Inspection on 21/10/08 for Sydervelt Lodge

This inspection was carried out on 21st October 2008.

CSCI found this care home to be providing an Good service.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sydervelt Lodge 21/11/06

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

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Coopers Mill Ltd

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Paradise Lodge

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Upaya Ananda

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Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sydervelt Lodge 2 B Sydervelt Road Canvey Island Essex SS8 9EF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sharon Lacey     Date: 2 1 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Sydervelt Lodge 2 B Sydervelt Road Canvey Island Essex SS8 9EF 01268695821 F/P01268695821 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Gary John Engedahl Type of registration: Number of places registered: Estuary Housing Association Ltd care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Sydervelt Lodge is a care home providing personal care and accommodation for up to four service users with a learning disability. The premises is 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. There is a large communal lounge/dining area, as well as a separate quiet/activities room. There is also 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 stated the weekly fees are £1696.43 per week. Additional charges/costs identified as incurred by residents relate to chiropody and toiletries. 4 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was a routine unannounced inspection, which took place over seven hours. It was a Key Inspection covering 37 of the National Minimum Standards. A tour of the home and inspection of the environment was completed and records and documentation were viewed. Areas looked at included information given to residents about the home and its services before being admitted, information gained by the home residents when they first come into the home, information given to staff on the care required, the facilities and environment of the home, and any complaints that may have been received since the last inspection. An Annual Quality Assurance Assessment (AQAA) was sent to us by the Manager. The AQAA is a self-assessment which focuses on how well the service consider they are Care Homes for Adults (18-65 years) Page 5 of 30 meeting the outcomes of the people who live at the home. It also provides statistical information about the service and how the service intends to improve over the next 12 months. Information from this document has been used in this report were appropriate. Not all of the residents at Sydervelt Lodge are able to communicate verbally. Due to this much is the evidence gathered from the residents was through observation and their interaction with the staff. Questionnaires were sent out to the residents (4), relatives (4) and also healthcare professionals. Feedback from these questionnaires has been included in the report. All staff members on duty were spoken with informally during the inspection and any feedback has been included in the report. Staff questionnaires were also distributed and three were returned. At the end of the day the inspection was discussed with the Manager and advice and guidance is given regarding the findings. There is an easy read summary of this report available. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Adults (18-65 years) Page 7 of 30 following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Perspective residents are provided with information about the home, to help them make a choice on whether the home can meet their care needs. Evidence: There was a clear Statement of Purpose, which set out the aims and objectives of the home and the services available. The Manager had produced a pictorial Service User Guide, which used simple language and pictures for those residents who were unable to read. There was also a second document available, which contained fuller, more detailed information if required. All documents seen were well presented and provided good information on the services offered by Sydervelt Lodge and had recently been reviewed. The admission process was clearly set out in the Service User Guide. It was established that no new service users would be admitted to Sydervelt Lodge until a full assessment has been undertaken. The last new admission to the home was over two years ago. Documentation of assessments on present residents were viewed and these Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: were very comprehensive and highlighted each individuals care needs. Prospective service users have an opportunity to visit the home. The Service User Guide states a minimum of a half a day would be provided to the service users, family and their friends prior to the admission to the home, to ensure the home can meet their needs. There is evidence that each resident had an individual written contract on their file and details of the terms and conditions of the home could be found in the Service User Guide. A copy of the homes last inspection report and registration certificate were made available. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that the care plans in place clearly identify their specific individual needs and provide clear instruction to staff. Evidence: Each resident at Sydervelt Lodge has a Key Worker. The care plans in place had been well developed for each individual resident and these reflected their individual needs. Two service user files were inspected. The care plan included details of getting up, going to bed, bathing, shaving, oral hygiene, dressing, haircare, foot care, personal care, food and eating, activities, hobbies, communication and relationships. On viewing the information it was very detailed and covered the task, but also included the skills and the support needed to help implement the plan. The were clear risk assessments on the back of the care plan to highlight any risks and how these could be successfully managed. The staff members spoken to on duty were very aware of the residents needs. Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: There was evidence on the two files inspected that the residents had been involved in decisions about their lives and the staff provided the assistance required to achieve these. Risk assessments were also in place to highlight risk. It was clear from evidence gathered that residents are offered opportunities to participate in the day-to-day running of the home and contribute to the development of the service where possible. Systems were in place to ensure advocates and family members were involved in their relatives care. One compliment received stated the home has treated xxxx as a valuable member of our society, giving xxxx boundaries of acceptable behavior to integrate into the community as much as it is possible to do. Creating a safe environment. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities available do not always enhance residents leisure and educational opportunities. Residents are offered meals which offer them choice, variety and meet their dietary needs. Evidence: Residents at Sydervelt Lodge are given opportunities for personal development and to maintain social, emotional and communication skills. Evidence showed that three of the four residents attend some form of formal day-care service, and there had also been one-to-one activities organised. Although staff assisted residents to take part in appropriate activities, training and education, the number of staff on duty would limit the activities and outings that could take place. On the day of the inspection, there was only one staff member on duty and two residents at home, so activities and outings were not possible and both residents spent the whole day at home. One Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: resident at Sydervelt Lodge used to attend a day centre most days, but due to deterioration in their eyesight it had been decided by the day centre that they would not be able to continue. On looking at their activity plan, since they stopped attending the day centre they had spent most of their days at the home and had only gone out very occasionally. The Manager had tried to gain extra hours so that more one-to-one sessions could be provided and the individual could receive further stimulation. One health care professional also reported in their questionnaire that staffing levels may limit opportunities for individuals to access leisure activities of their choice and a staff member added at weekends we could do with another staff member to allow for trips and outings for all the residents. Staff at the home support the residents to be part of the community. There were clear records of activities and these provided details of what each individual had done each day. On viewing one residents folder it was clear that they had been taken to the shops, used the sensory room, had a foot massage, had a drink at the local pub, gone for a walk, and also played their guitar. There were also visits to the Phoenix club and other local pubs. Staff at the home support residents to maintain family links and friendship inside and outside the home. Comments received back from the questionnaires showed that family and friends are made welcome. On the day of the inspection there was evidence that a staff member had taken a resident to visit their father. It was clear that the daily routines at Sydervelt Lodge try to support the independence and choice of each individual resident. Care plans had been completed with relatives to ensure individuals choices and needs had been taken into consideration. Staff were observed supporting residents in making choices. Residents have access to all parts of the home, although some restrictions are made during the day due to safety reasons. The staff member on duty confirmed that most household tasks are completed by staff, but residents are encouraged if and when appropriate. Residents were observed being encouraged to take dirty plates and cups into the kitchen. One resident advised that they had been involved in the painting and decorating of the home and was very proud of their achievements. Staff advised that the menu had been made up using their knowledge of the residents likes and dislikes. The menu seen offered a variety and choice, but also took into account dietary needs of residents. On the day of the inspection it was noted that fresh vegetables were being used and there were plenty of food stocks in the kitchen. It was also observed during the day that residents were offered snacks such as crisps, biscuits, cups of tea and fruit. Care Homes for Adults (18-65 years) Page 15 of 30 Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Users of the service receive personal support in a way they prefer and have their physical and emotional care needs monitored and met appropriately. Evidence: The care plans seen clearly identified each individuals care needs, the assistance they required and ensured that they were being supported in a way they preferred. Each residents Key Worker was clearly identified on their file, and one staff member spoken to stated that they felt this system provided continuity of care and enabled them to achieve more with the individual. From a discussion with the Manager it was clear that residents privacy, dignity, independence was upheld and that they were encouraged to have control over their own lives where possible. Support is given to try and enable the residents to have choice on when they want to get up, go to bed and also other general routines in the home. Some of the residents had also been recently involved in choosing the colour of their bedrooms, when they were decorated. The care plans had identified each individuals ethnic, religious and cultural background and this had been incorporated as part of the individual care plan (if and when Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: appropriate). Those staff who returned questionnaires confirm that they felt that they had the experience and knowledge to meet the different needs of the people they cared for, and this included disability, age, gender, race, ethnicity and faith. Relatives also confirmed that they felt staff upheld these issues in the care of their relatives. The Service User Guide stated that access is available to all community-based health care services including GPs, dentists, chiropodists, opticians and other health care professionals. It was clear that the home ensures that the health care needs of the residents are regularly assessed and procedures are in place to help meet these. Files contained evidence that residents health had been monitored and any problems identified had resulted in appropriate referrals being made. There was a Health Action Plan in place for all of the residents and this contained evidence of hospital appointments, GP visits, flu injection and x-rays. There was also a separate health care folder, which recorded intervention from other health care professionals. Sydervelt Lodge has a clear policy and procedure for the recording, storage, handling, and the administration of medicines. None of the present residents are able to administer their own medication and rely upon staff to assist in this process. The medication folder contained photos of each resident to assist identification and medication sheets to record any medication that had been administered. On viewing these documents they had been appropriately completed. At the front of the folder there were signatures of the designated staff who are able to assist with medication. There was also a clear PRN protocol in place for those medications which are as and when. Medication had been appropriately stored and bottles and boxes were noted to have been dated when opened. It was confirmed that those staff who assist with medication had received training. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Users of the service and their families can be confident that their complaints will be listened to and appropriately handled. Evidence: Sydervelt Lodge has a clear complaints procedure, which is available to all residents and their families and is also part of the Service User Guide. The process includes timescales and who to complain to. The Manager stated that no complaints had been received since the last inspection and the CSCI had also not received any complaints. When looking at feedback from the questionnaires, both the Healthcare Professionals and relatives confirmed that they were aware of the procedure and who to raise any concerns with. Policies and procedures were available on Whistle Blowing and Safeguarding Adults. There was also evidence in the office that the Manager had copies of Local Authority guidance. It was noted from information that safeguarding training is mandatory for staff and that all but two had completed this. The Manager confirmed that there had been no safeguarding referrals since last inspection. There are clear policy and procedures regarding residents monies and financial affairs. Most of the present residents receive assistance from either relatives or through the home. Regular audits are completed. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable and safe environment, which meets their individual needs. Evidence: Sydervelt Lodge offers residents are safe and well maintained environment. There are good furnishings and fittings around the home, which help provide a homely atmosphere. There had been some redecoration since the last inspection. Three residents bedrooms were viewed and these had been nicely decorated in colours of the residents choice. Each bedroom contained personal belongings and photographs, which helped individualise and make the room a personal space. None of the bedrooms have ensuite facilities, but there was access to a hand wash basin. It was noted that the carpets in some parts of the home were beginning to look old and tired and in need of replacement. The Manager and a staff member spoken to confirmed that this was on the plan of maintenance for the home, and carpets had been identified for replacement. The Manager explained that there were also plans to decorate the rest of the home. There was sufficient toilets and bathrooms available throughout the home and it was established that the downstairs toilet was also on the list for redecoration. The Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: Manager confirmed that the boiler in the utility room is to be covered to ensure a safer environment for the residents. Two residents bedrooms presently have the taps turned off due to risk of flooding, but the Manager explained that these are to be replaced with push down taps to assist the residents to regain their independence. A maintenance/repair book was available and this contained details of faults and repairs that had taken place. Sydervelt Lodge offers a safe and well maintained environment, which is clean and free from odours. On looking at the training matrix and also randomly checking three staff files, it was not clear whether staff had attended infection control training. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that they will receive care from a skilled, experienced and appropriately supervised workforce, who have been safely recruited. Evidence: The Service User Guide confirmed that the present staffing levels in the home consisted of two staff on duty between 7:00 am and 14:30 p.m; three staff on duty between 14:00 p.m. and 21:30 p.m; one waking night staff and the home Manager who is on duty for three days a week. A clear staff rota was in place and this contained all the information required. Both the staff and the Manager stated that there was a low turnover of staff at the home and the last person to be recruited was over two years ago - providing residents with continuity of care. They had recently changed the hours of the shifts to be twelve and a half hours. Staff spoken to stated that they felt this helped give more continuity to residents and enabled them to plan individual outings and activities. It was discussed with the Manager about the resident who was unable to participate in any activities or go out in the community, due to having a low ratio of staff. It was agreed that staffing levels need to continue to be reviewed to take into account the residents changing needs. The Manager confirmed that staff had been provided with job descriptions at the Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: recruitment stage, to ensure they had an understanding of their own and others roles and responsibilities within the home. The Manager confirmed that staff are also provided with copies of the General Social Care Councils Code of Conduct. Those staff spoken to were aware of their role and also the aims and objectives of the home. When observing staff with residents, it was clear that they had developed a good relationship and were providing support to meet the individuals needs. Sydervelt Lodge has a recruitment procedure in place and the Manager has the responsibility for the recruitment of new staff. On discussion it was clear that the recruitment procedure covered all the areas required. The Manager advised that there had not been any new staff taken on since the last key inspection. Previously recruited staff files were inspected and these contained application forms, references, Criminal Record Checks etc. There was evidence on staff files that a local induction had been carried out and the Manager also confirmed that the induction provided to new staff members was in line with the Skills for Care induction standards. Evidence of this could not be gained due to the fact that no new staff had started in the past two years. It was confirmed that mandatory training provided to staff consisted of moving and handling, medication, first aid, food hygiene, risk assessments, health and safety and safeguarding adults. Specialist training that some staff had attended included epilepsy, key worker skills and care planning. When looking for evidence of training it was established that copies of certificates are placed on individual staff members files. There was also training matrix, but when cross-referencing the details of this to staff certificates it was apparent that this had not been kept up-to-date. From the certificate seen on staff files it was clear that regular training and updates had been provided and the home had a well-trained and competent staff team. Supervision for staff consists of staff meetings, one to ones, appraisals and general support. The Manager confirmed that staff meetings had taken place and evidence of the minutes of the meetings had been produced. Other evidence of supervision was available and all staff had received either three or four 1-to-1 sessions during 2008. The Manager added that there is an open door policy for staff if they have any concerns. Those staff spoken to were very complimentary with regard to the Manager and stated that they felt they are able to approach him with any concerns. It was also clear during observation of residents with the manager that they appeared very relaxed and there was a good rapport between them. Feedback from the Healthcare Professional questionnaires included Sydervelt Manager is very proactive in highlighting and seeking advice in the interest of the clients and I have found a very positive staff group who are always willing to support clients. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: There was evidence that staff had been provided with training to ensure they had the competencies and qualities required to meet the residents needs. The home presently have eight staff and of these two had achieved their NVQ 2, two have achieved their NVQ 3 and one had achieved their NVQ 4. It was also confirmed that three other staff had already registered to complete their NVQ training. From the evidence gathered it was established that the home has over 50 of its staff NVQ trained. Comments from staff, and healthcare professionals were positive around training within the home. Comments included specialised training courses has been delivered to the current staff team and thorough training and support is provided. Two relatives stated that the staff had the skills and experience to provide the care their relative required. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by a person who has the necessary skills and experience required and residents and relatives are regularly approached to gain their views about the home and the care provided. Evidence: The Registered Manager is qualified, competent and has the experience to run the home and meet its stated purpose, aims and objectives. He has achieved his NVQ 3; is an NVQ assessor; completed a City and Guilds 32502/03 and had also achieved an certificate in Advanced Management of Care. During the inspection he showed a good knowledge of the standards and regulations, and had clear systems in place to provide a written evidence that was required. It was clear from observations and written evidence seen that the Manager has the skills and experience to run the home. Staff spoken to stated that the manager was very supportive and approachable. There was a good homely feel. There are effective quality assurance and quality monitoring systems in place at Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: Sydervelt Lodge to help seek the views of the service users and their relatives. In the Service User Guide it stated that meetings between the staff, relatives and advocates and residents of the service were organised to gain the views of the residents. The Manager confirmed that these occur monthly to enable residents and staff to liaise over the running of the home. Monthly compliance reports are also completed by the Manager to ensure the Care Home Regulations and the organisations polices and procedures are being adhered to. Evidence was seen of Regulation 26 reports, which had been completed by the Organisation as a form of monthly audit of the home. Sydervelt Lodge has clear policies and procedures in place and these are regularly monitored and updated as necessary. Copies of the policy procedures were found within the office and it was confirmed the staff have access to these. Records kept at the home were very well presented and the information was easy to find. Most of the inspection was completed with out the Managers presence, but all the required information was easy to find and have been clearly labelled. Each resident had their own folder and their records were very clear. The Manager ensures that the health and safety of both staff and service users is promoted within the home and he is aware of his responsibilities. There was evidence that a health and safety audit had been completed by Estuary on the 25/3/08 and a quote from this stated that the health and safety in the care home was being well managed at the time of the audit. Evidence was gained that regular checks had occurred and certificates were available for gas, electricity, fire safety checks, fire drills and fire alarm system checks, water temperatures, accident and incident forms and emergency lighting. The homes insurance certificate was seen and in order. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 33 18(1)a The person registered must ensure that there are adequate staffing hours provided to meet residents individual needs to access the community. 01/03/2007 Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 33 18 There must be adequate staffing levels. There must be adequate staffing levels/hours at the home to provide and meet the residents individual assessed needs and to assist access to the community. 28/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 12 It is recommended that further work is done to ensure that the resident who does not attend formal day-care is encouraged and assisted to take part in training or other fulfilling activities and stimulation. Further one to work should be provided to help the individual gain access to the community. Staff receive training in safeguarding adults and that this is regularly updated. Staff receive infection control training and that evidence of this is available on future inspections. It is recommended that you ensure that the present system used to record staff training is kept up-to-date and correct. 2 3 4 23 30 35 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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