Inspection on 20/10/05 for Sylvandale

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Sylvandale 14/09/07

Sylvandale 17/01/07

Sylvandale 15/02/06

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Sylvandale 191 Spital Road Bromborough Wirral CH42 2AF Lead Inspector Les Smith Unannounced Inspection 20th October 2005 09:45 Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 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.V259323.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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.V259323.R01.S.doc Version 5.0 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.V259323.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The matters detailed in the schedule of requirements must be completed in the stated timescales. The service should at all times employ a suitable qualified and experienced manager who is registered with the National Care Standards Commission. Following the proposed review of the learning disability division, a written account of the service provided at Sylvandale is to be forwarded to the National Care Standards Commission. This information is to be provided by 30 March 2004. 7th March 2005 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. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 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. Two residents and two 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.V259323.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Prospective residents have access to all the information they need to make an informed decision about where they want to live and be confident that their needs and aspirations will be met. EVIDENCE: The combined Statement of Purpose and Service User Guide are comprehensive and include all relevant information about the home. The document also includes leaflets and forms e.g. complaint form in Makaton format so that prospective residents are actively involved in the choice of home. A new pre-admission assessment is now in place. The homes manager following referral by social services carries out assessments. Mental health Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 8 and cognitive abilities and compatibility with existing residents is included in the assessment. Staff members have the experience, skills and knowledge to communicate with and deliver the care and support which the home provides. Prospective residents are encouraged to have trial periods of stay before moving in on a permanent basis. Residency contracts were seen which detail the terms and conditions. A copy of the contract is also available in the Service Users Guide. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 10 stated. Monthly reviews clearly evidenced the involvement of the resident, relatives and the multidisciplinary team. Risk assessments and risk management strategies were found to be detailed and reviews were carried out on a monthly basis. 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. On the day of inspection two members of staff were taking a resident out for lunch. House meetings are held on a bi-monthly basis and residents attend and participate in these meetings. 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 book to detail care given. It is practice to start a new diary sheet each day resulting in large gaps on the sheets. It was strongly recommended by the inspector 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. The use of the night book to contain detailed care information about more than one resident is not in accordance with the Data protection Act 1998. It was also strongly recommended that the use of the night book be discontinued and that all entries be made on the resident’s individual diary sheet and that black pens be used rather than the red that is the current practice. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) 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. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 12 There are healthy, nutritious meals served at Sylvandale that take into account residents personal likes and dislikes. 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. 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.V259323.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 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 safeguards 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 DS0000035841.V259323.R01.S.doc Version 5.0 Page 14 Sylvandale liaises with 5 GP practices and district nurses visit as and when required. At the time of this inspection the flu vaccination programme was in progress. Visits by doctors and members of the multidisciplinary care team are recorded in the care plans as are visits by specialist nurses such as the Parkinson nurse. 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. Prescribed items are now printed on the MARS sheets in accordance with good practice guidelines. Sylvandale has a newly revised policy and procedure on aging, death and dying. This is completed with the resident and kept in the care plan. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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: 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 registered manager has recently downloaded the most recent Wirral Adult Protection policy. This has been distributed to each unit for staff to read and sign as having been read. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 Sylvandale provides a safe well-maintained environment that meets resident’s needs and allows them to live in safe, comfortable surroundings. EVIDENCE: The home is comprised of the four units, which share a common courtyard. Gardens at the rear of the home are well maintained ensuring that residents can derive benefit from them. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 17 On the day of inspection the home was clean, tidy and appeared well maintained. The inspector observed that a large table in the courtyard was badly damaged and was told by the registered manager that relevant repair was in progress. A shower room in one house had leaked due to a failure of sealing which resulted in damage to adjacent decoration. This had been reported and repair and redecoration of the damaged area was in hand. 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. With the exception of the shower room mentioned earlier 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, bed rails and a special chair for a resident with Parkinson disease that also serves as a bed. 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. The registered manager had downloaded updated policy and procedure for the prevention and spread of Methicillin Resistant Staphylococcus Aureus (MRSA) and Hepatitis B on the day of this inspection. This will now be cascaded down to all staff. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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 will be a recommendation of this report that a copy of all relevant documents be made available to the registered manager so that they are available to be seen at future inspections. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 19 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 5 in progress. Three members of staff have NVQ3 and a further 6 are in progress. The deputy manager has NVQ4. Staff supervision records were seen. The inspector was told that supervision was carried out bi-monthly and this was confirmed from the records seen. Staff appraisals are carried out half-yearly and these were recorded and seen. The registered manager ensures that all new staff receive appropriate induction training, which is documented, and this was seen. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 21 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 undertaking the registered managers award, NVQ4 and expects to complete this before Christmas this year. 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 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. However, the use of the night record book, as per the comments made earlier in this report does not comply. 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. On the day of this inspection the home was displaying an invalid public liability certificate. The registered manager was able to obtain a copy of the valid certificate. A fire risk assessment and gas safety certificate were not available. The registered manager assured the inspector that the relevant work had been done but as with the public liability certificate the documents had not as yet been forwarded to the home. The registered manager will forward the relevant certificates as soon as they are available . Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 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 37 3 38 3 39 3 40 3 41 2 42 3 43 3 Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 3 3 3 3 3 3 3 3 3 3 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 23 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 Regulation 23(4)(5) Requirement The registered manager must provide copies of the Fire Risk Assessment and Gas Safety Certificate. Timescale for action 30/11/05 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 YA41 Good Practice Recommendations It is strongly recommended that all comments relating to a resident are made on the appropriate diary sheet and that the use of a book for such comments at night be discontinued. It is recommended that all entries be made in black ink. The use of a red pen for night staff entries is not best practice. It is recommended that entries on diary sheets be continuous and all entries be clearly dated and timed using the 24-hour format. DS0000035841.V259323.R01.S.doc Version 5.0 Page 24 2 YA6 3 YA6 Sylvandale 4 YA34 It is strongly recommended that copies of all relevant documents be forwarded to the registered manager so that they are available in the personal staff files It is strongly recommended that copies of appropriate documents e.g. public liability certificate are forwarded to the registered manager in a timely fashion so that they are available to be inspected/displayed 5 YA43YA42 Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI. Sylvandale DS0000035841.V259323.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!