Inspection on 21/11/05 for Sydervelt Lodge

This inspection was carried out on 21st 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sydervelt Lodge 21/10/08

Sydervelt Lodge 21/11/06

Sydervelt Lodge 16/07/05

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 Mrs Bernadette Little Unannounced Inspection 21st November 2005 10:00 Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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 Sydervelt Lodge DS0000018034.V267594.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 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. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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 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) Estuary Housing Association Limited Mr Gary John Engedahl Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 July 2005 Brief Description of the Service: Sydervelt Lodge is a care home providing personal care and accommodation for up to four service users who have a learning disability. The premises are a detached two-storey house, situated in a quiet residential area of Canvey Island. The home has four single bedrooms, none of which have ensuite facilities, but all have a washbasin. There was a large communal lounge/dining area, a separate quiet/activities room and a separate sensory room on the ground floor. The office is located on the first 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 DS0000018034.V267594.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second routine unannounced inspection of Sydervelt Lodge this year. It took place on a Monday afternoon. Four staff were spoken with and all residents were seen. The registered manager was not at the home at the time, but did call in at the end of the inspection. Time was also spent looking at records and all parts of the premises were seen. The help provided by the residents, visitors and staff was appreciated. Any standards not covered at this inspection were considered at the last inspection. What the service does well: What has improved since the last inspection? Since the last inspection one new member of staff has come to work in the home on a regular basis. The manager explained that he and the staff had had more training recently. The downstairs quiet/activities room had been decorated and equipped and could now be used by residents. The service uses guide which gives information about the home had been updated. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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 Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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): 1, 3, Sydervelt Lodge had a good range of information available for those thinking about using the service. The premises, equipment and staff training supported the homes ability to meet residents’ needs. EVIDENCE: The home’s Statement of Purpose and Service User Guide were readily available and displayed in the home. The Service User Guide had been updated since the last inspection. Discussion with the staff, inspection of the care records and observation of practice demonstrated that staff had an understanding of residents’ individual needs and the ability to meet them. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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 the following standard(s): 6, 8, 10 The care management documentation sampled continued to be of a standard that supported consistent care for residents. EVIDENCE: Two care plans were sampled to ascertain whether known recent events and changes had been recorded for the resident. This had been undertaken with one omission for one resident in relation to an infringement of their rights. Discussion with staff and observation of practice indicated that residents were involved in everyday decisions on life in the home, taking their individual abilities into account. Staff were aware of the homes policy on confidentiality and described appropriate ways to maintain confidentiality as well as sharing it safely. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 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 the following standard(s): 13, 14, 16 Sydervelt Lodge was providing residents with an improving range of activities to support a fulfilling lifestyle. EVIDENCE: One resident was at home for the major part of the inspection and was being visited by their family, who had lunch with them and the staff. The other residents were out at their various day resources, including attending college courses or circuit training. Staff confirmed that the additional staffing greatly assisted them to provide a wider range of leisure activities to all residents. This includes karaoke evenings at a local pub, going to football matches and eating out. Staff and the manager advised of plans to continue to improve this for residents, and that the lack of access to employment was one of the issues that came out of Estuary’s Quality Network report that is to be worked on. One resident had the key to his room and locked it when he went out. Staff interacted with residents who were confident in their environment. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 11 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): 20, 21 The homes practice, policy and procedure on the use of medicines protected residents. EVIDENCE: Residents’ health and well being continued to be supported with limited use of prescribed medications. Evidence of staff training and regular updates in relation to medication was again not available. The Royal Pharmaceutical Society guidelines on the use of medications in care homes was found on this occasion, but staff could be made more aware of its availability. No other aspect of the medication system was considered as these were found to be satisfactory at the last inspection. Information was seen on one resident file sampled in relation to the families wish for the resident’s end of life practices, including religious rites. This was recorded as having been read to the resident. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 12 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): 23 Arrangements for protecting residents were satisfactory. EVIDENCE: The staff and management at Sydervelt Lodge, supported by Estuary, had recently taken appropriate action to protect a resident from a situation that was recognised to make them vulnerable. Staff had reported this accordingly, the home had worked with other professionals, and actions taken included increasing the staffing levels when all residents at home. Additional protection had been provided by the use of visual alarms and this had been included in one resident care plan. Some permanent staff have recently attended part two of the Positive Responses Training. Training records were not available to confirm that agency staff had attended training on the protection of vulnerable adults or management of behaviour that challenged. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 13 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, 26, 30 Sydervelt Lodge was clean, bright and well maintained and provided the residents with homely and comfortable surroundings. EVIDENCE: The premises was seen to be maintained to a high standard of cleanliness and décor and all areas were well presented. The activities/quiet lounge had been completed with the exception that the two new sofas were awaiting delivery. This room provided a pleasant alternative to the main living room and was equipped with entertainment equipment. One resident was seen to be resting in this room at one point in the inspection. Additionally, new furniture and curtains had been provided in the resident’s bedroom that was being done up at the time of the last inspection. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 14 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): 31, 32, 33, 34, 35 and 36 The increased staffing level better supported and protected residents. Staff effectively met residents’ needs. The lack of records showing safe recruitment practices and appropriate training for agency did not best protect residents. EVIDENCE: Staff demonstrated awareness of their responsibility and role within the staff team. Staff were seen to work effectively together. None of the care staff were undertaking NVQ training. Training records for regular staff indicated specialist training. Evidence of updated mandatory training was not always available. The manager advised that obtaining certificates following completion of a course often proved difficult. Estuary needed to support staff to access this evidence of training. Sydervelt Lodge has several care staff vacancies and regularly use agency staff. Training records were again not available for agency staff. Evidence of safe recruitment practices/records required by regulation were again not available for agency staff. The recruitment file for the most recently appointed member of staff was inspected and found to be appropriate, with the exception that the application form was not signed, and there was no declaration of physical and mental health by the applicant. The induction sheet on file for this new member of staff had been completed initially, and records evidence that training was planned in mandatory topics. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 15 Access was not available to staff supervision records but a staff member spoken with confirmed that staff have regular supervision sessions, probably monthly, with the registered manager. They confirmed an appropriate agenda for this to which they have input. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 16 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, 42, 43 Sydervelt Lodge was effectively managed. The leadership style promoted an ethos that the home was run for the benefit and well being of the residents. EVIDENCE: The registered manager is currently undertaking NVQ4 training in Care and Management. He has several years experience in caring for people with learning disabilities and regularly attended relevant training courses. Staff advised that two of the residents at Sydervelt Lodge are to be included in Estuary’s next Quality Review. Records indicated that a residents’ meeting had not been undertaken for some months. Safety audits, for example tests of the water temperatures, or of the fire equipment had not been undertaken regularly within their own timescales. Fire drills had been undertaken regularly but had not included all staff, especially agency/night staff. A letter was on file from the fire authority that identified issues within the home that needed to be addressed, including a fire risk assessment and Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 17 maintenance of the fire door self closures. The staff member advised that the home is to have a planned visit from the fire authority in the very near future. There was no evidence available to staff have recently attended updated fire training. Current certificate of liability insurance was displayed. From observations during this inspection and discussion with the manager and staff there was nothing to indicate that the home is anything other than financially viable. Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 18 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 3 X 3 X x Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sydervelt Lodge Score X X 2 3 Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 3 DS0000018034.V267594.R01.S.doc Version 5.0 Page 19 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 YA20 Regulation 13(2) Requirement Staff must be provided with medication training and evidence be available for inspection. The person registered must ensure records are available for inspection in line with regulatory requirements. This includes a declaration of physical and mental fitness and complete records for all agency staff working in the care home, to be in place prior to their first shift ( previous timescales of 29/03/04 and 01/08/05 not met). The person registered must ensure that training/relevant qualification records are available for all staff working at the care home. This refers to agency staff. (Previous timescale of 29/03/04 and 01/08/05 not met). The person registered must, after consultation with the fire authority, take adequate precautions against the risk of fire. this refers to the requirement for a fire risk DS0000018034.V267594.R01.S.doc Timescale for action 01/01/06 2 YA34 17(2) 21/11/05 3 YA35 17(2)Sch 4(6) 21/11/05 4 YA42 23(4) 21/11/05 Sydervelt Lodge Version 5.0 Page 20 5 YA42 23(4)(c) (d)(e)(v) assessment and maintenance of the fire doors/self closures The person registered must ensure the regular testing of fire equipment, that staff are provided with regular training in fire prevention and the inclusion of all staff in fire drills 21/11/05 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 YA14 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.(This is a recommendation from the last inspection not considered on this occasion. It will be carried forward to the next inspection). The whistleblowing policy and procedure should be written in plainer language. (This is a recommendation from the last inspection not considered on this occasion. It will be carried forward to the next inspection). 50 of care staff should achieve NVQ training. Residents’ views should continue to be sought at residents’ meetings on a regular basis. 2 YA23 3 4 YA32 YA39 Sydervelt Lodge DS0000018034.V267594.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex 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. 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