Inspection on 06/06/06 for Sydmar Lodge

This inspection was carried out on 6th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sydmar Lodge 11/06/07

Sydmar Lodge 23/01/07

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 6th June 2006 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.V292044.R01.S.doc Version 5.1 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.V292044.R01.S.doc Version 5.1 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 Mrs Jill Forder 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.V292044.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd March 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.V292044.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 6 June 2006 and took a total of 3 ½ hours to complete. The inspector found that many of the National Minimum Standards assessed had been met and the feedback from residents was generally positive. During this inspection, the inspector was accompanied by the manager of the home (Mrs Jill Forder). The inspector was able to interview four residents and a relative. The feedback received from them indicated that they were generally satisfied with the care provided. Statutory records including four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home were examined. The premises including bedrooms, bathrooms, laundry, main kitchen, gardens and communal areas were inspected. Four staff on duty were interviewed on a range of topics associated with their work and staff training records were examined. In addition, some staff records and the minutes of residents’ meetings were examined. What the service does well: The home was clean, well maintained and well furnished. The garden was attractive and residents were seen sitting in the garden. The home had a comprehensive weekly programme of activities and residents interviewed were satisfied with the social activities provided The manager and her deputy were knowledgeable regarding their responsibilities. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 6 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. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 7 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.V292044.R01.S.doc Version 5.1 Page 8 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): 1, 3, 4, 6 The quality in this outcome area is adequate. This judgement has been made form evidence gathered both during and before the visit to this service. Satisfactory arrangements were in place to ensure that residents admitted are appropriate. This ensures that the home can meet the needs of residents accommodated there. Further action is needed to ensure that a resident with challenging behaviour is adequately cared for. EVIDENCE: Four residents who were interviewed indicated that their care needs had been met at the home and they were generally satisfied with the care and services provided. Comments made included, “satisfied with care”, “alright here” and “no complaints”. The inspector observed that residents in the home were clean and appropriately dressed. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 9 The statement of purpose had been updated following a requirement made in the last inspection report. This now specified that nursing is not provided at the home and the criteria for admission has been clarified. A pre-admission assessment examined was noted to be comprehensive and included the required risk assessments (such as lifting and handling and risk of falls). The inspector noted that a resident had challenging behaviour and the manager reported that staff had experienced difficulty managing this resident. A complaint had also been received by the home regarding this resident. A requirement had been made for this resident’s care to be reviewed and for the resident to be transferred to more appropriate accommodation if appropriate. This is in the process of being actioned. Attempts had been made by the home and the family of the resident concerned to arrange a suitable transfer. However, difficulties had been experienced in finding a suitable home. The inspector was informed by the manager that the home does not provide intermediate care Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 10 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 form evidence gathered both during and before the visit to this service. Arrangements were in place to ensure that the healthcare and personal needs of residents are attended to. Improvements are needed to ensure that a resident requiring close supervision is adequately cared for and there is a strategy to reduce the number of falls and fractures in the home. EVIDENCE: The four residents interviewed informed the inspector that their healthcare needs had on the whole, been attended to and staff treated them with respect and dignity. The sample of four case records examined were up to date and plans of care had been regularly reviewed. Records of medical and healthcare treatment were available for inspection. These included appointments made with the GP, chiropodist and other healthcare professionals. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 11 The medication administration charts examined were up to date and had been appropriately signed and photos of residents concerned had been provided. Residents who were able to express an opinion stated that they had been given their medication. Following requirements made in the last inspection report, there was evidence to indicate that staff had been instructed to treat residents with respect and dignity. One of the residents had exhibited challenging behaviour and complaints had been made regarding his behaviour. This was discussed with the manager. To ensure that he is safely cared for, this resident must be provided adequate supervision. A requirement is therefore made for arrangements to be in place to ensure that he is adequately supervised. This should include a procedure for close supervision which identifies staff responsible for his supervision. The inspector noted that several fractures (4) had occurred in the home since September 2005. This was discussed with the manager. To ensure that residents are fully protected and fractures and falls are prevented, the home is required to have a strategy for the prevention of falls. This must include instruction / training on falls prevention. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 12 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 form evidence gathered both during and before the visit to this service. The daily life and routines of residents were well organised and arrangements were in place to ensure that residents social and cultural needs are met. EVIDENCE: The home’s comprehensive programme of weekly social and therapeutic activities was displayed on the ground floor. This was varied and included exercise sessions, entertainments sessions, art and crafts, music and bingo. The activities co-ordinator who was interviewed was knowledgeable regarding the social needs of residents. She informed the inspector that the activities were tailored to meet the needs of residents. In addition, she stated that she had organised for school children to visit the home and sing for the residents. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 13 Meetings had been organised in which residents were consulted regarding their preferences. The minutes of these meetings were available for inspection. Residents who were interviewed stated that they were generally satisfied with the meals provided. The menu was examined and noted to be varied and balanced. Choice of main dish was available at meal times. The kitchen and dry food store were inspected and found to be clean. Daily records of fridge and freezer temperatures had been documented. These were satisfactory. The chef who was interviewed was knowledgeable regarding her responsibilities. The kitchen had also been inspected by the local environmental health officer in March of this year. The report was available for inspection. This indicated that the arrangements were on the whole, satisfactory. One resident was not totally satisfied with the meals provided as he indicated that there was limited choice of meals.This was discussed with the chef. She provided the inspector with documented evidence that the personal dietary preferences of each resident had been responded to and consultation was carried out individually each day. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 14 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 adequate. This judgement has been made form evidence gathered both during and before the visit to this service. Arrangements were in place to ensure that the rights of residents were protected. EVIDENCE: The home had policies and procedures for adult protection and for responding to complaints. Staff on duty who were interviewed were aware of the procedure to follow when responding to allegations of abuse received. The complaints book was examined. Complaints recorded had been responded to. The inspector had however, received complaints from relatives alleging that the home had not responded promptly to their complaints and certain staff had been insensitive and unsympathetic when concerns were brought to their attention. These complaints had been brought to the attention of CSCI, the home manager and company officers. They had responded promptly and co-operated with those involved in the investigations. Requirements had been made in the previous inspection report in response to the findings of investigations. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 15 (These included a a requirement to ensure that staff are provided with instruction on how to respond to complaints made and treat all residents and their representatives with respect and dignity.) Requirements which have not yet been fully responded to are restated in this report. One relative who was interviewed indicated that there had been an improvement in staff attitude towards her in the past two months. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 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. Residents live in a comfortable, pleasant home which is well maintained. This ensured that they are happy and satisfied with their accommodation. EVIDENCE: The premises including bedrooms and communal areas were inspected and found to be clean and well equipped. The required maintenance certificates (including the safety certificates for the gas installations and lifts) were available for inspection. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 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 regarding her responsibilities. The gardens were attractive and seating had been provided. Residents were seen sitting in the garden during the inspection. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 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. Improvements had been made in the staffing arrangements However further training is required for some staff. 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. An administrator was also on duty during the day. 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. (At the time of this inspection, there were 5 vacancies in the home.) Staff who were interviewed on a range of topics (such as health and safety, fire procedures and adult protection) were 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. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 19 The two new staff records examined contained the required documentation such as two references, satisfactory CRB disclosures, contracts and evidence of identity. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 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 good. 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. EVIDENCE: Weekly fire alarm checks, fire drills and fire training had been documented. Window restrictors were in place in the bedrooms and communal areas inspected. The portable appliances and electrical installations had been inspected. There was a record of accidents. These were well maintained. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 21 When interviewed, the manager was found to be knowledgeable regarding the needs of residents. Following requirements made in the last inspection report the management arrangements of the home had been reviewed to ensure that the needs of residents are met. This included the role and working arrangements of the manager, her deputy and other senior staff. The home had a current certificate of insurance. A sample of three of the financial records of residents were examined. These were noted to be satisfactory. Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 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 3 X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 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 3 X 3 X 3 X X 3 Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 10(10) 12(1) Requirement 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. (Please see comments in the section on Choice of Home) The registered person must ensure that the home has a strategy for falls prevention. The registered person must ensure that arrangements are in place for close supervision of residents who require it. This must include a procedure for close supervision. The registered person must ensure that the remaining care staff (who have not received training in dementia care) receive training in the care of residents with dementia. This requirement is restated as it Sydmar Lodge DS0000065700.V292044.R01.S.doc Version 5.1 Page 24 Timescale for action 13/07/06 2. OP8 13(4) 01/08/06 3 OP8 13(4) 06/07/06 4. OP16OP30 18(1)(c) (i) 01/08/06 5. OP16 OP30 18(1)(c) (i) is partially met. The previous timescale was 1/5/06. The registered person must ensure that care staff in charge of shifts receive training in: First Aid to be provided when a resident has a wound, which is bleeding. This requirement is restated as it is partially met. The previous timescale was 1/5/06. 01/08/06 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.V292044.R01.S.doc Version 5.1 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.V292044.R01.S.doc Version 5.1 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. 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