Inspection on 14/09/07 for Sylvandale

This inspection was carried out on 14th September 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sylvandale 17/01/07

Sylvandale 15/02/06

Sylvandale 20/10/05

Sylvandale 07/03/05

Sylvandale 24/01/05

Sylvandale 17/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Sylvandale 191 Spital Road Bromborough Wirral CH42 2AF Lead Inspector Julie King Key Unannounced Inspection 14 September 2007 09:30 th Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 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 Sylvandale DS0000035841.V346068.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 Adults 18-65. 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. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sylvandale Address 191 Spital Road Bromborough Wirral CH42 2AF 0151 334 0142 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) suesimpson@wirral.gov.uk Metropolitan Borough of Wirral Susan Catherine Simpson Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 5 (five) named people over the age of 65 in the category of Learning Disability (LD). 17th January 2007 Date of last inspection Brief Description of the Service: Sylvandale is a purpose built unit, owned and managed by Wirral Social Services. The unit was opened in 1986 to accommodate up to 24 residents with a learning disability. The unit is located in a residential area and is within a 15-minute walk of Bromborough village, which has a range of facilities including a Post Office, banks, shops, pubs and other town amenities. The home is also easily accessible by bus and train. The accommodation at Sylvandale is provided in four units. Each of the units have their own kitchen/dining area, lounge and all bedrooms are single occupancy. At present the home provides accommodation for 22 residents. The fees range from £346.92 - £405.79 Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out one day. During the inspection the inspector toured the building, spoke with some residents and several staff members. A selection of documentation was viewed including resident care files, medication records, and complaints file, staff personnel files, training records and policies and procedures. Certificates relating to Health and Safety were seen. What the service does well: What has improved since the last inspection? What they could do better: All areas of the interior environment require improvement; also the recruitment and retention of staff , especially cleaners / domestics needs improving. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 6 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. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User guide contains enough information to enable service users and their families to make an informed choice regarding the suitability of the service. EVIDENCE: The Statement of Purpose and Service User Guide are detailed and informative, and give prospective residents and/or their relatives a good overview of the home, the accommodation, the staff and qualifications, the meals, social activities, contact numbers for the registered providers and what to do if there are any concerns/complaints about the service. A detailed pre-admission assessment process is in place. The home’s manager carries out assessments once a referral has been made by social services. Mental health, cognitive abilities and compatibility with existing residents are included in the assessment. Staff members have substantial experience in communicating in various ways including Makaton and other picture based communications. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 9 The admission is needs led and both parties are given time to settle and adjust before making any commitment. Prospective residents are offered the opportunity of having a trial visit to the home prior to making a commitment, and can visit the service as often as they need before making up their mind whether it is the right place for them or not. Admissions are not made to the home until this needs assessment has been undertaken. The assessment involves the prospective resident, and to a lesser extent, their family or representative where appropriate. If the assessment has been undertaken through care management arrangements the manager obtains a summary of the assessment and a copy of the care plan from the liaising social worker. All residents have contracts on file signed by relevant parties giving clear details of the terms and conditions of residency. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in Sylvandale encourage the residents to follow an independent lifestyle which includes making decisions and taking responsible risks. EVIDENCE: A selection of resident’s care files and related documentation were examined as part of the ‘case-tracking’ process. The care plans seen were person centred and agreed with each resident, with some residents signing each element themselves. The plans are written in plain language, easy to understand and looked at all areas of the resident’s life; and it was evident that the staff involved individuals in the planning of care that affects their lifestyle and quality of life. Staff have skills and ability to support and encourage residents to be involved in the ongoing development of their plan, and an established key worker Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 11 system allows staff to work on a one to one basis and contribute to the care plan for the individual resident concerned. The care plan is a working document, and since the previous site visit is now reviewed regularly involving the resident and their representatives if agreed. It is kept up to dated and focuses on how individuals will develop their skills and considers their future aspirations. Each care plan includes a detailed risk assessment, which is also reviewed regularly with the resident and their key-worker. Again, this agreement was seen to be signed by some of the residents concerned. Management of risk is positive addressing safety issues whilst aiming for better quality of life. Where limitations are in place, the decisions have been made with the resident and are recorded. There are procedures in place to ensure that residents are informed of their rights to confidentiality, and all staff spoken to were able to evidence their knowledge of the importance of respecting confidentiality. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. 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 exercise choice and flexibility about how they spend their day, inclusion in all home activities is encouraged as these practices promote confidence, independence and socially valued lives. EVIDENCE: Residents are encouraged to participate in activities as they choose. Some residents attend education, day centres and community social groups. Residents are encouraged to participate in maintaining the home with the assistance of staff as necessary, and on the day of inspection one resident was observed being very busy vacuuming her room and carrying out general household chores. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 13 Outreach workers are supposed to assist residents to participate in their interests such as shopping, and other leisure pursuits. This would help promote independence and provides residents with a wider range of staff members of whom to build up relationships with, but despite outreach workers being required by a hospital consultant, this has not been done due to staffing shortages. Examination of care files also evidenced that two new residents in particular would greatly benefit from having this outreach intervention, and urgent consideration must be given to the provision of this service. Residents are encouraged to manage their own personal allowances, with staff providing assistance and support as needed. All finances are recorded with signatures and receipts are obtained for all transactions. Residents are actively encouraged to maintain contact with family members and friends, the home operates a safe open house policy to protect residents and staff. Care staff and residents prepare meals in the home, residents are able to access each house’s kitchen, and are encouraged to participate in all kitchen duties. Risk assessments are completed for residents who participate in this activity. Residents and staff plan the weekly menu together, healthy meals are encouraged to assist in maintaining healthy lifestyles. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s physical and emotional health needs are met in a flexible and sensitive way that maximises resident’s privacy, dignity and independence. Medication management is in accordance with current good practice guidelines which helps safeguard individual residents. EVIDENCE: A number of resident’s care plans and associated records were examined as part of the case tracking process. All the files seen evidenced that the residents have access to health care services both within the home and in the local community; and the majority of residents are able to choose their own GP and attend local dentists, opticians, etc. Documented evidence showed that health needs are monitored, with some monthly reviews, including risk assessments, such as for nutrition. The service is generally able to provide the aids and equipment needed by the residents, but more attention should be given to a couple of the resident’s lifestyle needs regarding external socialization (as discussed above). Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 15 There is evidence in the care plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update of each resident. The staff encourage residents to be as independent as possible, and to take responsibility for their own personal hygiene, with assistance if necessary. Staff spoken to think in a person centred way when considering an individual’s personal care needs, and appeared aware of the need to treat individuals with respect and to consider dignity when delivering personal care. The views of residents are sought in the way all personal care is delivered, and it was observed that staff clearly had a good rapport with all the residents. The manager has a medication policy which is accessible to staff, and medication records are up to date for each resident, and medicines received, administered and disposed of are recorded. The staff understand the need to comply with the administration, safekeeping and disposal of controlled drugs, and follow good, safe practice guidelines. The home has good support from the local pharmacist and medication is only in the home as needed. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy; which clearly defines the procedure, this assists in ensuring residents that their views are listened to and acted upon. EVIDENCE: The home has a satisfactory complaints policy in operation, the home has not received any complaints since the last inspection. The Commission for Social Care Inspection has not received any complaints relating to Sylvandale since the last inspection. The home has an up to date policy on Protection of Vulnerable adults, all staff during the induction process receive training in adult protection, staff are also due to attend further training on adult protection in the forthcoming months. There have been no adult protection referrals made since the last inspection. During the inspection staff were able to inform the inspector what they would do if they were not happy or had concerns, residents who spoke with the inspector stated they had no complaints at present as they were very happy in the home. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This home has not improved the quality of the environment, therefore not providing the residents with a homely place to live. EVIDENCE: A full tour of the premises took place, with all communal areas and individual resident’s bedrooms looked at with the resident’s permission. All residents have their own room, which they are encouraged to personalise with their own memorabilia. Residents are responsible for maintaining their own rooms and communal areas with the assistance of staff if required, and one resident was observed busily cleaning their room themselves. The courtyard has been significantly improved since the previous site visit, as have the gardens to the front, side and rear of the property. Unfortunately Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 18 though, the interior of the home has deteriorated yet again, and the provider has not complied with the twice previously issued requirements. The main findings causing concern are:• Floor coverings in house corridors and some bedrooms very badly stained, worn and damaged • Kitchen units damaged / missing / chipped • None of the cookers work • Wall coverings very badly damaged in all units • Extractor fans throughout building full of black fluff, some not working • Furnishings such as chests of drawers, wardrobes, some beds, sink units, settees, chairs, curtains & light fittings damaged and in poor condition • Uncovered pipes in bathrooms, chipped enamel inside bath • Wooden bath surrounds x 2 rotting • Numerous lights without shades, some without bulbs • Some bedrooms very bare and institutional Also numerous bathmats are in clear need of replacement, communal toiletries should not be left out in bathrooms, and the large trees are restricting the light to a number of rooms. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes recruitment policy is good, all potential staff are fully checked to ensure resident safety is promoted and residents are protected from any risk of harm. EVIDENCE: Staff on induction receive comprehensive training and support, all induction material is signed to ensure all have completed the adult protection protocols. There is on going training being provided for all staff, currently staff are attending training on NVQ courses and resident specific training as needed. A sample of staff personnel files were viewed, all staff are checked against the Criminal Records Bureau. Staff personnel files were found to contain all the required information as required, and they have supervision with the manager at least 6 times per year. This provides staff the opportunity to discuss issues that relate to care being provided. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 20 Staff rotas show that the home is not staffed efficiently, with some attention given to busy times of the day and changing needs of the residents. The staff are very hard working, but cannot be in two places at the same time. This low staffing level cannot provide all the time and attention needed to fully enable each resident to live their lives as far as they wish. The manager and service manager have been trying to address the staff shortage with recent advertising and a recruitment campaign. Also required are domestic staff which are needed as soon as possible to help to improve the internal environment of the home. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed by an experienced and motivated manager. This promotes staff motivation thus providing residents with a committed team to help and support their needs. EVIDENCE: During the inspection it was noted the staff and residents had a good rapport with each other, staff respected decisions made by residents and residents stated all staff were supportive and helpful. Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 22 The home regular reviews all its policies and procedures to ensure they are safe and up to date. The home has a quality monitoring system, this involves staff from Head Office to visit to monitor practices and provisions for care, and an action plan is devised with who is responsible for completing the work and in what time frame. This quality tool is a continuous system to measure services provided and to develop all aspects of care, and the AQAA (Annual Quality Assurance Assessment) required by the CSCI was well completed with all the required information. All documentation and records are held in accordance with the Data Protection Act 1998. Records are held securely and restricted access to files is promoted. Residents are able to view their own files at any time. The homes certificates relating to all aspects of Health and Safety including the Employers Liability certificate were seen, all were found to be in date and appropriate. Sylvandale DS0000035841.V346068.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 Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(d) Requirement The registered person must ensure that all parts of the home are kept clean and reasonably decorated. Previous timescales not met. 2. YA24 23(2)(d) The registered person must ensure that a programme of maintenance and refurbishment is produced and implemented. Previous timescales not met. 3. YA13 12(3) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual plans. The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. 31/10/07 31/12/07 Timescale for action 31/12/07 4. YA33 18 31/10/07 Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 25 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 YA30 Good Practice Recommendations It is strongly recommended that an industrial carpet cleaner (or equivalent) is obtained on a permanent basis for the home. It is strongly recommended that consideration be given to cutting back some of the large trees that overshadow the home, especially certain bedrooms. 2 YA26 Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Sylvandale DS0000035841.V346068.R01.S.doc Version 5.2 Page 27 - 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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