. They have not yet received their certificates for this but a contact number for the tutor responsible for this was provided. Staff spoken with confirmed this had been completed and from their conversations it was clear they have a good understanding. The home has experienced some problems with the dispensing doctor’s practice, dispensing incorrectly on several occasions and this has been taken up by the manager with the practice to resolve this. The staff on-duty were seen to carry out their duties quietly and efficiently, maintaining dignity and respect in all they do. One relative quoted how sensitively they handle the situation if a resident has had ‘an accident’ and needs changing. Staff were also observed knocking on doors prior to opening them and residents are always addressed respectfully with the form of address they prefer. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Activities provided in the home aim to cater to individual needs of the residents providing them with meaningful ways of spending their time. Residents were able to choose their daily routine. Service users maintain contact with family, friends, representatives and the local community as they wish and are helped to exercise choice and control over their lives. Service users receive a wholesome diet offering choice, alternatives and special diets where required. EVIDENCE: No evidence of a planned programme of activities was seen but several residents and their families mentioned the entertainer who visits regularly. The homes Statement of Purpose does state that the home offers a wide range of activities that the residents could pursue if they wished. Up to date information about activities should be circulated to all service users in formats suited to their capacities. There were mixed comments as to the popularity of the entertainer as not everyone enjoyed the entertainment provided. Two residents said they found the time dragged and one said she was very bored, with no residents in the Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 13 home who she could talk to. One resident was seen knitting which was discussed with her; otherwise residents appeared to sit in either the lounge, conservatory or garden according to their choice, some chatting but others just dozing. The provider later reported that although there is no written programme of events the home has a pianist entertaining every Thursday, a music and movement session with an organist, every other Monday, miscellaneous entertainers once a month, flower arranging twice a year and communion monthly. It stated in the last inspection report that ‘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 reportedly did not work and has since ceased, as evenings were the times when most people had visitors. However the additional member of staff is called in when required for escort duty etc. The providers’ husband also takes individuals out in the homes’ vehicle on occasions such as one quoted to see the bluebells in the forest recently. One or two residents preferred to remain in their rooms although one usually joins the others for lunch. The hairdresser visits twice a week and was visiting on this occasion, which is an event, especially for the ladies. One or two were watching television or listening to music in their rooms. One mentioned she receives talking books and one had headphones to watch and listen to her television. One relative did comment on the television being on continually in the lounge and ‘no escape from it, although nobody appears to watch it very much’. This was confirmed but the owner did say that residents could sit in the conservatory if they sought a quieter area. Staff were seen sitting in the lounge and chatting to residents after lunch. A summer fete is usually held in the grounds of the home in July and other events are held in the local community hall. Several residents spoke of going out with their families. The home currently takes two people for day care, which brings different people into the home. Day care services have now been limited to those who are waiting for admission to the home. One relative spoke of the birthday celebrations organised for her mother and the excellent Christmas celebrations the home had. One of the homes’ surveys completed stated’ the parties and entertainment provided are greatly appreciated and help residents to be aware of seasonal festivities’. One of the care staff or the provider is usually allocated to catering in the home. A record of the food provided is kept and cleaning schedules were seen. One of the care staff has recently been given the responsibility of ensuring the food safety procedures are maintained. Residents were seen finishing breakfast at the start of the inspection, most having, cereals, toast or possibly fruit. Cold drinks were in evidence in the Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 14 lounge and most residents’ rooms and were being offered during the day. Lunch was either salad or savoury mince. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are in the main confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse through policies held in the home but staff awareness should be raised. EVIDENCE: The home has a complaints procedure, which is contained within the service users guide provided in each room. It is slightly out of date referring to NCSC rather than CSCI. It was reported that there had been no complaints received by the home although Social Services had received one regarding a gentleman who was given notice and asked to move elsewhere because of inappropriate behaviour. This was apparently dealt with through Social Services who did not notify CSCI. The owner did inform CSCI of the transfer of this service user, by telephone. One resident did say that she had constantly complained about her toilet being faulty since admission and despite a number of people looking at it, there was still a fault (see standard 19). Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 16 However, there is still 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 two inspections. The requirement has still not been met. Staff spoken with did not appear fully aware of Adult Protection procedures and Protection of Vulnerable Adults although when questioned more fully did express knowledge of what to do if they had concerns about anything they saw and related that they had all had POVA checks as required. Abuse training is to be arranged and a copy of the Alerters’ guide was left at the home, which already has a whistle blowing policy and No Secrets’ guidance. The home has been sent information regarding POVA training from CSCI but is trying to prioritise the training that the staff require as ‘they are unable to attend it all at once’. This was a recommendation at the last inspection. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Residents in the home are provided with a clean and comfortable environment to live in with a good standard of décor. EVIDENCE: A tour of the home took place and most rooms were visited. It is the homes’ policy to redecorate rooms as they become vacant prior to a new resident moving in and this was confirmed by one resident. All areas seen appeared to be well maintained and in good decorative order. One exception to this was a bathroom on the top floor, which is undergoing work at present. It was advised that when no one is working here this room should be kept locked for safety. One resident also reported that her en suite toilet had been faulty (wouldn’t flush properly) since admission although a number of people had been to look at it. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 18 It was tried and this was confirmed although when reported to the owner she agreed that people had been to repair it and had said that there was nothing wrong with it. One resident also queried why she was bathed in an assisted communal bathroom when she had an assisted bathroom en suite. This was to be followed up. There is a high standard of cleanliness maintained in the home, which was confirmed by residents and their relatives. One mentioned that clothes taken off in the morning were laundered and returned by afternoon and were always well done. There were just two negative comments in the homes’ own surveys; one suggested the hall, stairs and landing carpet should be renewed and another commented that their mother did not like one of the pictures in the lounge. All of the residents rooms visited had evidence that they were able to furnish their rooms with items of their own furniture, ornaments, pictures and other objects of choice all of which greatly personalised each room. As one resident said, her ornaments were not valuable but meant a lot to her as her grandchildren had given them to her. Others were happy to talk about photographs of their families and pets. Renovation work on the roof of the home is due to take place through the summer. Residents and their families are to be informed of this in writing prior to work commencing. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff and are in safe hands at all times. Service users are supported and protected fully by the homes’ recruitment policy and practices. Staff are trained and competent to do their jobs but appear to have difficulty accessing some training. EVIDENCE: There were two care staff, the manager who was cooking and overseeing the home, and a cleaner on-duty during the inspection. The owner was also present for the duration of the inspection. Two further care staff came on-duty at 4 pm to cover the late shift. The owner who lives opposite the home is oncall for any emergencies that occur. The two care staff and manager were interviewed during the inspection. All had worked at the home for a number of years and none felt under pressure with the work they were required to do. All felt well able to meet the needs of the residents and were able to demonstrate this when questioned. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 20 As the home has an excellent record for continuity of staff there had been no new staff appointed and all the staff files have been checked before and have all the required documentation and checks in place. They were therefore not checked on this occasion. All the staff had previously been enrolled with a company to do NVQ training, all financed by the owner. Having all completed a number of elements, the company went bankrupt, which greatly disheartened everyone. Recently all the staff have commenced distance learning from Swindon College to complete safe handling of medicines training. They have just completed infection control with the Forest of Dean College and are now commencing Health and Safety with ASET (work books in progress were seen) and as no one has yet received certificates of the training completed, contact numbers of the tutors were given. It is believed that this will all be accredited towards completion of NVQ training. The last report also stated that the Provider is an NVQ Assessor, but this training was also not completed, due to the reason given above. Certificates were seen on file for moving and handling updates 5.12.05; training on use of the hoist by Arjo- no date given, fire service training 7.9.05 and fire instruction 30.6.05. Some also attended a training session of fractured neck of femurs on 7.10.05. The last first aid was completed 23.1.04 and food hygiene 17.6.03. Staff induction could not be assessed since there had been no staff appointments. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,37,38 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is run and managed jointly by the provider and the registered manager. The home is run in the best interests of service users and their financial interests are safeguarded. The homes record keeping policies and procedures do not always safeguard the service users best interests. Systems are not yet in place to ensure that staff are appropriately supervised. The health, safety and welfare of service users are promoted and protected provided an ongoing maintenance programme is in place. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 22 EVIDENCE: The provider stated the registered manager was competent and experienced to run the home. She has not yet the Registered Manager’s award/NVQ 4, which is seen as the expected qualification, and a timescale must be provided as to when this will be achieved. Appraisal and supervision forms have now been devised but few staff have received their appraisals as yet and the home has not achieved the standard of at least 6 formal supervision sessions for each member of staff. This has been an outstanding requirement for four inspections now. Currently the home seeks the views of residents, their representatives and stakeholders in the community, which is good practice. Some of the last surveys completed, which were issued in April 2006 were seen and on the whole were very positive. The only two negative remarks have already been included elsewhere in the report. The process needs to be further developed to fully meet this standard. Collation and publishing these results together with development of an action plan were discussed as part of the quality assurance cycle, which must continue on a regular basis. 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. It has come to the attention of the Commission, when a recent incident was reported by telephone that the home has never completed a Regulation 37 to notify the Commission of any death or untoward incident. The home notifies Social Services, which they thought was sufficient. A specimen form was hand delivered to them and they have assured the inspector that they will complete notifications in future. Service and maintenance records were seen to confirm that regular servicing of equipment takes place, as do safety checks such as fire alarm and emergency lighting tests. Just one health and safety risk was noted as detailed in standard 19 above. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 24 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. This requirement has been repeated from the last three inspections. 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. This requirement has been repeated from the last two inspections. A staff appraisal and supervision programme to be in place This requirement has been repeated from the last three inspections. Timescale for action 31/07/06 2. OP16 17 (2) 31/07/06 3. OP36 18 (2) 31/07/06 Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 25 4. OP33 24 The registered person should 31/07/06 maintain an effective quality assurance and quality monitoring system for the home, reviewing at appropriate intervals and improving. A report should also be completed and be available for CSCI, the service user and/or their representative. The registered person shall give notice without delay of the occurrence of a death of a service user, an outbreak of any infectious disease, any serious injury, serious illness, events which adversely affect the wellbeing or safety of the service user, any theft, burglary, accident or allegation of misconduct of any member of staff. The registered manager must have the qualifications, skills and experience necessary for managing the care home. 31/07/06 5 OP38 37 6 OP31 9 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations Nutritional screening is should be undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss and appropriate action taken. Up to date information about activities should be circulated to all service users in formats suited to their capacities. 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. 2. 3. OP12 OP18 Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 26 OP28 4. 5. 6 7 OP31 OP36 OP38 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 have a qualification at level 4 NVQ, in management and care, or equivalent. Care staff should receive formal supervision at least 6 times a year. Ensure the health and safety of service users and staff by maintenance of a safe environment through securing areas where work is ongoing when there is no one present. Sydenham DS0000016596.V299534.R01.S.doc Version 5.2 Page 27 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.V299534.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!