Inspection on 28/11/05 for Sydney House

This inspection was carried out on 28th November 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 24/06/05

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 Norfolk NR12 9BJ Lead Inspector Linda Wells Unannounced Inspection 28th November 2005 09:45 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 Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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 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) Norfolk County Council-Community Care Mrs Gillian Margaret Medland Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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. 24th June 2005 Date of last inspection 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 washbasin 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 DS0000034885.V260064.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 28th November 2005 over five hours and was carried out as part of a routine inspection plan. Prior to the inspection eight comment cards were received from residents and twenty from relative/visitors. All of those who returned the comment cards indicated that the residents were well cared for, the home was always clean and tidy and that staff members were caring. Relatives/visitors wrote, “the home is warm and friendly” and “I am very happy that my relative lives in such a nice home”. On the day of inspection thirty-seven residents were living at the home and residents were seen to be having a meal, sitting in the lounges or their bedroom listening to the radio, reading or watching television. The hairdresser was providing a service to residents and the handyman was putting up the Christmas decorations. The inspection took the form of a tour of the premises, individual discussion with six residents, five staff members, a senior care assistant and the manager, group discussion with two residents and a visitor, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? Residents have benefited from improved facilities by the increase in the activities program, the fitting of a “Prima” bath, an additional visitors room Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 6 being provided and refurbished, the replacement of window restrictors and the building of a new sewerage pumping station for the home. 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. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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 Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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, 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. A resident who had lived at the home for six months said that she and her relative had visited the home prior to admission, had been given enough information about the home to help them make a choice, that staff had made her feel welcome and that her key worker had helped her to settle into the home. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 11 The health, social and personal care needs of residents were met, they were well cared for but medication administration records were not all completed. 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 and risk assessments. Also included was detail on interests, routine, visiting professionals, a photograph, record of falls, preferences, health condition information and management, a plan of care and improved resident reviews. Medication policies and procedures were seen and demonstrated that they protected residents. Staff had undertaken training and mediation was stored correctly however, in four instances seen the records for the medication administered to residents were incomplete and a requirement was made that accurate records be held to ensure residents are fully protected. . Records were seen in the plans of care on the arrangements for each resident at death and demonstrated that residents were consulted and that their wishes were acknowledged and recorded. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 10 Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 11 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, 14, 15 Improvements have been made to the social and creative activities and meals that were varied and took into account the preferences of the residents. EVIDENCE: Residents are stimulated by the improved 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 with their family or staff member and playing bingo and the visitor spoken to said that she joined in with the homes organised events and was always made to feel welcome in the home. The manager said that one member of staff had been provided twice a week to carry out activities with residents and that two members of staff were in the process of completing a training course in Reminiscence. Residents said that staff members encouraged them to constantly make choices in all aspects of their lives, to maintain contact with relatives and friends and to be as independent as possible. The main meal and menus were seen and were balanced and varied. Records showed that residents were given a choice and an alternative offered. Residents said that the meals had improved since the menus had changed and the manager said that the quality of the meals could vary at times due to the Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 12 home only having a permanent cook for three days a week and agency staff being used by NPS on the other days. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 13 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): 17, 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 Care co-ordinators and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. The home had recorded two complaints received this year that a staff member had treated a resident disrespectfully and not given choice and that a call bell rung by a resident had not been answered. Records held demonstrated that the manager and in one instance the complaints officer at County Hall investigated the complaints 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 DS0000034885.V260064.R01.S.doc Version 5.0 Page 14 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, 21, 22, 23, 25, 26 Residents live in a home that is maintained to a reasonable standard in most areas but there are some areas of the home that require attention to make it fully safe, attractive and comfortable for those living and working at the home. EVIDENCE: The health, safety and comfort of residents were not fully protected at the home and although an additional visitors room had been provided and refurbished and a bath replaced with a specialist Prima bath 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. Also the metal framed windows that let in a draught and the lift that is too small were in need of replacing, an exposed waste pipe needed to be covered and in two toilets hot water was required for the handwash basins. Six requirements were made. Five were repeated and two were repeated for the second time from the last and previous inspections. The home was clean and odour free and residents were seen to have personalised their bedrooms. The communal bathrooms and toilets on each Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 15 floor were adapted to suit the needs of the residents, specialist equipment was provided and infection control measures were in place. A recommendation was repeated that pictures be put on the upstairs hall walls to make this area of the home more homely. The manager said that this would take place after the redecoration of those areas and that plans were in place to replace the lift. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 16 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 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 but not all records were held. EVIDENCE: The staff members spoken to said that they were supported by the care coordinators, by handover and supervision, attended staff meetings and were aware of their role and responsibilities. The manager outlined her plans to improve staff morale and communication in the home and demonstrated that she was working to promote teamwork. Records showed that residents were protected and that all staff recruitment checks were carried out but not all staff had copies of their CRB, proof of identity, references and personal details in their staff file because they were held at County Hall. Therefore a requirement was made that all staff have copies of their recruitment checks and proof of identity in their staff file. Staff members have a mix of experience and skills and all are well trained with over 50 of staff having completed or undertaking NVQ2 and two staff undertaking or have completed NVQ3. 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. Residents said that at times there were not enough staff on duty and that they had to wait longer than usual for assistance. The staff spoken to said that Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 17 there were enough staff on duty to meet the needs of each resident if all shifts were covered. The manager said that she had made changes to the staffing rota to ensure that five staff members were on duty at each daytime shift, that the Care co-ordinator could be called upon to help, if available and that agency staff members were being used until the two new staff members that she had recruited were in post. A recommendation was repeated that all shifts are covered to ensure adequate staffing levels are in place at all times. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 18 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): 32, 34, 35, 37, 38 The manager is competent and is 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. Residents and staff members said that the home was well organised and the manager said that she was working hard to improve the quality of life and care provided for residents by motivating staff members. 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. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 19 Staff members are supported and regularly supervised by the care coordinators to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs are identified, clarified and reviewed. Residents were protected, by the accounting and financial procedures held in the home and individual records were seen to demonstrate that all debits and credits were recorded for any money held for residents and that it was stored securely. Records demonstrated that the manager monitors and manages budgets allocated to the home and that there is no reason to doubt that Norfolk County Council is not financially sound. The Quality Assurance system in place and seen takes into account the opinions, views and feedback of residents, relatives, visitors, staff members and other professionals on the standard of care and service provided at the home to ensure everyone is consulted and an action plan of improvements produced. 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. The hot water in the bedrooms upstairs tested to 52.9 degrees C and a requirement was made that the hot water be regulated to close to 43 degrees C to ensure residents are fully protected. The manager took immediate action and said that thermostatic blender valves were fitted to the washbasins in the bedrooms and a new boiler had been fitted. Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 20 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 2 X 2 3 3 X 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 3 3 3 3 2 Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 21 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 OP9 Regulation Requirement Timescale for action 01/01/06 2. OP19 3. OP19 4. OP19 5. OP19 6. OP19 17.1.sch.3 The registered person must ensure that medication administered to service users is recorded. 23.2.b The registered person must ensure that the walls in the hallways are kept in a good state of repair and redecoration. (Previous timescale of 31st December 2005 will not be met) 23.2.b The registered person must ensure the windows in the home are replaced. (Previous timescale of 31st December 2005 will not be met) 23.2.d The registered person must ensure all bedrooms are kept in a good state of decoration. (Previous timescale of 31st December 2005 will not be met) 23.2.n The registered person must ensure that the passenger lift is replaced with one suitable for the needs of the service users. (Previous timescale of 31st December 2005 will not be met). 13.4.a The registered person must ensure that the exposed waste pipe in room 10 is covered. DS0000034885.V260064.R01.S.doc 31/03/06 01/06/06 31/03/06 01/06/06 31/03/06 Sydney House Version 5.0 Page 22 7. OP21 8. OP29 9. OP38 (Previous timescale of 31st August 2005 not met) 13.3 The registered person must 01/01/06 ensure that hot water is available at washbasins in all toilets. 19.1.sch.2 The registered person must 31/03/06 ensure that copies of recruitment checks and proof of identity are stored in the file of each staff member. 13.4 a-c The registered person must 01/01/06 ensure that the hot water into all washbasins is regulated to close to 43C. 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. 2. Refer to Standard OP19 OP27 Good Practice Recommendations It is recommended that appropriate creative items be placed on the upstairs hall walls to make the area more attractive and homely. (Repeated from last inspection) It is recommended that all care shifts be covered to ensure adequate staffing levels. (Repeated from last inspection) Sydney House DS0000034885.V260064.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 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. 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