Inspection on 03/06/08 for Sylvan House

This inspection was carried out on 3rd June 2008.

CSCI found this care home to be providing an Adequate service.

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 25/10/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sylvan House 2 - 4 Moss Grove Prenton Wirral CH42 9LD Lead Inspector Beate Field Key Unannounced Inspection 3rd June 2008 10:15 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.V366092.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.V366092.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 Dementia (6), Old age, not falling within any registration, with number other category (22) of places Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 22 Date of last inspection 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. This registration includes providing a service to 6 people who have dementia. 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. There are sufficient bathroom facilities available on the first floor. Outside the home there are garden areas and some parking spaces. 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 £380.17. Additional charges are made for hairdressing, newspapers, clothing, toiletries and other items of a luxury nature and chiropody. The manager advised that a service user guide and a statement of purpose, which describe the services offered is made available to people who are interested in using the service, their relatives and professionals before a person 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.V366092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection is based on a site visit to the home over a 6.5 hour period and is also informed by information received about the service since the last inspection, including an Annual Quality Assurance Assessment (AQAA) completed by the manager and by questionnaires completed by relatives and staff. 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 the people who use the service and staff and made observations of the care given by staff. What the service does well: The assessment process ensures that a service is only offered to people whose needs can be met. The people who use the service are consulted about the day-to-day operation of the home. The people who use the service are treated with respect and their health needs are given appropriate priority. The wellbeing of the people who use the service is promoted by the flexibility of the daily routines, their being able to make choices and visitors being made welcome to the home. The people who use the service are safeguarded by the home’s procedures for managing complaints. A clean and comfortable home environment is provided. Staff are friendly and polite towards the people who use the service. This creates a pleasant and relaxed atmosphere within the home. Staff are encouraged to obtain an appropriate qualification in caring for older people. The majority of staff have an NVQ in Caring for Older People. The people who use the service made positive comments about the care and support provided by staff. Some comments made were “I like being here. I am well cared for and get the support I need.” “ Staff here are good, kind and always aim to please and always available when you need them.” “I am happy Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 6 here. I see a GP or a chiropodist when I need to. The staff give me the support I need.” “Staff treat me with respect.” Relatives who returned a survey to the CSCI also said they are happy with the service provided at Sylvan House. Some comments made were “Mum is well looked after and the atmosphere is always happy.” “Staff exceptional. Staff are compassionate, caring and very attentive. I am very satisfied.” “Staff are always happy and willing to help and most of all my relative is well looked after.” “The home is very well run and staff are always happy.” What has improved since the last inspection? What they could do better: Improvements need to be made to the staffing levels at the home to ensure that at all times there are sufficient staff to meet the needs of the people who use the service. Care plans need to contain clearer guidance on the management of falls so as to ensure that staff have the information they need to appropriately support the people who use the service. Some improvements are needed to the record keeping around the administration of medication in order to ensure that the welfare of the people who use the service is safeguarded. A range of planned activities needs to made available to ensure that the people who use the service receive appropriate stimulation in accordance with their wishes. There must be a clear audit trail relating to the management of the monies held on behalf of the people who use the service. This is to ensure that they are safeguarded from financial abuse. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 7 Records of staff training need to be available on all staff records to demonstrate that staff have received the training they require to appropriately support the people who use the service. Some improvements are also needed to the home’s recruitment processes in order to ensure the people who use the service are adequately safeguarded. Detailed information regarding the operation of the home needs to be provided to the CSCI in the Annual Quality Assurance Assessment (AQAA) prior to inspections to demonstrate the quality of the service being provided. 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.V366092.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process ensures that a service is only offered to people whose needs can be met. The people who use the service and their relatives benefit from being able to visit the home to see if it is right for them before moving in. EVIDENCE: Since the last visit to the service the manager has began recording initial assessments of need. Basic information is recorded which would form the basis for a care plan to be developed. Where a person is referred by a social worker, a social work assessment is also available. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 10 Polices and procedures in the home encourage people who are interested in using the service and their family/friends to visit the home and to spend some time there before taking the decision to move in. A person 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. Contracts were available for 3 people who have begun using the service since the last inspection. This shows the current charges and terms and conditions of residence at the home. The contracts had been signed by a representative of the person using the service. Advice was given to the manager to update the contracts as they have the old address of the CSCI. Intermediate care is not provided at the home. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to the practices around the management of medication in order to safeguard the people who use the service. EVIDENCE: Care plans were seen for 4 people who use the service. Care plans are directly available for staff to refer to. The care plans provide basic information to staff on what the needs of the people who use the service are and how to meet them. There is also information recorded about the lives of people who use the service before coming to live at the home. There has been an overall improvement to the content of information recorded in the care plans since the Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 12 last visit to the service. Care plans seen had not been dated. Care is to be taken to ensure that this information is recorded. Care plans included information about the health needs of the people who use the service. 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 the people who use the service who were spoken with said that they have access to health and social care professionals when they are needed. Records showed that the care plans had been reviewed. However, there was little information recorded to show that the person using the service or their representative/relative had been involved in the drawing up of the care plan or the review. Advice was given to the manager regarding this. The falls risk assessments available do not provide sufficient guidance to staff on the actions to be taken to minimise the risk of falls. The assessments do not indicate the observations and assistance to be given by staff, how nutritional and medication factors may be significant. This needs to be addressed so as to provide detailed information on falls prevention. The manager recognised this and said that although not recorded these factors are considered. The people who use the service who were spoken with during the visit and those who returned a survey to the CSCI said they are happy with the service provided at Sylvan House. Some comments made were “I like being here. I am well cared for and get the support I need.” “ Staff here are good, kind and always aim to please and always available when you need them.” “I am happy here. I see a GP or a chiropodist when I need to. The staff give me the support I need.” “Staff treat me with respect.” Relatives who returned a survey to the CSCI also said they are happy with the service provided at Sylvan House. Some comments made were “Mum is well looked after and the atmosphere is always happy.” “Staff exceptional. Staff are compassionate, caring and very attentive. I am very satisfied.” “Staff are always happy and willing to help and most of all my relative is well looked after.” “The home is very well run and staff are always happy.” 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 in general found to be correctly maintained. On several occasions staff had not signed for medication that had either been given or refused. A clear record needs to be made to account for the whereabouts of all medications available at the home to ensure there is no mishandling. The manager advised that this matter would be addressed without delay. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 13 Where medication is administered as a result of agitation or distress, the care planning records need to provide clear information for staff around the circumstances in which this should be administered. 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. The people who use the service said that the 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 the people using the service. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. A range of planned activities needs to made available to ensure that the people who use the service receive appropriate stimulation in accordance with their wishes. EVIDENCE: The records showed that since February 2008 there have been few organised activities provided at the home. There is a timetable of weekly activities displayed in the reception of the home however the manager and staff said that often there are insufficient staff to enable activities to be provided. The manager reported that an activities co-ordinator post has been advertised with no success. Three residents spoken with said that they think there is enough to do at the home. They said they prefer reading and television rather than organised Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 15 activities. This view does not however, represent the views of all the people who use the service. Since the last visit to the home the manager has reviewed the activities offered with the people who use the service and tried to implement the suggestions made, however, lack of staff has meant that it has not been possible to offer daily activities on a consistent basis. On the day of the visit the planned activity of a quiz did not take place as there were only two staff available on the afternoon shift. The home is equipped with TV and radio/music systems and has a range of board games for the people who use the service. Links have been developed with the local library and books, many in large print, are changed on a regular basis. Most of the people who use the service have a TV in their own bedrooms. A hairdresser visits the home on a regular basis. The people who use the service spoken with said that they 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. Staff confirmed this and said that they encourage the independence of the people who use the service in accordance with their abilities. The bedrooms that were seen had been personalised with photographs, cards and items brought in from their own homes. The religion of the people who use the service 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 the people who use the service throughout the day. The people who use the service can see visitors in private in their bedrooms or in the dining room. Surveys and a discussion with the people who use the service showed that their relatives are welcomed to the home by the staff. The menus showed that varied meals are provided. There is a choice of cooked or light breakfasts. A cooked or cold midday meal is prepared but people who do not wish to take this meal are offered an alternative. A choice of food is offered at the evening meal and a light supper is provided around 8pm. 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. The people who use the service who were spoken with said that they liked the food. Some comments made were “the food is good and always varied”. “I love the food.” “The meals are of a good quality with fresh ingredients.” Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 16 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 people who use the service are safeguarded by the systems in place to protect their wellbeing. It was not possible to assess if the finances of some people who use the service were being appropriately managed. EVIDENCE: The home has a complaints procedure in place. The manager was asked to update this with the new address of the CSCI. The people who use the service who were spoken with were aware of how to raise any concerns they may have about the operation of the home. Some comments made were; “I can speak to the manager if unhappy. The manager’s door is always open.” “I have no complaints but if I needed to complain I would speak to the manager or the deputy.” No complaints have been made to the home or to the CSCI since the last inspection. The home has policies and procedures in place to protect the people who use the service from abuse and encourage its staff to raise any concerns through a Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 17 “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 to follow should they suspect abuse. The majority of staff completed a formal training event about adult protection 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 people who use the service have their monies looked after by the homeowner. Only one person has an individual bank account. There was not a clear link between the bank records supplied by the owner since the last visit and the incomings and outgoings of the monies of the people who use the service. The manager was unable to explain the system that is in operation. A simpler system needs to be into operation so the manager can oversee the finances of the people who use the service. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a safe and comfortable home. EVIDENCE: There was evidence that a number of improvements have been made to the home since the last inspection. Furnishings have been replaced in some bedrooms. New dining tables and chairs and lounge furnishings were available. Further bedrooms have been redecorated, the ground floor bathroom has been redecorated and work is in progress to improve the appearance of a further bathroom. The hoist in the ground floor bathroom is in the process of being renewed. The manager reported that this will be Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 19 completed within the week. The first floor bathroom is in need of some attention. The flooring has lifted slightly by the hoist and needs to be secured. This room would also benefit from general redecoration. The manager reported that this bathroom is to be redecorated when the works to the other bathrooms have been completed. The improvements that were identified at the last inspection to ensure the safety of the people who use the service were made without delay following the last inspection of the home. 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 also available. 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. Steps should be taken to enhance the outdoor area for the people who use the service. The bedrooms are light and airy and are furnished in a domestic style. The people who use the service 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 people have brought with them some treasured items to personalise their room. The people who use the service can choose to hold a key to their bedroom in accordance with a risk assessment. In double rooms, curtain screening is provided to support the maintenance of privacy. At present 3 rooms are shared. The manager reported that the people who share bedrooms have made a positive choice to share. There was no record of this or of the compatibility of the needs of the people who are sharing bedrooms. This needs to be considered to ensure that the people who use the service are being appropriately supported The home is centrally heated and radiators have individual thermostats that can be adjusted for comfort. Since the last visit to the home the majority of radiators have been fitted with protective covers. A recorded risk assessment is available for any unguarded radiators. On the day of this inspection the home was clean. There were no offensive odours noted anywhere in the home. 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.V366092.R01.S.doc Version 5.2 Page 20 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 people who use the service. The people who use the service are not fully safeguarded by the home’s recruitment processes. EVIDENCE: Previous inspection reports have raised concerns over the staffing levels. There has been a change to the needs of the people who use the service since the last visit. The manager reported that 3 staff should be on duty on the morning and evening shifts, however, due to staff vacancies, sickness and holidays there are times when there are only 2 staff available. In the morning/afternoon, during the week, the manager and deputy manager are available to make up for staffing shortfalls but this is having an impact on the work that they need to carry out. The rotas for the last 4 weeks were seen. These show that there are times when there are only 2 care assistants on duty with a senior carer and the manager being available during the day. During the evening from 4 – 10 there are generally 2 staff available with a third member of staff being available on occasion. At weekends when senior staff Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 21 are not available the rotas show there have been times when 3 care staff where not available on the evening shift. Agency staff are being deployed to make up any staffing shortfalls at the home where this is possible. A record of a recent residents meeting showed that the people who use the service prefer not to have agency staff working at their home as they are “strangers” to them. There were 18 residents living at the home at the time of the inspection. Three staff spoken with said that they do not consider that there are a sufficient number of staff available all the time. Staff who returned surveys made similar comments. Staff said although the needs of the people who use the service are met, when 3 staff are not on duty they can feel rushed and as though they do not have time to spend with them. Staff said that activities are not taking place in the afternoon due to the lack of staffing. A requirement has been made as a result of this visit that sufficient staff need to be available at all times to meet the needs of the people who use the service. The manager reported that in spite of several attempts to recruit care staff the manager has been unable to appoint the numbers required. There are currently 3 care staff vacancies and a vacancy for an activities coordinator. It continues to be recommended that the owner review the terms and conditions of employment to see if this is having an impact on recruitment. Records showed that staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; care planning 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 3 have achieved the NVQ level 3. Since the last visit to the home the majority of staff have completed or are in the process of completing a 12-week distance learning course around meeting the needs of people with dementia. All staff have undertaken training around safeguarding vulnerable adults and completed training around the safe handling of medication. There was no training plan in place for future training and an audit had not been completed that identifies when staff need refresher training in health and safety matters. Some staff files contained no training records or certificates of training so it could not be ascertained who was in need of which training. The manager was advised to use staff supervision as a method of planning future training based on the identified needs of the staff. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 22 The recruitment records for three staff were seen. These contained the required information. Records indicating the suitability of agency staff to be employed at the home were not available. There was no confirmation from the agency as to the recruitment checks undertaken, training, skills or experience. Volunteers visit the home and buy personal shopping for some people who use the service. A criminal records bureau check had not been undertaken on the volunteers. The manager was advised to do so. 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 the people who use the service. This creates a pleasant and relaxed atmosphere within the home. The people who use the service said staff listen and act on what they say, are “caring,” “attentive” and “kind.” Relatives who returned surveys were very positive about the care and support provided by the staff. They said that their relatives get the care they need, the staff keep them informed about important issues and encourage their relative to keep in touch. One relative commented on the turnover of staff and said that more permanent staff need to be recruited. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 23 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. Detailed information regarding the operation of the home needs to be provided to the CSCI to demonstrate the quality of the service being provided to the people who use it. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 24 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, including dementia care and has completed an NVQ level 4 in care and the Registered Managers Award. The deputy manager has completed an NVQ Level 3. The Annual Quality Assurance Assessment (AQAA) did not provide detailed information. It is recommended that the AQAA provide detailed information as it is the main way that the registered persons let the CSCI know how well a service is delivering good outcomes. There was clear evidence that the views of the people who use the service are obtained about the day-to-day running of the home. People spoken with had been consulted about the food and the ongoing redecoration of the home. Questionnaires are issued to all the people who use the service and their relatives once a year and are due to be sent out again. The results of the questionnaires from July 2007 show that the people who use the service are happy with the food, activities and home environment. Staff were aware of the likes and dislikes of the people who use the service and were conscious of their individual personalities. The manager was clear that Sylvan House is the home of the people who live there 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. Staff meetings take place every 2 months. Since the last visit to the home the manager has introduced regular staff supervision. Records showed that staff last received supervision in April 2008 and prior to this February 2008 and December 2007. As already indicated it was not possible to assess if some finances of the people who use the service were being appropriately managed as the records relating to this were not easy to understand and the manager could not explain the system in operation. Records showed that electrical wiring, the gas and portable appliances, hoists had been checked and were safe for use. The records of staff checks of the fire alarm and emergency lighting showed that this equipment is being tested within suitable time limits. Records show that some staff have received fire safety training. The names of the staff are not recorded so it was not possible to see which staff have received this training. The last record of training provided was undated so was not possible to tell if the training is occurring within the recommended frequencies of every 6 months for day staff and every 3 months for night staff. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 25 A sample of records of accidents were seen, these indicated that appropriate action had been taken when an accident had occurred. It is recommended that a monthly audit of accidents at the home is undertaken to enable any patterns to be identified and action to be taken where needed. Water is thermostatically controlled. The manager reported that regular checks of the water are undertaken. A record was not being made of this. The manager was advised to do so. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 26 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 2 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 2 Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 27 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 risk assessments in relation to falls are comprehensive in order to provide clear guidance to staff around what they need to do to prevent a fall. The registered persons must ensure that a clear record is made to account for the whereabouts of all medications available at the home to ensure there is no mishandling. The registered persons must ensure that care planning records clearly indicate the circumstances when any medication is to be administered as a result of agitation or distress. This is to ensure that staff have access to clear guidance. The registered persons must ensure that a range of planned activities is made available to ensure that the people who use DS0000064575.V366092.R01.S.doc Timescale for action 03/07/08 2. OP9 13 03/06/08 3. OP9 13 03/06/08 4. OP12 16 03/07/08 Sylvan House Version 5.2 Page 28 the service receive appropriate stimulation in accordance with their wishes. 5. OP18 OP35 17 The registered persons must ensure that there is a clear audit trail relating to the management of the monies held on behalf of the people who use the service. This is to ensure that they are safeguarded from financial abuse. The registered person must ensure that at all times there are sufficient staff given the number and needs of the of the people who use the service, size and layout of the home. The registered person must ensure that where agency staff are employed evidence is obtained from the agency to confirm that they are appropriately skilled and have received the necessary recruitment checks to work at the home. Where volunteers are employed. They need to have a criminal records bureau check so as to ensure the safety and well being of the people using the service. The registered person must ensure that there is a clear record of all training provided to staff at the home in order to demonstrate that staff are being provided with the training they need to carry out their roles. The registered person must ensure that that all staff receive fire safety training at suitable intervals. DS0000064575.V366092.R01.S.doc 03/06/08 6. OP27 18 03/06/08 7. OP29 17 03/06/08 8. OP30 17 03/06/08 9. OP38 23 03/07/08 Sylvan House Version 5.2 Page 29 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 The care plans and reviews should record the views of the people using the service and their representatives where appropriate. 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. Steps should be taken to enhance the outdoor area for the people who use the service. 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. An audit of the training needs of staff needs to be identified and a clear training plan developed. Staff should have access to a more thorough induction, which meets the standards of Skills for Care. The AQAA should provide detailed information as this is the main way that the registered persons can let the CSCI know how well a service is delivering good outcomes to the people who use the service. It is recommended that a monthly audit of accidents is DS0000064575.V366092.R01.S.doc Version 5.2 Page 30 2. 3. OP9 OP12 4. 5. OP19 OP23 6. OP27 7. 8. 9. OP27 OP30 OP31 10. OP38 Sylvan House undertaken to enable any patterns to be identified and action to be taken where needed. 11. OP38 A record is to be made of the tests of water temperature. Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North West Regional Contact Team d Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Sylvan House DS0000064575.V366092.R01.S.doc Version 5.2 Page 32 - 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. 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