Inspection on 21/11/06 for Sydervelt Lodge

This inspection was carried out on 21st November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 21/11/05

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 2006 10.25 Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 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.V319466.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 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.V319466.R01.S.doc Version 5.2 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.V319466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 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 separate 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. The registered manager states the weekly fees as £1,447.68 per week. Additional charges/costs identified as incurred by residents relate to chiropody at £26 every 4 weeks and toiletries at £5 per week. The Service Users Guide additionally advises that residents will be required to purchase items for personal use such as televisions for their bedroom, as well as their bedroom furniture and any specialist equipment they need. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the key inspection of Sydervelt Lodge and seven hours were spent at the home. Time was spent with all four of the residents who were living at the home at the time of the inspection. Most of the residents were unable to express views verbally due to their individual needs. Four staff and the registered manager were spoken with. A tour of the premises was undertaken and records, policies and procedures were sampled. Records for one resident were case tracked and were sampled for another resident. Discussion of the inspection findings took place with the manager and staff during the inspection and the help given by residents and staff was appreciated. A pre-inspection questionnaire had not been received from the home prior to the unannounced site visit. The registered manager advised that this had not been received and that there had been some problems with the homes’ mail being delivered to another, similar, address. Comment cards for relatives were left with the registered manager who offered to distribute them to those relatives who were in contact. No responses were received. Compliments from relatives were noted in the home’s records and are included in this report. Comments were obtained by telephone from a social care professional involved with the home and also from a relative. These are included in the report and showed a positive view of the care provided to residents at the home. What the service does well: What has improved since the last inspection? There were records on the files looked at to show that the staff had had training on medication. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 6 The registered manager had had fire training and had done the home’s fire risk assessment. The records looked at showed that the fire equipment had been tested regularly and that staff had had fire training and been involved in fire drills. Records also showed that staff had sat with residents individually to try to find out what they think and like. 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. The summary of this inspection report can be made available in other formats on request. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 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.V319466.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home was readily available and had enough detail to help people to make an informed choice about the service. Much of the information was in a format that was easier for residents to understand. Procedures in relation to assessment, admission and trial visits protected residents. EVIDENCE: The statement of purpose and service user guide were readily available and each resident had a copy of the service user guide on their file. The service user guide will need to be updated to reflect the changes in Regulation that came into effect in September 2006. There have been no admissions to the home since the last inspection. The registered manager’s confirmation of the homes admission process, and Estuary’s supporting documentation clearly identifies that residents will have a detailed pre-admission assessment, including input by relevant professionals, as well as trial visits to ensure the appropriateness of the placement. The resident’s file sampled had a copy of their licence to occupy as well as a pictorial format statement of terms and conditions. This had been signed by the resident. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided very detailed information to assist staff to consistently meet residents assessed needs. Residents were encouraged to retain independence skills and take risks according to their individual abilities. EVIDENCE: One care file was inspected and another was sampled for specific issues. One of the care plans looked at had in excess of twenty identified care aims with specific details of actions to be taken to achieve them. They included medication, finance, specific behaviour practices and individual leisure pursuits and interests as well as general aspects of health and welfare. Each was supported by a risk appreciation assessment. The care plan was also detailed and individual and looked at supporting the client in relation to independence skills such as cooking, budgeting and accessing the community. Staff spoken with showed awareness of residents needs and plan of care. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Consideration had been given to resident’s individual needs for personal development and social and leisure activities, with some success. The home continues to develop this for/with residents. Residents’ opportunities would benefit from additional staffing hours. Residents’ relationships with relatives were actively supported. Residents were offered a varied, nutritional diet. EVIDENCE: One member of staff has designated responsibility for residents’ social activities. A plan was displayed of each resident’s weekly activities along with the required drop off and pick up times as a staff planner. An activities record was maintained. Activities varied for residents and included attendance at day centre, church service, family visits and lunch, circuit training as well as outings at evenings and weekends such as attending a music club or a karaoke evening at a local pub. Special events also included a planned trip to a pantomime. Pictorial Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 11 minutes of a service user forum were readily available along with a voting slip to choose from a range of events such as dog racing or a trip to the zoo. While a resident had funding for a two to one staff ratio while at day centre, this was not available to staff at the home for the identified outside activities that required this. The registered manager advised that this restricted the resident from accessing community social events at weekends in some cases although they can take the resident to the park or to other Estuary premises. This is referred to again in this report in the section on Staffing. He advised that where the home are endeavouring to provide additional staffing it is using up their budget for leisure activities. The registered manager advised that it is planned to replace the current day resource used by another resident once the structure and staffing are provided, as this will provide them with more appropriate stimulation. Residents were encouraged to undertake everyday tasks such as taking their own cups to be washed. Ample food stocks were available. The record of food served showed choice and variety. Residents were regularly offered drinks and staff responded to resident’s indications for a drink. A resident spoken with said that the food was nice. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported and their health care needs are met. Medication management protected residents. EVIDENCE: A relative spoken said that they are very satisfied with the care provided and that the resident loves living at Sydervelt Lodge. The relative advised that the staff communicate well them. All residents at Sydervelt Lodge are mobile and none had any specific moving and handling or equipment needs. Residents have an allocated key worker for additional support. Residents health care support needs were identified and monitored in a separate folder. This clearly showed access to routine health care appointments for example with the dentist, optician, chiropodist and flu jab. Over time they also indicate that staff have monitored the resident’s health and contacted the GP for example relating to a chest or urine infection. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 13 Records indicate the date of the resident was seen, who by, the reason for the appointment, the outcome and any follow-up needed. Comments received from a social care professional involved with the home indicated that the home worked in partnership, with good communication, provided the multidisciplinary team with information from non-obtrusive observations and positive participation and that this was supported by the stability of the staff team. Some residents at Sydervelt Lodge do not any prescribed medication. However, appropriate records were maintained for example in relation to antibiotics, and this indicated that the course was completed. The Medication Administration Recording sheets for residents who did have some prescribed medication showed no omissions. A record of medications received and returned was maintained. The registered manager advised no residents are prescribed rectal diazepam. Policies and procedures in relation to medication were available, as was an upto-date staff signatory list. The registered manager confirmed that staff receive initial medication training followed by an annual competence assessment in house. Staff are also provided with annual updates and a written assessment. Certificates confirming this were seen on five files randomly sampled. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy and a positive approach to hearing people’s view of the service. Staff are aware of the issues relating to the protection of vulnerable adults. EVIDENCE: Estuary established policies and procedures relating to complaints. A pictorial poster explaining who to raise any worries or concerns with was displayed in both the hall and the office. Forms for recording complaints were readily available. The complaints log was available and the manager confirmed that no complaints have been received by the home. The Commission has not received any complaints regarding Sydervelt Lodge. The registered manager stated that he would prefer for people to bring him concerns and complaints directly so that they can be addressed positively and quickly within the home. One of the compliments recorded came from a member of the social services behavioural team and also there were two from a resident’s family. These related to feeling welcome in the home and the resident looking very settled and happy, thanking a member of staff for the great comfort and support they provided when accompanying the family and the resident to a hospital appointment, and thanks to the home for the invitation to the family to join in the resident’s birthday party. No referrals regarding Sydervelt Lodge had been made under POVA (protection of vulnerable adults) since the last inspection. The home had previously identified an issue very effectively and continue to manage it with the support of other professionals. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 15 The registered manager advised that all staff have up to date training in the protection of vulnerable adults. Evidence of this was not available in relation to agency staff. The agency staff member on duty at the time of this inspection evidenced a stamped training record that included POVA, and more importantly was able to describe appropriate actions and confidence to whistle blow. Estuary have not yet rewritten the whistleblowing procedure for staff in clearer language as recommended in previous reports. The majority of staff attended positive responses training last year. While new staff have not attended this training, all the current permanent staff have recently attended specific training on behaviour. Certificates were seen for attendance at a one-day workshop entitled insight into developing effective boundaries with the challenging clients. Registered manager advised that new or agency staff would always be put on shift with the trained and experienced member of staff. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sydervelt Lodge provided a clean, safe and generally pleasant environment with premises and equipment that met residents’ needs. EVIDENCE: All areas of the premises were seen with the exception of one bedroom, which the resident had locked while they were out. The communal rooms were well decorated and homely. Residents had a choice of areas to sit in to be with other people or to be alone. Staff advised that a new kitchen is to be fitted. One resident’s bedroom is in need of decorating. The registered manager advised that flooring is to be fitted into bedrooms and in the new kitchen. However, decorating has been delayed due to cracks in the walls needing to be addressed first. Staff advised that, through choice, residents mainly use the bathroom and that the shower room is really only used by sleeping in staff. The sleeping in member of staff uses a sofa bed in the residents’ separate activity lounge. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 17 A resident spoken with said that they were happy with their room and the premises in general. Resident’s bedrooms were individually personalised. Staff confirmed that none of the residents need any specific individual equipment. A relative spoken with confirmed that they may visit the resident in private if wished. The premises was clean and tidy. COSHH items {Control of Substances Hazardous to Health} were safely stored. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a consistent and established staff team. Staffing levels were adequate to meet resident needs in the main, with some exception in relation to support for social stimulation. Staff recruitment practices generally protected residents but there is an outstanding requirement relating to this. Staff training in both mandatory and service user specific issues generally supported residents, but would be better supported by clearer records for agency staff. EVIDENCE: A relative spoken with said that all the staff at the home are very nice and a resident spoken with also stated this. The registered manager advised that there are currently no staff vacancies. Since the last inspection staffing levels have increased by one each shift to meet residents’ specific needs. The additional care hours are covered by regular agency staff, or the home’s own staff doing additional shifts, as the home endeavour to provide consistency of care for residents. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 19 The section on Lifestyle indicated a need for a review of the staffing hours provided to the home related to some additional extra staffing to meet a residents specific needs. The rota shows that some staff worked twelve and a half hour shifts. The registered manager advised that this is worked for the person who is the driver on that shift, to ensure that residents have appropriately skilled staff to take them to their varied activities. Drivers work three long shifts with four shifts off. The registered manager advised the home has a good sickness record and there are no staff on long-term sick. The registered manager is currently undertaking NVQ level 4. One member of staff has achieved NVQ level 3, three staff are undertaking NVQ level 3, one staff is undertaking NVQ level 2 and two staff are currently on probation so cannot begin the appropriate level of NVQ until this is completed. Two new permanent staff had been appointed since the last inspection. Both recruitment files contained an application form, job description, evidence of identity, two references received prior to employment commencing and criminal record bureau checks. The application form refers to disclosing offences but does not include a declaration in relation to health. One file did not contain a photograph as required. The agency member of staff on duty at the time of the inspection had evidence of their identity and a copy of their training record. A record was maintained in relation to the agency staff used at the home. This did not include information on the three most regularly used agency staff and there was no confirmation from the agency that appropriate records and checks have been done on each individual member of agency staff sent to Sydervelt Lodge. Additionally there was no evidence of criminal record bureau checks having been undertaken for two of the three regular agency staff (although there were training records were several other agency staff that contained a criminal record bureau check number). A medication certificate was the only evidence of training for one of the agency staff used regularly. Both permanent new staff files contained an induction record. Both files had certificates in relation to recent moving and handling, foundation in food hygiene, management of behaviour that challenge, and sexual issues in learning disability. The registered manager advised that these, and all staff, had fire training and evidence was seen of his fire managers training. Neither staff administer medication. One staff had completed training on the protection of one of vulnerable adults recently and the other was booked to attend in the near future. Both staff were booked to attend training on risk assessment on the day following the site visit. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 20 The registered manager advised that staff will be undertaking training next year in dementia and Down syndrome in line with perceived changes in resident need. Training is also planned in autism and Fragile X, and specialising in behaviours. Each member staff has an individual training plan. The staff training matrix provided indicates that all staff have current first aid and food hygiene certificates as well as fire safety training. Six staff had recently attended moving and handling training and four have had recent training and protection of vulnerable adults. A resident spoken with confirmed positive relationships with staff. Observations indicated that residents felt comfortable and confident in the company of and in approaching staff. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager demonstrates competence and good leadership skills. The home is well run and organised internally and resident’s views are sought. Estuary’s lack of monitoring of the conduct of the home did not best protect residents. Health and safety checks to protect residents and staff were recorded as routinely completed. EVIDENCE: The registered manager is currently undertaking NVQ level 4, Registered Managers Award. He advised that he has been out of the home for the past week working on agenda for change. As he will also be out of the home and involved in reviewing the old policies and procedures for Estuary, he has requested and appointed a deputy who can take responsibility in his absence, to ensure consistency and continuity. Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 22 Staff spoken with confirmed that the manager is approachable and supportive. The most recent regulation 26 report available on site was dated May 2006. Estuary needed to ensure that these are completed monthly as required by regulation. The registered manager advised that he now has a new service manager and has recently had an e-mail to confirm that regulation 26 reports will be re-established in the very near future. The registered manager advised that Estuary’s quality network group was still operating and the two of the residents at Sydervelt Lodge were involved. The registered manager stated he understood that questionnaires were sent to relatives this year by Estuary. Questionnaires were also done with residents by keyworkers this year and while the information was fed back to Estuary, there was no information as to what may have been done with it as yet. The home had endeavoured to undertake individual meetings with residents using drawings and pictures with very different levels of success with different residents. Current inspection certificates were displayed in relation to the fire alarm, fire equipment, gas, and electrical fixed wiring. The registration certificate and certificate of liability insurance were also displayed. A fire risk assessment has been completed since the last inspection. Regular fire drills were recorded as evidenced the inclusion of the two new staff and one of the regular agency staff. Sydervelt Lodge DS0000018034.V319466.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 X X 3 X Sydervelt Lodge DS0000018034.V319466.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation YA5 Requirement The service user guide must be amended to reflect the changes in regulation and include the required information. The person registered must ensure that there are adequate staffing hours provided to meet residents individual needs to access the community. The person registered must ensure that all parts of the premises are well decorated and maintained. The person registered must ensure that there are adequate staffing hours provided to meet residents individual needs to access the community. 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 records confirming appropriate references and checks for each DS0000018034.V319466.R01.S.doc Timescale for action 01/03/07 2. YA13 18(1)a 01/03/07 3. YA24 23(2)d 01/03/07 4. YA33 18(1)a 01/03/07 5. YA34 17(2) 01/01/07 Sydervelt Lodge Version 5.2 Page 25 agency staff working in the care home, to be in place prior to their first shift ( previous timescales of 29/03/04, 01/08/05 and 21/11/05 not met). 6. YA34 19 Sch 2 The person registered must ensure records are available for inspection in line with regulatory requirements. This includes a photograph of each staff member. 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, 01/08/05 and 21/11/05 not met) The person registered must ensure that visits and reports as required by regulation are undertaken monthly and available in the home for inspection. 01/01/07 7 YA35 17(2)Sch 4(6) 01/01/07 8. YA39 26 01/01/07 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 YA23 Good Practice Recommendations 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 staff should achieve NVQ level 2. DS0000018034.V319466.R01.S.doc Version 5.2 Page 26 2. YA32 Sydervelt Lodge Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000018034.V319466.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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