Inspection on 25/10/07 for Sylvan House

This inspection was carried out on 25th October 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 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

Sylvan House 09/02/10

Sylvan House 10/11/09

Sylvan House 09/06/09

Sylvan House 03/06/08

Sylvan House 25/05/06

Sylvan House 29/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sylvan House 2 - 4 Moss Grove Prenton Wirral CH42 9LD Lead Inspector Beate Field Key Unannounced Inspection 10:00 25th October 2007 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 Sylvan House DS0000064575.V341451.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. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sylvan House Address 2 - 4 Moss Grove Prenton Wirral CH42 9LD 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) 0151 608 1401 no email account available Prime Care (UK) Ltd Carol Dixon Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2006 Brief Description of the Service: Sylvan House is a large converted property situated in the Prenton area of Birkenhead, Wirral. It is close to local shops, and bus routes to towns on the Wirral and Liverpool. The home offers care and support to 22 residents who are over the age of 65 years. Accommodation is provided on two floors with passenger lift and stair access. The home has some shared bedrooms. On the ground floor there are two sitting areas and a separate dining room, some bedrooms, an adapted bathroom and WC’s. Outside the home there are garden areas and some parking spaces. Adaptations to assist residents who have a disability are in place. Basement areas in the home are used as an office, a staff room, a laundry and for storage. At the time of this inspection, the weekly fees for the home ranged from £352.42 to £380.00. Additional charges are made for hairdressing, newspapers and chiropody. The manager advised that a service user guide and a statement of purpose, which describe the services offered is made available to new residents, their relatives and professionals before a resident comes to live at the home. A copy of the most recent inspection report can be obtained from the manager or deputy manager. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is based on a site visit to the home over a 6-hour period and is also informed by information received about the service since the last inspection and by questionnaires completed by the manager, residents and relatives. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with residents and staff and made observations of the care given by staff. What the service does well: What has improved since the last inspection? There has been an ongoing improvement to the decoration of the premises. A requirement was made at the last inspection of the home to repaint the laundry floor to ensure a good standard of infection control. This has been addressed. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 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 Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning could be improved by having a separate record of a residents’ assessment of needs before coming to live at the home. EVIDENCE: Assessments are either carried out by a social worker or by the manager of the home. The assessments for two new residents that had been completed by the manager were seen. These assessments were completed on care planning forms, which form the residents current care plan. Although basic information about the residents needs was available it was difficult to form a judgement as to all the residents needs before coming to live at the home. A separate assessment of need should be completed to ensure that there is a clear record of the residents needs before coming to live at the home. This can then form the basis of the care plan that details how the residents’ needs are to be met. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 9 Polices and procedures in the home encourage prospective residents and their family/friends to visit the home and to spend some time there before taking the decision to move in. A resident spoken with and one who returned a questionnaire said they had visited the home before deciding to move in and that this had been helpful. All residents who returned questionnaires said that they had been given enough information to help them to make a decision about moving to the home. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their health needs are given appropriate priority. EVIDENCE: A sample of residents’ care plans were seen. Care plans are directly available for staff to refer to. The care plans provide basic information to staff on what the residents needs are and how to meet them. There is also information recorded about the residents’ lives before coming to live at the home. Records showed that the care plans had been reviewed. Further information needs to be recorded in the care plans so that staff have the information they need to fully support the residents. For example, how staff are to support residents with their personal care needs and mental health needs, where residents are showing signs of confusion is not fully documented. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 11 The care plans need to give clear information to staff as to how they are to meet the personal care needs of the resident and what residents can do for themselves. This clear guidance will enable residents to maintain their independence where this is appropriate. The manager had recognised this but said that staffing shortfalls had led to less time being able to be spent on developing care planning at the home. Residents spoken with and those who returned questionnaires said they are happy with the care they receive. Some comments made were “the home is a friendly place where people are cared for” and “I feel happy with the care I get”. Relatives who returned questionnaires were generally happy with the care provided. Care plans included information about the health needs of residents. The manager told the inspector that the home receives good support from GP’s and district nurses. Links have been maintained with a visiting optician. Records showed and residents said that they have access to health and social care professionals when they are needed. Policies and procedures for handling and recording medication are available. A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected and found to be correctly maintained. Staff who administer medication have undertaken training in the safe handling and administration of medication. Staff interviewed were clear that they could not administer medication unless they had been appropriately trained. A record should be made of the assessed competence of staff to administer medication. A few residents administer their own medication. Care needs to be taken to ensure that the risk assessments around this are regularly reviewed. Residents told the inspector that staff are very caring and that they are treated with respect. The inspector observed that staff knocked on bedroom doors and waited for a reply before entering. Curtain screening is provided in shared rooms to protect the privacy of residents. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make decisions about their day-to-day lives. EVIDENCE: The home is equipped with TV and radio/music systems and has a range of board games that residents can use. Links have been developed with the local library and books, many in large print, are changed on a regular basis. Most of the residents have a TV in their own bedrooms. A hairdresser visits the home on a regular basis. The records for the last month show that organised activities are made available for residents about 3 times per week and include board games, singa-longs, skittles and manicures. Outings are arranged from time to time. The activities provided seemed a bit limited given the potential activities that could be made available. There is no designated person who undertakes activities with the residents. The manager reported that this position is being advertised. Due to staffing shortfalls the staff reported that it has not been Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 13 possible to provide a planned range of activities for the residents. Three residents spoken with said that they think there is enough to do at the home and that they prefer reading and television rather than organised activities. Most of the residents who returned questionnaires were happy with the level of activities provided. One resident said they would like to have more activities offered. It is recommended that a review of activities takes place with residents to look at what activities they may like to take part in. Further opportunities should be made available for residents to take part in activities outside of the home. The residents spoken with and staff said that residents make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. The residents’ bedrooms that were seen had been personalised with items brought in from their own homes. The religion of residents is documented. A minister from a local Church of England church and a priest from a Catholic church visit the home every Saturday. Visitors are welcome at the home and observations showed that visitors call to see their relatives throughout the day. Residents can see visitors in private in their bedrooms or in the dining room. The menus showed that varied meals are provided. Residents have a choice of cooked or light breakfasts. A cooked or cold midday meal and a cooked or cold evening meal are prepared but residents who don’t wish to take this meal are offered an alternative. The menu identifies a range of foods that are appropriate to give a balanced diet and meets the preferences of older people. The food served on the day of this visit looked appealing and well balanced. Residents spoken with said that they liked the food. Staff carry out personal shopping for the residents twice a week. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general the residents are safeguarded by the systems in place to safeguard their wellbeing. It was not possible to assess if some residents finances were being appropriately managed. EVIDENCE: The home has a complaints procedure in place. Residents spoken with were aware of how to raise any concerns they may have about the operation of the home. Residents and relatives who returned questionnaires were aware of how to make a complaint. One formal complaint had been made to the CSCI since the last inspection. This concerned staff not being able to go shopping for residents and there being limited opportunities for residents to go out. The homeowner was asked to investigate the issues raised. The CSCI was satisfied that the homeowner took the complaint seriously and dealt with this in a responsible manner. The home has policies and procedures in place to protect residents from abuse and encourages its staff to raise any concerns through a “whistle blowing” policy. A copy of Wirral Borough Council’s procedures on reporting abuse is also held in the home. The adult protection procedure is worked through with staff during the induction. Three staff spoken with were aware the procedure Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 15 to follow should they suspect abuse. A few of the home’s staff have completed a formal training event about adult protection. The remainder of the staff are attending this training in November 2007. The home looks after monies deposited by relatives or advocates. The records of this were seen and were found to be in order. Two of the residents’ have their monies looked after by the homeowner who has set up a bank account for them. The records relating to this were not available and so it was not possible to form an opinion as to whether this was being appropriately managed. Sylvan House DS0000064575.V341451.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A comfortable home is provided however at this visit some works were needed to improve the safety and comfort of the home for residents. EVIDENCE: There was evidence that a number of decorative works have taken place since the last inspection. Furnishings have been replaced in some bedrooms. New dining tables and chairs were being stored at the home ready to be used when the decoration is finished in the dining room and lounge furnishings have been ordered for the newly decorated lounge. At this visit it was identified that some works were needed to ensure the safety of the residents. The carpet in the downstairs hallway was rucked and could Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 17 present a tripping hazard. The floor covering in the lift had lifted and could also present a hazard. An unsteady wardrobe (in a room that had recently been redecorated) had not been secured to the wall again. Following the visit the manager reported that the wardrobe had been secured and all wardrobes checked to ensure safety and that the carpet in the hall had been evened out as much as possible but will be replaced to provide a longer-term solution. The manager reported that the floor covering in the lift and the carpet in the hall is to be replaced on 8th November 2007. Additional works are needed to enhance the presentation of the home for the residents. The wallpaper was peeling off in some areas in the ground floor bathroom. The hoist in this bathroom was rusty and this did not give the bathroom a well-kept appearance. This hoist had recently been serviced and although it is working adequately the engineer has recommended this be replaced. A large lounge is the main communal sitting area and overlooks the front of the home. A second, quiet lounge that holds the library books is rarely used. A separate dining room is provided across the hallway from the main lounge. There is a small front garden, a larger side garden area and a rear yard. The manager reported that steps are being taken to enhance the outdoor area for the residents. Residents’ bedrooms are light and airy and are furnished in a domestic style. Residents have been included in the arrangements to redecorate their room and have assisted in the choice of colours and soft furnishings. Adequate storage for clothing and belongings is provided and many residents have brought with them some treasured items to personalise their room. Residents can choose to hold a key to their bedroom. Since the last inspection all residents have been provided with an additional lockable facility in their bedrooms. In double rooms, curtain screening is provided to support the maintenance of privacy. At present 3 rooms are shared. The manager reported that these residents made a positive choice to share. There was no record of this or of the compatibility of the needs of residents who are sharing bedrooms. This needs to be considered to ensure that residents are being appropriately supported The home is centrally heated and radiators have individual thermostats that can be adjusted for comfort. The manager reported that there are plans for all radiators to be covered. In the meanwhile a recorded risk assessment needs to be put in place. On the day of this inspection the home was clean. There were no offensive odours noted anywhere in the home. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 18 Laundry facilities are located in the basement. Washing machines are fitted with an appropriate sluice facility and the staff are aware of infection control procedures. The inspector understands that the homeowner is planning to extend the home and create additional places. Any new developments must achieve the space standards set out in National Minimum Standards for both bedroom and communal areas in the home. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the numbers of staff available in order to fully support the residents. EVIDENCE: Previous inspection reports have raised concerns over the staffing levels. The rotas for the last 4 weeks were seen. These show that generally there are 2 care assistants on duty at all times with a senior carer and the manager being available during the day. At weekends when senior staff are not available there are 3 care staff. There were 17 residents living at the home at the time of the inspection. Four staff spoken with said that they do not consider that there are a sufficient number of staff at the busiest times of the day. They said they find themselves rushing to complete tasks and do not have time to sit and talk to the residents. There are currently 7 day care staff employed at the home. Due to the small number of day care staff currently employed, staff are working additional hours to cover any staffing shortfalls. The manager reported that in spite of several attempts to recruit care staff the manager has been unable to appoint the numbers required. Staff spoken with said that they are tired of working additional shifts. It continues to be recommended that the owner review the Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 20 terms and conditions of employment to see if this is having an impact on recruitment. At the time of the visit the manager and senior carer were covering the duties of the cook, which had an impact on staff availability. An assessment needs to take place of the current staffing arrangements at the home. Sufficient staff need to be available at all times to meet the needs of the residents. This assessment needs to consider the size and layout of the home. Records showed that staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; resident’s care plans and health and safety issues. Following this staff attend mandatory training in first aid, food hygiene, moving and handling, abuse awareness, medication management and fire safety. Staff should have access to an induction, which meets the standards of Skills for Care. A more detailed evidence based recording system should be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. 8 of the 11 care staff at the home have an award at NVQ level 2 in care and some are working towards level 3. Training around dementia care and the protection of vulnerable adults is planned for November 2007. The manager has carried out a training audit and has identified that some staff need to have updated training in food hygiene, moving and handling and first aid. The manager reported that this training is in the process of being arranged. The recruitment records for two new staff were seen. In general they contained the required information. One record did not have evidence of a health declaration. The application forms have recently been updated and now provide a section to complete this information. Staff interviewed said that they enjoy working at the home and are well supported by the manager. Staff were observed to be friendly and polite towards residents. This creates a pleasant and relaxed atmosphere within the home. Residents said staff listen and act on what they say. Some comments made were, “the staff are very good and will always come when called.” “The staff are attentive, nothing is too much trouble.” A relative who returned a questionnaire said the “staff are polite and helpful.” Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in general run in the best interests of the residents. Staff need regular supervision in order to ensure they have the support they need to carry out their duties. EVIDENCE: The manager of the home is registered with the CSCI. The manager has sufficient experience of working with older people in a residential care setting and has an NVQ level 4 in care and the Registered Managers Award. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 22 There was clear evidence that the views of residents are obtained about the day-to-day running of the home. Residents spoken with had been consulted about the food and the redecoration of their bedrooms and the lounge. Questionnaires had been issued to all the residents in July 2007. The results show that residents are happy with the food, activities and home environment. Residents had identified that they would like a walk in shower and the owner is planning to provide this. Some of the comments made were “ I have a lovely room,” “I feel happy with the care I get” and “It’s just like being at home.” The residents who returned questionnaires to the CSCI also made positive comments. Staff were aware of the resident’s likes and dislikes and were conscious of their individual personalities. The manager was clear that Sylvan House is the resident’s home and that they should be able to make decisions about how their care is provided. The owner is visiting the home on a monthly basis and completing a report of his findings. Residents meetings are taking place. The manager reported that staff meetings are usually every 2 months but due to low staff levels it has not been possible to keep to this. The records showed the last team meeting was May 2007. The manager reported that it has been difficult to provide supervision every two months due to staffing shortfalls. The manager said that supervision was last provided to staff in September 2007 and prior to this February 2007. As already indicated it was not possible to assess if some residents finances were being appropriately managed as the complete records relating to this were not available at the home. Records showed that the gas and portable appliances had been checked and were safe for use. The electrical wiring had been inspected in September 2007 and the report of this showed that there are urgent works that require attention. Evidence that these works have been attended to is to be forwarded to the CSCI. The fire alarm and the emergency lighting were also inspected as part of the inspection of the electrical wiring. Evidence that this equipment is working satisfactorily is also to be forwarded to CSCI. The records of staff checks of the fire alarm and emergency lighting showed that the fire alarm had not been tested weekly for the last three weeks. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 23 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 2 3 X 3 2 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 2 Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement The registered persons must ensure that the residents care plans contain clear information as to how staff are to meet the residents needs. The registered persons must ensure that records of all monies held on behalf of residents are available at the home. The registered persons must ensure that the ground floor bathroom is reasonably decorated. The registered persons must ensure that action is taken to prevent the floor covering in the lift and the carpets in the hallways becoming a tripping hazard. The registered persons must ensure that a record of the risk assessments undertaken in relation to the unguarded radiators is documented. The registered person must ensure that an assessment takes place of the current staffing arrangements. There must be sufficient staff to DS0000064575.V341451.R01.S.doc Timescale for action 25/11/07 2. OP18 OP35 OP19 17 25/11/07 3. 23 25/11/07 4. OP19 23 25/11/07 5. OP19 23 25/11/07 6. OP27 18 25/11/07 Sylvan House Version 5.2 Page 25 7. OP38 23 8. OP38 23 9. OP38 23 meet the needs of the residents given the number and needs of the residents, size and layout of the home. The registered persons must provide evidence that the fire alarm and emergency lighting are working satisfactorily. The registered persons must provide evidence that the electrical wiring of the home is safe. The registered persons must ensure that the fire alarm is tested on a weekly basis. 25/11/07 25/11/07 25/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP9 OP12 Good Practice Recommendations An assessment of need record should be completed to ensure that there is a clear record of the residents needs before coming to live at the home. A record should be made of the assessed competence of staff to administer medication. A review of the activities currently available should be undertaken with residents with a view to providing a greater range of activities that meet the preferences of the current residents. Further opportunities should be made available for residents to take part in activities outside of the home. It is recommended that the hoist in the ground floor bathroom be renewed. An assessment should be made of the compatibility of residents before they share a bedroom. Where residents have made a positive choice to share a bedroom this should be recorded. It is recommended that in order to improve recruitment a review of the terms and conditions of employment takes place. DS0000064575.V341451.R01.S.doc Version 5.2 Page 26 4. 5. OP19 OP23 6. OP27 Sylvan House 7. 8. OP30 OP36 Staff should have access to a more thorough induction, which meets the standards of Skills for Care. Staff should receive formal staff supervision on not less than six occasions each year. Sylvan House DS0000064575.V341451.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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