Inspection on 23/01/07 for Sydmar Lodge

This inspection was carried out on 23rd January 2007.

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

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

Other inspections for this house

Sydmar Lodge 11/06/07

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 Daniel Lim Key Unannounced Inspection 23rd January 2007 09:00 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.V313326.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.V313326.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 Ms Margaret Guillern (awaiting registration) Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (54) of places Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Sydmar Lodge is a purpose built care home which is registered to provide personal care for a maximum of fifty four 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 a personalised, individual care to individuals 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 four 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 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 £695.00 to £750. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 23 January 2007. The inspection took a total of five hours to complete. The inspector noted that the quality of care provided at the home was satisfactory. During this inspection, the inspector was assisted by the home manager (Ms Margaret Guillern). The inspector was able to interview four residents. The feedback received from them indicated that they were satisfied with the care provided. Completed questionnaires received from residents (6) and relatives (6) indicated that they were generally satisfied with the care provided. Completed questionnaires were also received from two healthcare professionals. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home. The premises including residents’ bedrooms, treatment room, communal rooms, laundry, bathrooms and main kitchen were inspected. Four staff on duty were interviewed on a range of topics associated with their work. What the service does well: The home was clean, well furnished and appeared cosy. The gardens were attractive and well maintained. The home had a comprehensive weekly programme of activities and residents interviewed were satisfied with the social activities provided. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 6 Feedback received from residents and their representatives indicated that improvements had been made in the overall management of the home and their views had been listened to. What has improved since the last inspection? What they could do better: Improvements are required in the care arrangements for residents. The registered person must ensure that the care of the resident referred to in the section on Choice of Home (who has challenging behaviour) is reviewed and transferred to appropriate accommodation if necessary. Comprehensive care plans which address the assessed needs of residents must be provided. These must address the spiritual and cultural needs of residents and include a mental health / dementia care plan. The manager and her staff must be knowledgeable of the home’s procedures for close supervision of residents who require it. All care staff must receive training in the care of residents with dementia. Improvements are required in the financial records kept. Individual records must be kept for each resident. These must contain receipts for items purchased. Improvements are required in the laundry. The registered person must ensure that staff working in the laundry room are provided with a warm environment to work in. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 7 The registered person must ensure that the new manager submits an application to be the registered manager. In addition, a further requirement is made for the registered person to review the management and administrative support to the manager to ensure that she is able to fulfil her responsibilities. 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. Sydmar Lodge DS0000065700.V313326.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.V313326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 6 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Arrangements were in place to ensure that residents’ aspirations and needs are assessed. This ensures that their needs can be identified and met at the home. A deficiency was however, noted in the care of a resident with challenging behaviour. EVIDENCE: The four residents who were interviewed indicated that their care needs had been met at the home and they were happy with the care provided. Comments made by them included, “lovely home” and “well cared for”. This was reiterated by two relatives interviewed and in completed questionnaires received. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 10 A sample of four residents’ case records which were examined, contained comprehensive assessments. Risk assessments together with strategies for minimising risks had also been prepared. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. The inspector was informed by the manager that the home does not provide intermediate care. The inspector noted that a resident (identified to the manager) had challenging behaviour and staff had experienced difficulty managing this resident. The inspector discussed the appropriateness of the placement with the manager. Following this, a requirement is made for this resident’s care to be reviewed with professionals involved in her care and for the resident to be transferred to appropriate accommodation if necessary. Sydmar Lodge DS0000065700.V313326.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents had been treated with respect and arrangements were in place to ensure that their personal and healthcare needs are met. Improvements are however, needed in some of the care arrangements to ensure that care plans are comprehensive and residents are provided with the required support. EVIDENCE: Feedback received from residents and their representatives indicated that residents’ healthcare and personal needs had on the whole been met. This was confirmed by completed questionnaires received from two healthcare professionals. Five case records were examined. These contained details of personal care provided and healthcare information which residents had access to. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 12 Care plans were available for residents. The care plans examined were however, not sufficiently comprehensive as they did not address the holistic needs of the residents’ concerned (or meet Standard 7.2, NMS). The records of two residents who had dementia did not contain dementia care plans. These are required to ensure that staff are fully informed of the care to be provided. A resident with challenging behaviour did not have a care plan with guidance to staff on how this behaviour is to be managed or what the procedures for close supervision are. These deficiencies were discussed with the manager who agreed that improvements would be made and she would ensure that she is familiar with the close supervision procedures for residents requiring it. The manager further reassured the inspector that the home’s care documentation was under review. The medication administration charts examined had been appropriately signed. Residents interviewed stated that they had been given their medication. The temperature of the fridge and room where medication was stored had been recorded daily. These were satisfactory. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life and routines of residents were on the whole, well organised. This ensures that the dietary, cultural and social preferences of residents are met. EVIDENCE: The inspector discussed the provision of activities with the activities organiser and the home manager. The manager stated that the provision of activities was an example of good practice in the home. He was informed that the home had a varied programme of weekly social and therapeutic activities which reflected the needs and preferences of residents. Residents interviewed were of the opinion that the activities were appropriate. The daily programme was on display outside the office. Activities provided included art, music sessions, bingo, gentle exercise and celebration of Jewish Holy days. The activities organiser stated that an outing and more exercise sessions were planned. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 14 The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen was clean and well equipped. Residents interviewed indicated that they were satisfied with the meals provided. The issue of equalities and diversity was discussed with the manager. She reassured the inspector that all residents are treated with respect and dignity whatever their background. In addition, she stated that the home has a statement promoting equalities and valuing diversity. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents are well treated and protected from abuse. EVIDENCE: The complaints record was examined. No complaints were recorded since the last inspection of the home. The manager explained that none had been received. Staff interviewed were aware of the procedure to be followed following when responding to allegations of abuse. There was evidence that staff had been provided with adult protection training. Residents who were interviewed indicated that they had been well treated by staff. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was well maintained and furnished to a high standard. This ensures that residents live in a comfortable and pleasant environment. EVIDENCE: The premises including bedrooms and communal areas were inspected and found to be clean and well equipped. The required maintenance certificates (including safety certificates for the gas installations and lifts) were available for inspection. All the portable appliances were in the process of being tested by the home’s maintenance person. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 17 Residents’ bedrooms were inspected and found to be well furnished. Residents interviewed stated that they were happy with the accommodation provided and their bedrooms had been kept clean. The laundry facilities were satisfactory and the laundry staff interviewed was knowledgeable of her responsibilities. Following a complaint made, the seating arrangements in the vicinity of the reception and toilet area had been reviewed. A chair had been provided in this area. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing arrangements were generally satisfactory. However, not all staff had received the required training in the care of residents with dementia. The lack of training in this area may undermine the ability of staff to care for residents concerned. EVIDENCE: The staff rota was examined. This indicated that there was a minimum of 9 staff on the morning shifts and 6 on the afternoon and evening shifts. A part time administrator was also on duty during the weekdays. There were 4 staff on the night shifts. The manager and her deputy were supernumerary. Following requirements made in the last inspection report, a review of staffing had been carried out and a plan for effective deployment of staff had been implemented. Residents and two relatives who were interviewed made positive comments about staff and indicated that they had been treated with respect and dignity.They further informed the inspector that there had been improvement in the running of the home and their views had been listened to. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 19 Staff interviewed were generally knowledgeable regarding their roles and responsibilities. The inspector however, noted that not all staff had been provided with training in the care of residents with dementia. This is required. The three new staff records examined contained the required documentation such as two references, satisfactory CRB disclosures, contracts and evidence of identity. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Improvements had been made in the management of the home and systems were in place to ensure the welfare and safety of residents. However, further improvements are required in health and safety and other areas identified. EVIDENCE: The manager (appointed in November 2006) was noted to be knowledgeable regarding the general management of the home. She reassured the manager that she was in the process of applying to CSCI to be the registered manager. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 21 Residents and their representatives interviewed were of the opinion that the improvements had been made in the care of residents and the manager was responsive to their views. Compliments had been received from residents and relatives and these were available for inspection. The minutes of residents / relatives meetings were available for inspection. Weekly fire alarm tests, fire drills and fire training had been documented. The emergency lighting had been checked weekly. The portable appliances and electrical installations had been inspected. There was a record of accidents. These were well maintained. The home had a current certificate of insurance. A sample of three of the financial records of residents were examined. These were not well maintained and it was not possible to determine if the required receipts had been obtained for items or services purchased on behalf of residents. The manager explained that she had been very busy since starting work at the home recently. A requirement is made for the financial records to be properly maintained. Individual records must be kept for each resident. These individual records must contain receipts for items purchased. A further requirement is made for the registered person to review the management and administrative support to the manager to ensure that she is able to fulfil her responsibilities. The inspector was informed by the laundry assistant that she had been feeling cold. She explained that there were two vents in the laundry providing ventilation and the room gets very cold in winter. This was discussed with the manager. For health reasons, and to ensure that staff in the laundry are able to perform their duty, a requirement is made for staff in the laundry to be provided with a warm environment to work in. Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 22 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 x X 3 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 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 2 X 3 X 2 X X 2 Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 10(10) 12(1) Requirement Timescale for action 21/03/07 2 OP7 13(1) 14(1) 15(1) 3 OP8 13(4) 4 OP16 18(1)(c) (i) The registered person must ensure that the care of the resident identified in the section on Choice of Home (who has challenging behaviour) is reviewed and transferred to appropriate accommodation if necessary. 21/03/07 The registered person must ensure that residents are provided with comprehensive care plans which address the assessed needs of residents. These must be in accordance with Standard 7.2 (NMS). They must address the spiritual and cultural needs of residents and include a mental health / dementia care plan. The registered person must 13/03/07 ensure that the manager and her staff are knowledgeable of the home’s procedures for close supervision of residents who require it. The registered person must 13/04/07 ensure that care staff receive training in the care of residents with dementia. DS0000065700.V313326.R01.S.doc Version 5.2 Sydmar Lodge Page 24 5 OP31 6 OP31 7 OP35 This requirement is restated as it is only partially met. 01/04/07 9(1)(2)8(1 The registered person must )(2)(a) ensure that the manager submits (b) an application to be the registered manager. 10(1) The registered person must 01/04/07 12(1) review the administrative and 18(1)(a) management support to be provided for the manager. 13(6) The registered person must 21/03/07 ensure that the financial records are properly maintained. Individual records must be kept for each resident. These must contain receipts for items purchased. 8 OP38 12, 23(1) The registered person must ensure that staff working in the laundry room are provided with a warm environment to work in. 27/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sydmar Lodge DS0000065700.V313326.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!