Inspection on 11/06/07 for Sydmar Lodge

This inspection was carried out on 11th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sydmar Lodge 23/01/07

Sydmar Lodge 06/06/06

Sydmar Lodge 02/03/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Sydmar Lodge 201-205 Hale Lane Edgware Middlesex HA8 9QH Lead Inspector Peter Illes Key Unannounced Inspection 11th June 2007 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydmar Lodge Address 201-205 Hale Lane Edgware Middlesex HA8 9QH 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) 020 8931 8001 020 8931 8003 European Care (GB) Ltd Malgorzata Guillen Care Home 57 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 57 23rd January 2007 Date of last inspection Brief Description of the Service: Sydmar Lodge is a purpose built care home that is registered to provide personal care for a maximum of fifty seven service users over the age of sixty five. Service users with either dementia or physical frailty may be accommodated. The home is owned and managed by European Care. The company also owns numerous other care homes in this country. The aims and objectives of the home are to offer personalised, individual care to people who live there and to assist them to live as they wish within any constraints placed on them by their physical or mental frailty. The home is a three storey detached house. There are forty seven single bedrooms and five shared bedrooms located across all three floors. All bedrooms have en-suite facilities (a shower, toilet and wash hand basin). There is a lift, which provides access to all floors. On the ground floor, there is an office, a large lounge, diner, bathrooms, toilets and service users’ bedrooms. On the first floor, there is a kitchenette, large lounge, bathrooms, toilets and service users’ bedrooms. The layout on the second floor is similar to that of the first floor. The kitchen and laundry room are located in the basement. There is a small parking area at the front of the building and a large garden at Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 5 the rear with wheelchair access. The home is situated in a residential area of Edgware with easy access to public transport, shops, restaurants and other community services. The fees of the home range from £730 to £750 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has registered 3 new single bedrooms at the home since the last inspection. This unannounced key inspection took approximately ten hours with the registered manager being present or available throughout. There were forty six people living at the home at the time of the inspection. The home has five double bedrooms but these are occupied on a single basis unless two people make a positive request to share. The inspection consisted of: meeting and speaking to a significant number of people living at the home, five of them independently; discussion with a number of relatives including with four of them independently; discussion with the registered manager; discussion with a G.P. that visited; discussion with a community nurse that visited; discussion with the activities coordinator; discussion with the deputy manager; discussion with a number of care staff; discussion with the head chef and discussion with the housekeeper. Further information was gained from a tour of the home, a range of documentation kept at the home and a pre-inspection questionnaire. What the service does well: The home provides high quality care to older people with a range of complex needs. The home meets their cultural and religious needs and enables them to be part of the wider Jewish community. Staff encourage people to be as independent as possible and support them to undertake a wide range of activities, both inside and outside the home. Relatives and other visitors are made welcome to the home. They are given the opportunity to meet with the managers of the home at regular relatives meetings and are invited to a number of formal social events through the year, all of which they appreciate. The home has effective systems to monitor the quality of care that people receive. The home provides good quality meals that people enjoy. The home is well decorated and provides a pleasant environment to live and work in. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has enough information available to help people make a decision about moving into the home. The interests of people accommodated are also suitably protected by written contracts. The needs of people are assessed by the home to assist staff meet these needs when they are first admitted. Their needs continue to be monitored once admitted to the home to ensure that their changing needs can also be effectively addressed and appropriate action as required. However, some documentation relating to this process needs a slight improvement. EVIDENCE: The home has a thorough statement of purpose that has been updated to reflect the recent change of registered manager and the increase of three additional bedrooms. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 10 Contracts for people living in the home were sampled. These were clear, including the cost of the placement, the basis that people are accommodated on and specified which room the person is allocated. Files for five people living at the home were inspected and each showed a range of satisfactory assessment information that was obtained by the home at or prior to the point of admission. This included: an overall admission assessment, a social care assessment, a dependency assessment, a nutritional assessment and a Waterlow assessment regarding skin condition. The social care assessment included the person’s relevant past events, happiest memories and their personal choices/ preferences regarding how the care they needed was provided. There was also evidence that people’s needs are reviewed on a regular basis to assist staff be aware of people’s changing needs. The assessment information was clear and most of it showed evidence that the information had been obtained as part of the pre-admission procedure to assist the home make a decision as to whether it could meet those needs. However, a minority of the different elements of the assessment, described above, had not been signed and/ or dated. A requirement is made that all assessment information is signed and dated by the person undertaking the assessment to provide a line of accountability for the information and to evidence that the information was current at the time of admission. At the last inspection two requirements were made relating to a person whose needs had become more complex. This included that their needs be reviewed and the person transferred to more appropriate accommodation if necessary and that in the meantime close supervision was provided for that person. These requirements had been complied with. The home does not provide intermediate care. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people living in the home and how these are to be addressed are recorded in their care plans although people accommodated would still benefit from some further improvement in this area. People are well supported to have their health needs addressed including by accessing a range of healthcare professionals. Effective medication policies, and procedures for its proper administration, safeguard people living in the home although an identified improvement would assist this further. Managers and staff are working hard to treat people with respect and dignity and this is appreciated. EVIDENCE: The care plans of five people living at the home were inspected. These care plans were based on current assessment information and were being reviewed and evaluated on a monthly basis by the person’s key worker. The plans were also informed by risk assessments including a moving and handling risk Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 12 assessment, a falls risk assessment and a risk management plan. At the last inspection a requirement was made that people living at the home are provided with comprehensive care plans which address their assessed needs, their spiritual and cultural needs and include a mental health / dementia care plan. This requirement had been complied with although on some plans seen the guidance to staff on how to address the identified needs was too general. Given the complex needs of some of the people living at the home a new requirement is made that care plans give detailed guidance to staff on how to meet each assessed need including indicating the outcome required. The registered manager stated that the home was still working to improve the current plans. She also stated that the provider organisation was about to introduce a new care plan format that would significantly help with this. The new format was seen to be much more detailed and specific than the current format and the registered manager was enthusiastic about its implementation. People living at the home are registered with a G.P., either retaining the G.P. that they were registered with prior to moving to the home or a G.P. practice arranged by the home. A G.P. who visited the home during the inspection was spoken to independently. She stated that she had visited the home regularly over the last year and had no concerns about the care. She went on to say that she was reviewing 2 people on this visit but the number varied according to people’s needs at the time. A community nurse who also visited the home on the day was spoken to independently. She stated the she had only been visiting the home for 1 month and had made 4 weekly visits in that time. She stated that she felt the home had a nice atmosphere and that the care was good. She also stated that she had bought one issue to the attention of the staff and the inspector confirmed with the registered manager that this had been appropriately dealt with. Evidence was seen that a dentist, optician and chiropodist also visit the home on a regular basis. The home had a satisfactory medication policy that was seen and the home’s documentation relating to the safe administration of medication was good. This included medication administration record (MAR) charts having a photograph of the person attached to minimise the possibility of error. There was also a list of specimen signatures of the staff who are trained to administer medication to assist monitor administration. Records seen of medication arriving in the home and of its disposal were up to date. Three people were supported to selfadminister their medication and satisfactory records relating to this were seen. Five people were prescribed controlled medication and this was stored appropriately with administration being recorded by 2 staff in a controlled medication record book. Medication and MAR charts for 3 people living at the home were inspected and were generally satisfactory. The medication prescribed for one of those people included a medication to be administered when required (PRN) and guidelines for staff regarding this were in place. However it was noted that the dosage specified on the medication packaging stated 1 or 2 tablets to be administered when required but the MAR chart, printed by the dispensing chemist, stated 2 tablets when required. A Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 13 requirement is made that the home ensures that the directions on the medication packaging corresponds to the directions on the MAR chart when it is received into the home. People living in the home were seen to be treated with respect and dignity by staff during the inspection. This was confirmed by a number of people and relatives spoken to independently. One person stated that “the girls are very kind” although another person commented that “some were kinder than others” but did not wish to elaborate any further on this. A number of relatives visit the home on a very regular basis. Those spoken to were very articulate and clear about their expectations for a high standard of care. The feedback from these relatives was generally positive although some felt that further progress was still needed in some areas. There was a consensus that the home and the care it provided had generally improved since the new manager had been appointed. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a wide range of social, and recreational activities both in and outside of the home, which meet their needs and preferences. Families and visitors are made welcome at the home, which they and people living at the home appreciate. People accommodated are encouraged to exercise as much choice and control over their lives as they can to maximise their independence. They also enjoy a range of good quality meals that they enjoy. EVIDENCE: People living at the home have access to a wide range of social, therapeutic and religious activities that they can choose to attend and are supported to participate in. The home has an activities organiser who is employed for 20 hours per week and she was spoken to independently. Regular activities include live music and visiting entertainers, keep fit, quizzes, bingo, reminiscence sessions and craft activities. A volunteer runs a Jewish studies group. The inspector was also informed that a Rabbi visits the home regularly and actively participates in the general activities programme as well as Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 15 providing religious support to the home. The activities organiser stated that the home had organised a trip to Brent Cross shopping centre in April 2007, which had been successful. She went on to say that she was hoping to organise a trip further a field in July or August 2007 to a stately home or formal garden. The home has access to L.B. of Barnet transport for such trips. In addition the home has a “Friends of Sydmar Lodge” that assists fund raise and provide activities. The June newsletter displayed in the home was informing people that a Fun Day was being organised in July 2007 with the Wimbledon tennis tournament being a theme. The activities organiser stated that she also spent some time just chatting on a 1 to 1 basis with some people who for various reasons did not like to attend group activities. Most people spoken to throughout the inspection stated that they enjoyed the activities the home provided although some said they preferred not to attend. The home’s statement of purpose includes that the home operates an open visiting policy including that “we encourage active involvement from our service users and friends and any suggestions and comments are most welcome”. A significant number of relatives visited the home throughout the inspection and four of these were spoken to independently. These relatives were clearly engaged with the home and the care it provided. The home also holds three monthly meetings for people living in the home and for relatives that are appreciated. During a tour of the building some people invited the inspector to see their bedrooms. All those seen had been personalised including with photographs and other personal possessions. People living at the home are supported to manage their finances to the extent that they are able and more detail regarding this is given in the Management and Administration section of this report. The home’s head chef was spoken to independently and the inspector found her competent and knowledgeable, including about the individual dietary needs and preferences of the people living in the home. The head chef stated that she compiles the menu and consults people living at the home regarding their preferences, both on an individual basis and from feedback from residents meetings. There are two choices for lunch and supper and the head chef stated that the home is able to provide other alternatives for people if they request it. The inspector was invited to have lunch with the residents and chose the meat option, which was well presented and very enjoyable. The majority of people spoken to were very complimentary about the meals served by the home. The kitchen is properly equipped to prepare and cook kosher meals and the head chef stated that the Rabbi gives ongoing and positive advice and guidance regarding this. Records of a range of health and safety records were checked including temperatures of the fridge and freezers and were satisfactory. An Environmental Health inspector had recently inspected the kitchen. Requirements had been made from this that were in the process of being addressed although work regarding some of these had yet to start. A Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 16 requirement is made that the requirements of the Environmental Health inspector are carried out and that identified repairs to the floor in the kitchen and to an identified pipe in the kitchen are also carried out. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home and their relatives can be confident that any concerns they raise with the home will be properly dealt with. People living at the home are also protected by a clear adult protection policy and procedures. EVIDENCE: The home has a clear complaints procedure that was also seen in the home’s statement of purpose. The home had received one complaint since the last inspection and evidence was seen that this had been dealt with effectively and promptly. The registered manager was clear about the importance of dealing with complaints effectively as part of the overall quality monitoring of the home. People living at the home and relatives spoken to were clear that if they raised issues or concerns with the registered manager or her staff they would be dealt with appropriately. The home had a satisfactory adult protection policy that indicated it had been reviewed in April 2007. The home also had a copy of the London Borough of Barnet’s adult protection procedure, the local authority for the area the home is situated in. No allegations or disclosures of abuse had been made to the home since the last inspection. Staff spoken to were aware of the actions that Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 18 needed to be taken should an allegation or disclosure of abuse be made to them. The home also had a satisfactory whistle blowing policy that was seen. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is well decorated, generally well maintained and that meets their needs. The home was generally clean and tidy throughout creating a pleasant environment for people living there, staff and visitors. Some identified actions are needed to ensure that people’s welfare, health and safety are maximised. EVIDENCE: The registered manager showed the inspector around the home. The building is very well decorated, well equipped and maintained and is generally well suited to meeting the needs of people living there. The home has 47 single bedrooms and 5 double bedrooms, all with en-suite facilities, situated on three floors. The registered manager stated that the double rooms are only used for two people if specifically requested e.g. if a couple wanted to share. All rooms Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 20 were occupied on a single basis at the time. The inspector was invited by some people to see their bedrooms. These were furnished and decorated to a high standard and had been personalised with photographs and other personal possessions by the person living in them. People spoken to indicated that they were happy with their rooms and the accommodation in the home generally. The home also has a very attractive garden that people living in the home enjoy on fine days. It was noted during the inspection that some people, who spent more time in their rooms, wished to keep their bedroom doors wedged open during the day time although they were kept shut at night. Following discussion with the registered manager a requirement is made that the wishes of the person be formally recorded including in their care plan, appropriate stakeholders including relatives, any referring authority and the fire officer to be informed and for a formal risk assessment of each person in relation to this to be undertaken and kept under review. It was also noted that two magnetically controlled fire doors in communal areas needed adjusting to ensure they closed properly when released. These adjustments were undertaken on the day. A requirement is made regarding this. The home is registered to accommodate people with a diagnosis of dementia. The registered manager stated the provider organisation was exploring the option of designated one area of the building as a specialist dementia unit. The building appeared to meet the needs of the people currently living there and this included a coloured theme for carpets and decorations on each floor. However, there was no pictorial or other accessible signage on key communal areas such as toilets, bathrooms, lounges and the dining room to assist people with a diagnosis of dementia and a requirement is made regarding this. The home has satisfactory laundry facilities that were seen. The housekeeper who is responsible for these facilities explained the way that laundry was dealt with to minimise loss or damage to people’s clothing. People spoken to indicated that this service worked well for them. The home also had satisfactory infection control policies and procedures. At the last inspection a requirement was made that staff working in the laundry room are provided with a warm environment to work in. This requirement had been complied with. At this inspection it was noted that the ventilation grilles and other areas in the laundry were in need of deep cleaning and that the laundry needed redecorating. Requirements are made with negotiated timescales regarding both of these. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a staff team with sufficient numbers to support the people currently accommodated. People living at the home benefit from staff having access to relevant qualification training. People are also protected by the home’s recruitment policy and procedures. Further staff training needs to be undertaken to ensure that staff skills are up to date to meet the needs of people living at the home. EVIDENCE: The staff rota for the home was inspected and was satisfactory with staff on duty during the inspection matching those recorded on the rota. Staffing levels in the home were as follows: 8 staff on the morning shifts plus the deputy manager, 6 staff on duty on the afternoon and evening shifts and 4 waking night staff. The registered manager’s hours were in addition to the above. The home also employs support staff including a head chef, kitchen staff, a housekeeper and domestic staff. The registered manager remains aware of the need to keep staffing numbers under review to ensure that the home can continue to meet the changing needs of the people living there. The home is meeting the national minimum standard that at least 50 of care staff are qualified to national vocational qualification (NVQ) level 2 in care. The Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 22 registered manager stated in the pre-inspection questionnaire that the home was employing 31 care staff and 21 of these had achieved NVQ level 2 in care. 7 of these were currently working towards NVQ level 3 in care. Evidence to support the above was gathered from some staff files seen and from discussion with some staff. Four staff files were inspected and indicated that the home was operating an effective recruitment procedure. The files inspected included: satisfactory proof of identity; a satisfactory criminal records bureau (CRB) check that included a protection of vulnerable adults (POVA) clearance, evidence that satisfactory references had been obtained and a contract of employment. The home provides a range of training for staff and the registered manager provided a training matrix summary that showed what core skills individual staff had been trained in. At the last inspection a requirement was made that care staff receive training in the care of residents with dementia. The registered manager provided evidence that she and two other senior staff had just undertaken a 2 day accredited course run by the Alzheimer’s Society in dementia care and a further 1 day course trainers course in dementia care to allow them to train other care staff. The registered manager went on to say that she and the two staff who had undertaken this training were going to roll this training out to all staff. The inspector was pleased to see progress being made with this and the requirement for all staff to receive dementia care training is restated with a negotiated timescale. The training matrix seen also showed that some staff were due training or refresher training in some other core areas including protection of vulnerable adults. A requirement is made regarding this. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home and other stakeholders benefit from the home being run by a competent and enthusiastic registered manager although support to her should be kept under review. People living at the home and other stakeholders views are actively sought to assist develop the quality of care the home offers. People living at the home are protected by effective procedures to safeguard their financial interests although further action may assist maximise this. The home has clear health and safety policies in place to protect people living in the home and others that work in or visit although attention is needed in an identified area to maximise this protection. EVIDENCE: The registered manager has been in post since November 2006 and is now registered with the Commission as was required at the last inspection. She has Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 24 achieved the registered managers award and has twelve years experience in care and management. Feedback from people living at the home, relatives and staff spoken to was overwhelmingly positive. One relative stated “the manager phones to keep me informed of any issues”. Another relative indicated that the registered manager “is not in the office all day and comes out to talk to people”. Staff spoken to indicated that the registered manager was approachable. The inspector was impressed by her enthusiasm on the day and of her understanding of both the care and the management issues involved in running a large home. At the last inspection a requirement was made that the registered person must review the administrative and management support to be provided for the manager. This had been complied with and the administrator post had been increased from 24 hours per week to 35 hours per week. However, the day to day management tasks for a home of this size are considerable, particularly with the deputy manager covering care shifts. A good practice recommendation is made that the provider organisation continues to monitor the administrative and management support provided for the manager to allow her to develop the service further. The home has an effective quality assurance system. Satisfaction surveys are sent out on a regular basis, the registered manager analyses the information received and an action plan is produced from this. The home holds three monthly meetings for both people living at the home and for relatives to seek their views on the service the home provides. The registered manager undertakes medication and health and safety audits on a regular basis. A manager from the provider organisation undertakes monthly monitoring visits to the home each month and writes a report of the visit that is sent to the home. At the last inspection a requirement was made that that residents financial records are properly maintained and that individual records must be kept for each resident. These must contain receipts for items purchased. Financial records for people living at the home were sampled as a result of this requirement and the inspector’s view is that the arrangements are now satisfactory. Each person has an individual record kept of their money that is looked after by the home; the home has a separate bank account that residents money is kept in; receipts are kept for expenditure such as newspapers, although this is a combined receipt for the week a record is kept of each persons expenditure for such transactions in their individual record and records are kept for cash transactions involving residents money. The registered manager keeps residents cash in a locked tin. However, given the size of the home and the range of expenditure made each week, a good practice recommendation is made that the provider organisation manager spot checks the records as part of their monthly monitoring visits to the home. A range of satisfactory health and safety documentation was inspected. This included: a gas safety certificate, electrical installation certificate, portable appliances inspection certificate, servicing of fire fighting equipment and a Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 25 range of weekly and monthly checks carried out including testing of hot water temperatures. There was no evidence available for inspection that the home’s water system is inspected annually to minimise the risk of legionella and this is required. Requirements regarding fire precautions and a recent Environmental Health inspection of the home are made in other sections of this report. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement The registered persons must ensure that all assessment information is signed and dated by the person undertaking the assessment to provide a line of accountability for the information and to evidence that the information was current at the time of admission. Timescale for action 31/07/07 2. OP7 15(1) The registered person must 31/07/07 ensure that care plans give detailed guidance to staff on how to meet each assessed need including indicating the outcome required so that staff are confident in undertaking care tasks. 31/07/07 The registered persons must ensure that the directions on the packaging of medication received into the home corresponds to the directions on the MAR chart when it is received into the home too minimise the risk of the wrong amount of medication being administered. 3. OP9 13(2) Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 28 4. OP15 13(4) 5. OP19 23(4) 6. OP19 23(4) 7. OP19 23(2a) The registered persons must ensure that the recent requirements made by the Environmental Health inspector are carried out and that identified repairs to the floor in the kitchen and to an identified pipe in the kitchen are also carried out to minimise risk to people in the home. The registered person must ensure that where people wish to keep their bedroom doors open during the day that the wishes of the person be formally recorded including in their care plan, appropriate stakeholders including relatives, any referring authority and the fire officer are to be informed and for a formal risk assessment of each person in relation to this to be undertaken and kept under review. This is to maximise fire safety. The registered persons must ensure that electro-magnetic fire door closures are working properly at all times to maximise fire safety. The registered persons must ensure that pictorial or other appropriate signage is displayed on doors to communal areas including toilets, bathrooms, lounges and the dining room to assist people with a diagnosis of dementia access those parts of the building. The registered persons must ensure that the laundry is deep cleaned to minimise the risk of cross infection. The registered persons must ensure that the laundry is redecorated to promote good infection control. DS0000065700.V337067.R01.S.doc 31/07/07 31/07/07 31/07/07 31/08/07 8. OP26 13(4) 31/07/07 9. OP26 23(2d) 30/11/07 Sydmar Lodge Version 5.2 Page 29 10. OP30 18(1) 11. OP30 18(1) 12. OP38 13(4) The registered persons must ensure that all care staff receive training in the care of people with dementia to ensure their skills are up to date to meet peoples needs (the previous timescale of 13.04.07 was partly met) The registered persons must ensure that all care staff receive training and refresher training when due in core areas including protection of vulnerable adults to ensure that staff skills are up to date to meet peoples needs. The registered persons must ensure that the home’s water supply is inspected annually, by a person competent to do so to minimise the risk of legionella. 31/10/07 31/10/07 31/07/07 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 OP35 Good Practice Recommendations The provider organisation should spot check cash and records for those people that the home holds money for to maximise protection in this area. Sydmar Lodge DS0000065700.V337067.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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