Inspection on 16/07/05 for Sydervelt Lodge

This inspection was carried out on 16th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Sydervelt Lodge 21/10/08

Sydervelt Lodge 21/11/06

Sydervelt Lodge 21/11/05

Sydervelt Lodge 02/02/05

Sydervelt Lodge 20/09/04

Sydervelt Lodge 29/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Sydervelt Lodge 2 B Sydervelt Road Canvey Island Essex SS8 9EF Lead Inspector Bernadette Little Unannounced 16th July 2005 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 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 Stationary 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. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sydervelt Lodge Address 2 B Sydervelt Road Canvey Island Essex SS8 9EF 01268 695821 01268 695821 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Estuary Housing Association Mr Gary John Engedahl CRH Care Home 4 Category(ies) of LD Learning Disability (4) registration, with number of places Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2005 Brief Description of the Service: Sydervelt Lodge is a care home providing personal care and accommodation for up to four service users with a learning disability. The premises are a detached two storey house situated in a quiet residential area of Canvey Island. The home had four single bedrooms, none of which have ensuite facilities. There was a large communal lounge/dining area, as well as a separarte quiet/activities room. The homes office had been relocated from the ground floor to the first floor. There was a sensory room on the ground floor. The home is within walking distance of the local shops and amenities and has its own transport to facilitate access to the local community. There is a small garden which is accessible to service users. Limited parking is available to the front of the property. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that took place on a Saturday morning at about 9.30am. Time was spent with all four of the residents, two of the staff who were on duty and, at the end of the inspection, the registered manager. Records were looked at, as were all rooms in the house. Time was also spent looking at, and listening to, the everyday routines of the house and the way that residents and staff talked and communicated with each other. The help given by the staff at the residents at Sydervelt Lodge was appreciated. What the service does well: What has improved since the last inspection? What they could do better: The home need to make sure that there is always enough staff on duty to keep the residents safe, and to help the residents to do interesting things with their time. Records that show all the information needed for agency staff, including their training, must be available for inspection. The home could also try to find out more about what the residents and their families think about the way the home is run at the way they are cared for. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 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. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 4, Documents about the home gave enough information for a person to make a clear choice about living at Sydervelt Lodge. The assessment process protected residents. EVIDENCE: The statement of purpose and service user guide were clear and detailed. The registered manager advised that they are to be reviewed and a copy will be sent to the Commission. The assessment documents were detailed and relevant professionals, including the registered manager, were involved. A letter was seen on file to show that Estuary wrote to the prospective client to confirm that they could meet the persons needs at Sydervelt Lodge. A resident confirmed that they had visited the home prior to admission. A pictorial format contract was available on those residents’ files sampled. This was user-friendly and referred the person to the service user guide for more details on the services and facilities provided to them by the home, and for who was responsible for pay the fees. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 6, 7, 9, The quality of the care management documentation seen supported consistent care for the residents. EVIDENCE: A care plan inspected was relevant to the assessed needs of the resident. It provided clear instruction for staff on how to meet these, and covered all aspects of daily living as well as individual specific needs. Residents’ preferences were recognised within the care plan. Care plans were supported by risk assessment. The manager advised that professional assistance was also being undertaken in relation to appropriate risk assessments, for example from the occupational therapist. A crisis plan was also in place. Care notes were written regularly and were relevant. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Residents at Sydervelt Lodge were provided with an appropriate diet. The residents are generally supported to maintain appropriate and fulfilling lifestyles, although this could be developed with increased staffing levels at times, and the maintenance of longstanding financial support to residents. Residents’ right to privacy was respected. EVIDENCE: Care, activity and financial records inspected showed that residents have a range of social activities both at home and in the community. A resident spoken with advised of going to church each week and maintaining relationships with family. Some residents attended day-care facilities while another had been enrolled for appropriate courses at a local college. Additional staff had been put on duty for specific activities, which had benefited residents. One resident had two to one staff funding at Day Centre, but not at the home. This requires careful management of which resident goes where, and what activities are undertaken, to ensure safe staffing levels for all residents and staff involved. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 11 Two residents had been on holiday recently. Staff advised that one resident had been unable to have a holiday, as Estuary greatly reduced the budget allowed and the resident did not have sufficient personal funds to make up the difference. The contract with the funding authority was not available to assess whether this change had been negotiated and agreed. A resident said they liked the food and all were seen to enjoy their choice of breakfast. Food stocks, menu records, care plans and discussion with a resident and staff confirmed that appropriate attention was given to a healthy nutritious diet. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18, 19, 20 Residents received appropriate support for personal care and also to access all relevant health care professionals. Medication systems within the home were assessed as safe. This could be enhanced by evidence of staff training. EVIDENCE: Care records and practice observed indicated that residents were provided with prompts and encouragement to manage personal care to the best of their ability, with staff providing any additional necessary support. Consistency and continuity of care was ensured through knowledge of the care plan, the use of key workers and staff meetings. Clear health care records were maintained which record the date, the reason and the outcome. Records also showed the involvement of other professionals, for example consultant psychologist or occupational therapist. Residents were supported with a healthy eating plan and weight charts were maintained. There was limited medication usage in the home. Storage, administration and records observed were appropriate. Staff advised that they had had medication training, and updated assessments, although no evidence was available to support this. A current medication directory was available. A copy of the Royal Pharmaceutical Society guidelines for medication in care homes was not available. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22, 23 Arrangements for protecting the residents and responding to their concerns were satisfactory. EVIDENCE: The complaints procedure was available in a format that supported resident understanding. No complaints had been received by the home since the last inspection. Staff spoken with confirmed that they had had training on protection of vulnerable adults, this included the agency staff member on duty. Staff were aware of appropriate actions to take to protect residents. Staff spoken with confirmed they did not find the whistleblowing policy easy to read. Training records for permanent staff sampled contained certificates to evidence training on protection of vulnerable adults, as well as recent training on positive responses. The registered manager advised that the second part of this training is booked for all staff for September. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 25, 26, 27, 28, 29,30 The premises at Sydervelt Lodge met residents needs and provided a safe, clean and spacious environment. EVIDENCE: All areas of the home were inspected and seen to be clean, well decorated and furnished and to provide a range of accessible shared spaces, including the garden. A resident advised of having painted their bedroom recently, supported by a staff member, and of choosing the colour scheme. There was no chair or curtains, but the resident was clear that they would be provided with new soft to the furnishings, as well as furniture. All bedrooms were individually decorated and personalised according to the abilities of the resident. One resident had a key to their room. The downstairs bathroom has recently been retiled and the registered manager advised that new towel rails etc are ready to be installed. A new washing machine, complete with a sluice facility, had been installed since the last inspection. This freed the sink in the laundry to be used for hand washing. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 15 Staff were seen to wear a protective gloves and provide residents with support to use these as appropriate. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 The staff team were aware of residents’ needs and abilities, and demonstrated the ability to meet these. The staffing levels did not always protect residents. The home’s recruitment procedures and records of permanent staff demonstrated robust procedures that protected residents. Residents would be better safeguarded if this was evidenced for agency staff. EVIDENCE: The roster showed that the minimum staffing level of two each day and one awake at night had been met. This had also been exceeded on occasions to allow residents to attend activities in the community. However, at the time the inspection started, there was one agency member of staff alone on duty in the home. It was advised that the permanent staff member had gone to get the food shopping, as the staff were unable to do it as planned earlier in the week. This is considered seriously unsafe practice, particularly in light of the needs of all four residents who were at home at this time. The staffing levels at Sydervelt Lodge need to be continuously reassessed, due to the high level of need identified for some service uses, to ensure that the home is safely able to meet the needs of all it’s residents. The home had some staff vacancies. These were covered by regular agency staff or by the homes’ own staff working an additional shift each week. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 17 An induction training format was seen on file for one more recently appointed staff member. While this had been completed in its first week, the one-month, three-month and six-month end of probation period sections had not been completed. Staff training records however confirmed that the staff member had had appropriate mandatory training. One day basic induction training sheets were recorded for agency staff. Training files were sampled for two staff members. These evidenced that staff had had appropriate mandatory training, for example first aid, moving and handling or food hygiene, as well as more service uses specific training including Autism and Fragile X. Certificates were not available for all staff in relation to health and safety, which at Estuary includes fire training. It was advised that several staff were waiting to start their NVQ training, while others were waiting to re-start it, following difficulties with funding. As the person in charge of the home and the residents was not allowed to be in charge of the key to the metal cabinet, the registered manager was called from his day off, to allow access to the staff recruitment files. The files for two staff were inspected and contained the required records. The original copies of Criminal Record Bureau checks were on file, which is positive. Required records relating to agency staff, for example name, address, date of birth and evidence of training and experience were not available. Staff were seen and heard to respond positively to residents in a friendly and respectful way. Equally residents approach to staff freely and make their wishes and request known. Staff were skilled at interpreting residents’ communications. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 Sydervelt Lodge was well-organised, safe and efficiently managed. Staff felt well supported by the manager and were enabled to support residents. Development of the home’s quality monitoring systems would benefit residents. Detailed corporate policies and procedures safeguard residents. EVIDENCE: The registered manager had appropriate experience and had attended recent and relevant updated training courses. He was to recommence his NVQ level 4 training, Registered Managers Award, following difficulties with funding. Staff found the manager approachable and individual staff had designated responsibilities for specific areas within the home, for example nutrition. All policies and procedures requested for sampling were available. Residents records were well organised and readily available. Staff were aware of the recent clarification from Estuary on appropriate use of residents’ money. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 19 Residents meetings were undertaken and time was spent with residents trying to ascertain their views. The registered manager produced a flip chart of drawings used to help residents to understand the topics discussed at the residents’ meeting. Estuary had produced a quality audit report but, due to the abilities of the residents, there had been no input from those at Sydervelt Lodge. It is hoped that this will change in future and residents’ views will be included. Safety inspection certificates sampled were current and readily available and included the electrical wiring, gas, fire alarm and fire equipment. A current certificate of employers liability insurance was displayed. Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 2 2 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sydervelt Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 13 & 33 Regulation 16(2)m & n and 18(1)(a) Requirement The person registered must ensure that adequate staffing levels are in place at all times as required to meet each resident individual needs for activities, both at home and in the community, and to allow staff to undertake all necessary tasks in the home. The person registered must provide in rooms occupied by residents adequate furniture and other furnishing including curtains and carpets. The person registered must ensure that records are available for inspection in line with regulatory requirements. This refers to records required in relation to agency staff. (Previous time scale of 29/03/04 not met) The person registered ensure that training/relevant qualification records are available for all staff working at a care home. This refers to agency staff. (Previous timescale 29/03/04 not met) The person registered ensure that a quality assurance system Timescale for action 16th July 2005 2. 26 16(2)(c) 23rd July 2005 3. 34 17(2) 1st August 2005 4. 35 17(2) Schedule 4 (6) 1st August 2005 5. 39 24 1st April 2006 Page 22 Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 is in place, which includes the views of the residents, their representatives at relevant professionals. 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 14 Good Practice Recommendations Each resident should have as part of their basic contract price the real option of a minimum seven-day annual holiday outside the home. Details of this should be included clearly in the resident statement of terms and conditions. The home should have a copy of the Royal Pharmaceutical Society guidelines for medication in care homes. Evidence should be available of staff training in medication. The whistleblowing policy and procedure should be written in plain language. 50 of care staff should achieve an NVQ2 or equivalent. The registered manager should achieve NVQ4, Registered Managers Award. 2. 3. 4. 5. 6. 20 20 23 32 37 Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea SS2 6BG 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 Sydervelt Lodge I56-I06 S18034 Sydervelt Lodge V238995 160705 Stage 4.doc Version 1.40 Page 24 - 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!