Inspection on 15/02/06 for Sylvandale

This inspection was carried out on 15th February 2006.

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 14/09/07

Sylvandale 17/01/07

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 Les Smith Unannounced Inspection 15th February 2006 09:00 Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 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.V284224.R01.S.doc Version 5.1 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.V284224.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sylvandale Address 191 Spital Road Bromborough Wirral CH42 2AF 0151 666 4648 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) suesimpsonwirral.gov.co.uk Metropolitan Borough of Wirral Susan Catherine Simpson Care Home 23 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (3) of places Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 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. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a half day. Time was spent with the manager and in the office examining records, and policies and procedures. A tour of the home was undertaken with the manager. Residents present in the home and several members of staff were spoken with. What the service does well: What has improved since the last inspection? 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. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 6 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.V284224.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 Prospective residents can be confident that their needs and aspirations will be fully assessed and that those needs can be met through the skills, experience and facilities offered by the home. EVIDENCE: A comprehensive and detailed pre-admission assessment process is in place. The homes manager following referral by social services carries out assessments. Mental health and 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. The home has a wide range of facilities to support residents in maximising their independence and would obtain any specialised equipment if required. There has been an occurrence recently of a gentleman being admitted for respite care without appropriate assessment or discussion with the home. A senior manager notified the home in the morning of 10th February that the resident would be arriving later for two weeks respite care. The resident had previously received respite care at the home at Christmas time. The resident arrived early evening from his care home in Nottingham. There were no notes, care plan or any other information. There were still no notes available for the resident on the 15th February and the inspector was informed that they were arriving later that day. It is to their credit that the staff cared well for the Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 8 resident. The inspector was informed that this was not the first occasion that this had occurred. It is poor practice that puts residents and staff at risk and must not happen again. Prospective residents are encouraged to have trial periods of stay before moving in on a permanent basis and any new admission would be via a phased transitional programme wherever possible. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Residents are well supported by the care planning processes in place and benefit from the emphasis placed upon participation and consultation evident from the positive relationships, which have been formed between the staff and residents. EVIDENCE: Care plans seen were comprehensive and detailed and included a ‘health passport’ containing relevant information, which accompanied the resident when keeping an external appointment. A printout of the NMS for care plans is used as a guide. Care plans were completed by the key worker and agreed with the resident. Action plans are also discussed with and agreed with the resident. Short term and long term goals and coping strategies were clearly stated. Risk assessments and risk management strategies were found to be detailed and reviews were carried out on a monthly basis. There were several files examined that had not been updated in respect of visits by specialist staff and basic observations such as weights. The inspector was informed that this would be addressed as a priority. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 10 Residents’ care plans are kept secure in the individual care units. The residents’ daily routine is clearly documented and the key worker completes daily diary sheets during the day whilst night staff use a separate sheet to detail care given. It is practice to start a new diary sheet each day resulting in large gaps on the sheets. This is not good practice and very wasteful of resources. It was strongly recommended at the previous inspection that entries on the diary sheets should be continuous and that clear dating and timing of entries using the 24-hour format on the sheets be used and this recommendation is made again at this inspection. The majority of residents at Sylvandale have been there a long time and it was clearly evident that staff have the knowledge/information to provide the assistance and communication skills required to support residents to do their own shopping for clothes, items for their rooms and other articles. House meetings are held on a bi-monthly basis and residents attend and participate in these meetings. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Links with the local community are good and enhance the residents’ social and educational opportunities. Meals served at Sylvandale are good and take into account residents personal likes and dislikes as well as special diets. EVIDENCE: Home skills are encouraged e.g. washing and feeding and an individual home skills plan is detailed in the individual care plan. All the units are equipped with a kitchen and basic facilities and kitchen skills are encouraged. Residents are encouraged to develop kitchen skills subject to appropriate risk assessments. The majority of residents attend various day centres on a full or part-time basis. Residents regularly visit local café’s and pubs accompanied by staff. The residents are well accepted in the local community and the inspector was informed that the local population is generally friendly. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 12 Residents who do not attend day centres enjoy television, jigsaws and other facilities according to their ability. Family and friends are encouraged to visit residents in the home. Residents are able to develop and maintain personal relationships with people of their own choosing and guidance is available to help the resident make appropriate decisions. Individualised daily routines are made as flexible as possible and recorded in the care plan. Some residents may choose to help staff with tasks such as laying tables. In addition to the unit kitchens the home has a main central kitchen that serves all the units. Breakfast is served at the individual units; the central kitchen prepares lunch and tea. There is a three-week menu plan that takes account of the individual residents likes and dislikes as documented in the care plan. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents physical and emotional health needs are fully 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 and helps safeguard the residents. EVIDENCE: The majority of residents require assistance with personal care in varying degrees. Documented daily routines and diary sheets clearly evidence the individualised nature of personal care given. Sylvandale liaises with 5 GP practices and district nurses visit as and when required. Visits by doctors and members of the multidisciplinary care team are recorded in the care plans. A staff member accompanies residents to hospital appointments. Residents are supported to see Chiropodists, Dentists and Opticians as and when required. There are no residents self-medicating at the home. Medication for residents is kept in the individual units. The medication ordering and return systems were found to be appropriate and all staff dealing with medications had received relevant training. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Sylvandale has a satisfactory complaints system and policies in place to help ensure that residents are protected from abuse. EVIDENCE: There have been no complaints since the last inspection either to the home or directly to the CSCI. The complaints procedure is displayed in the entrance hall and includes the address and telephone number of the CSCI. The complaint form is also available in Makaton format to enable residents to complete a form with the help of their key worker. The home has a copy of the Wirral Adult Protection policy. Staff members were able to demonstrate a good understanding of abuse and the procedures to follow should they suspect an occurrence. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 The standard of décor and furnishings has deteriorated since the last inspection and is not conducive to a homely, comfortable and safe environment. EVIDENCE: The home is comprised of the four units, which share a common courtyard. The inspector observed that a large table in the courtyard remains badly damaged despite an attempt at repair. This should be replaced or repaired to a satisfactory standard. On the day of inspection the area of the courtyard containing the pool presented risks due to cables for lights and a pump lying across the ground. The damage to the shower room caused by a failure of sealing noted at the previous inspection had been repaired but the water damage to the outside of the room wall had still not been decorated and was left as bare plaster. The standard of furnishings and decoration in resident’s bedrooms was varied. Due to behavioural issues some rooms are decorated and furnished to a basic standard whilst others are highly personalised with linen and soft furnishings chosen by the residents themselves. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 16 Specific items noted by the inspector were as follows: The corridor carpets remain badly stained and worn. The inspector was informed that new floor covering for the corridors is currently being chosen. The recreation room was neither clean nor tidy with many items on the floor. The decoration in general throughout the home is looking tired and worn and the home would benefit from a significant redecoration programme. Bluebell House Carpet in lounge badly marked with cigarette burns Storage cupboard found unlocked Toilet noted to have no toilet roll or hand towels Poppy House The kitchen cupboards badly damaged with missing laminate. Such damage prohibits effective cleaning and is a clear infection control risk Rose House A cupboard used to store items of risk requires a lock to be fitted The standard of cleanliness in the home was varied although it was clear that effective prioritisation was in place. The inspector was informed that significant sick leave had placed a big strain on the service and that it had not been possible to arrange adequate cover for all of the time. Bathrooms, toilets and shower rooms were clean and homely in appearance. Communal lounges are all well furnished with comfortable furniture with television and music facilities provided. A range of adaptations and equipment has been provided to meet the individual needs of residents. These included special bathing facilities, hand and grab rails. The standard of hygiene throughout the home was good. The laundry was equipped with a washing machine that had a sluice facility and washed at the recommended standards. COSHH (Control of substances hazardous to health) assessments have been completed and relevant ancillary staff members have had the appropriate training. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 There are sufficient numbers of competent, qualified staff to support and meet the needs of residents. EVIDENCE: Individual staff files were seen and contained appropriate job descriptions. CRB check reports are sent directly to the Wirral Social Services Personnel Department who then write and inform the registered manager. A copy of this letter is kept on the individual staff file. It was evident that references and other relevant documents are still not being forwarded to the home to be available for inspection. This will now be requirement of this report. Staff members were observed interacting with residents and were clearly approachable by and comfortable with the residents. Personal development portfolios are in place for all members of staff. Training is ongoing. There are currently 6 staff with NVQ2 and a further 2 in progress. Three members of staff have NVQ3 and a further 3 are in progress. The deputy manager has NVQ4 and there is one member of staff currently working towards NVQ4. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 18 Staff supervision records were seen. The inspector was told that supervision was carried out bi-monthly and this was confirmed from the records seen. There has been some slippage in staff supervision due to the manager having been on a three-month secondment and the inspector was informed that this would now be brought up to date. Staff appraisals are carried out half-yearly and these were recorded and seen. The registered manager ensures that all new staff receives appropriate induction training, which is documented, and this was seen. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Residents benefit from a well qualified, experienced manager who is competent to ensure that the health, safety and welfare of residents is promoted and safeguarded. EVIDENCE: The registered manager is experienced in the management of care homes and has an honours degree in Sociology and Psychology from Liverpool University. She is currently completing the registered managers award, NVQ4 and expects to complete in the very near future. The registered manager has just returned to the home following a twelve-week secondment to another home. The registered manager has an open door policy. Staff meetings are held on a bi-monthly basis. Wherever possible residents actively contribute to the everyday running of the home. There are three types of performance review. Surveys are conducted of resident’s families, residents and visiting professionals. Surveys for residents Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 20 are formatted in such a way that residents are able with appropriate support to communicate their opinion. Policies and procedures complying with current legislation and the NMS are formulated and distributed by Wirral Social Services. Residents’ personal files are kept secure in the home in accordance with the Data Protection Act 1998. Pocket monies for two residents were checked against records and found to be correct. Receipts for expenditure are kept and were seen. Fire alarm and emergency lighting checks are appropriately done and recorded. COSHH assessments had been undertaken and cleaning materials were stored in an appropriate place. A fire risk assessment was available and seen, however the assessment was out of date and there was no evidence of a recent review. Gas and electricity safety certificates and a valid public liability insurance certificate were seen. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 21 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 X 2 3 3 3 4 3 5 X 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 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 2 3 X Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2) Requirement The registered manager must ensure that all care plans are reviewed regularly and kept up to date The registered person must ensure that all parts of the home are kept clean and reasonably decorated The registered person must ensure that a programme of maintenance and refurbishment is produced and implemented. The registered person must ensure that all records as detailed in schedules 3 and 4 are at all times available for inspection at the care home by any person authorised by the Commission to enter and inspect the care home. Timescale for action 31/03/06 2 YA24 23(2)(d) 30/04/06 3 YA24 23(2)(d) 30/04/06 4 YA41 17(3)(b) 31/03/06 Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 23 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 YA6 Good Practice Recommendations It is strongly recommended that entries on diary sheets be continuous and all entries be clearly dated and timed using the 24-hour format. Sylvandale DS0000035841.V284224.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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