Inspection on 24/06/05 for Sydney House

This inspection was carried out on 24th June 2005.

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

Sydney House 05/12/06

Sydney House 28/11/05

Sydney House 28/09/04

Sydney House 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Sydney House Brumstead Road Stalham Norwich NR12 9BJ Lead Inspector Linda Wells Unannounced 24 June 2005 at 12.30 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 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. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sydney House Address Brumstead Road Stalham Norwich Norfolk NR12 9BJ 01692 580520 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Norfolk County Council - Community Care Mrs Gillian Medland Care Home 40 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), of places Old age, not falling within any other category (39) Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Rooms numbered 22, 23, 27, 39, 41, 52, 53, 63, 64, 70 and 71 are not suitable for use by wheelchair users at point of admission. Date of last inspection 28 September 2004 Brief Description of the Service: Sydney House is a large, detached, two storey residential care home that was built in the late sixties and is owned and operated by Norfolk County Council. It is registered to provide personal care and accommodation for a maximum of forty older people. The home has single occupancy bedrooms on both floors that all contain a wash basin and there is a shaft lift to the first floor. There is communal use of a dining room, five lounge areas/rooms, three bathrooms one of which has a shower and ten toilets. The home is sited in its own grounds and is surrounded by pleasant walking and seated areas and has parking to the front and side of the building. It is situated on the outskirts of Stalham, but within walking distance of the shops and other facilities. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 24th June 2005 over four hours and was carried out as part of a routine inspection plan. On the day of inspection thirty-eight residents were living at the home. During the day they were seen to be having a meal, sitting in the lounges, sitting areas, their bedrooms, main entrance or the garden; listening to the radio, reading or watching television. The inspection took the form of a tour of the premises, individual discussion with six residents, four staff members and the manager, group discussion with one resident and two visitors. Care plans were examined as were records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The home is in need of upgrading and although redecoration and refurbishment have taken place further work is required. Evidence was not Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 6 fully available that all residents were consulted on decision-making and everyone spoken to said that the standard of meals could be poor at times. As a result of the inspection the following requirements and recommendations have been made. • • • • • • • • • The lift is too small and needs replacing. This is repeated from the last inspection. The metal window frames let in a draught and need replacing. This is repeated from the last inspection. The hallways in some areas are in need of repair due to wheelchair damage and require redecorating. Some bedrooms are in need of redecoration. A waste pipe requires covering to ensure health and safety is promoted. All staff shifts require covering to ensure adequate staffing levels. All reviews carried out with residents must be up to date. A review is needed of the standard of food provided. The upstairs hallway require pictures or items of interest to make the home more attractive and homely. 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. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 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 standard(s) 2, 4 and 5 The admission procedure and written information available is good and fully enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The manager said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. She said residents, their family or friends sometimes visited the home, that she often visited residents in their own home and that residents were admitted on a one-month trial basis. Residents spoken to were able to confirm this. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 9, 10 The health, social and personal care needs of residents were met, they were well cared for but records were not all fully up to date. EVIDENCE: Residents were well looked after and four individual plans of care were examined and found to contain relevant health, social and personal care information, daily records, risk assessments, choices, routine, visiting professionals, dementia care mapping scores where appropriate and some resident reviews. However, the reviews were not all fully up to date and a recommendation was made that reviews be carried out with each resident every month to demonstrate involvement, consultation and agreement of each resident on their plan of care. Medication policies and procedures protected residents, staff had undertaken training and mediation was stored, administered and recorded correctly. Residents were treated with respect and the six residents spoken to all said that staff members protected their privacy when they were assisted with personal care. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13 and 15 There are social and creative activities that meet the interests of the residents but the standard of the meals provided varies. EVIDENCE: Residents are stimulated by the activities provided and records were seen to demonstrate that residents take part in outings and activities. The residents spoken to gave examples of going out on their own or with their family and the two visitors spoken to said that they joined in with the homes organised events and were always made to feel welcome in the home. The main meal and menus were seen and were balanced and varied. Records showed that residents were given a choice and an alternative offered. However, everyone spoken to said that the standard of the meals provided could sometimes be poor and a recommendation was made that a review of the standard of the meals be carried out. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 and 18 The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: The residents spoke to all agreed that if they had reason to complain they would speak to staff or the manager and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. The home had recorded one complaint received this year that a staff member had treated a resident disrespectfully and not given choice. Records held demonstrated that the manager investigated the complaint and took appropriate action to resolve the issues. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 21, 24, 26 Recent improvements have been made to parts of the home but there are remaining areas that require attention to make the surroundings safe, attractive and comfortable for those living and working at the home. EVIDENCE: The health, safety and comfort of residents was not fully protected at the home and although the dining room had been redecorated and carpeted there was a need for further work. The walls, in some areas, were in need of repair due to wheelchair damage, some hallways, bedrooms and parts of the home were in need of redecoration, the metal framed windows that let in a draught and the lift that is too small were in need of replacing and an exposed waste pipe needed to be covered. Five requirements were made. Two were repeated from the last inspection. The home was clean and odour free and residents were seen to have personalised their bedrooms. The communal bathrooms and toilets on each floor were adapted to suit the needs of the residents and infection control measures were in place. A recommendation was made that pictures be put on the upstairs hall walls to make this area of the home more homely. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 Staff members are competent and the procedure for the recruitment and supervision of staff provides safeguards to offer protection for the people living at the home. EVIDENCE: The four staff members spoken to said that they were supported by the senior staff and manager by handovers, staff meetings and supervision and were aware of their role and responsibilities. Records showed that residents were protected and that all staff recruitment checks were carried out and CRB, proof of identity, references and personal details were held on each member of staff. Staff members have a mix of experience and skills and all are well trained with five people having completed NVQ2 and 50 of staff undertaking NVQ2, one NVQ3 and one NVQ4. An induction, foundation and updated training program is undertaken by all staff and enables them to gain the knowledge necessary for the range of needs of residents living at the home. The staff spoken to said that there were enough staff on duty to meet the needs of each resident if all shifts were covered, including during times of sickness and annual leave. On the day of inspection one member of staff was off sick and their shift had not been covered. This resulted in residents having to wait a little longer than usual for assistance and staff feeling under pressure. The manager said that the Care co-ordinator could be called upon to help, if available. A recommendation was made that all shifts are covered to ensure adequate staffing levels are in place at all times. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 38 The manager is competent and qualified and supported by the senior staff in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care. EVIDENCE: Residents are protected by the management and administration procedures carried out in the home. The manager has managed the home for five years and has completed the NVQ4 Registered Manager award. Policies and procedures have been produced on all aspects of the home and service provided and the records held promote and protect the rights and best interests of each service user. Staff members are supported and regularly supervised by the senior staff to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs are identified, clarified and reviewed. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 15 The servicing and testing of all equipment had been carried out and relevant and timely certificates were held to ensure that the health and safety of residents is protected. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x 3 x 3 Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 17 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23.2.b Requirement The registered person must ensure that the walls in the hallways are kept in a good state of repair and redecoration. The registered person must ensure the windows in the home are replaced. REPEATED REQUIREMENT The registered person must ensure all bedrooms are kept in a reasonable state of decoration. The registered person must ensure that the passenger lift is replaced with one suitable for the needs of the service users. REPEATED REQUIREMENT. The registered person must ensure that the exposed waste pipe in room 10 is covered. Timescale for action 31st December 2005 31st December 2005 31st December 2005 31st December 2005 31st August 2005 2. OP19 23.2.b 3. 4. OP19 OP19 23.2.d 23.2.n 5. OP19 13.4.a 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 OP7 Good Practice Recommendations It is recommended that monthly reviews are carried out with all residents and records held. I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 18 Sydney House 2. 3. 4. OP9 OP19 OP27 It is recommended that a review of the standard of food provided in the home is carried out. It is recommended that appropriate creative items be placed on the upstairs hall walls to make the area more attractive and homely. It is recommended that all care shifts are covered to ensure adequate staffing levels. Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 3rd Floor - Cavell House St Crispins Road Norwich NR3 1YF 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 Sydney House I55 s34885 Sydney House v233070 (un) 240605 Stage 4.doc Version 1.30 Page 20 - 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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