Care Home: Sycamore Lodge

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What the care home does well Before a person is offered a placement at Sycamore Lodge an assessment of their needs and personal expectations are made to make sure the home can meet them. Prospective service users are encouraged to visit prior to moving in so they have the opportunity to `test` drive the home. As much as possible service users are involved in the development of their care plans and risk assessments and are supported to play an active role in reviewing their care and support at regular intervals. Records show each service user has an activity plan and calendar, which provides information about activities enjoyed and actual activities undertaken on a weekly basis. Activities include daily living skills such as grocery shopping, domestic duties and attendance at specialised day services. Routines are flexible to support service users make decisions about what activities they wish to take part inSycamore LodgeDS0000069979.V378057.R01.S.docVersion 5.3Records show service users are supported to access health care services to maintain their physical and mental wellbeing. Records also show that guidance and support are sought from specialist services when specific care needs are identified. Policies and procedures are in place that gives clear guidance and direction to the manager and staff team on how to report allegations of abuse, neglect or poor care practices. The physical environment of the home is appropriate to the specific needs of service users the building is well maintained. The manager and the company who own and run Sycamore Lodge support the staff team to access training to enable them to provide appropriate care and support. There are management systems in place, which promote the safety and welfare of service users. What has improved since the last inspection? The manager and the staff team have worked hard to improve the level of information recorded in service users support plans. This enables the staff team to offer a person centred service and to recognise service users as individuals. The manager has proactively worked to improve the communication between the management team and the staff team. This results in service users benefiting from a service that is more responsive to their needs and any presenting difficulties. What the care home could do better: More detailed information about service users nursing care needs must be included in support plans this is to ensure their healthcare needs are effectively and safely managed. We discussed with the manager the need to review some of the quality assurance systems currently being used. To make sure the views and opinions of service users, their representatives and other professionals involved in theirSycamore LodgeDS0000069979.V378057.R01.S.doc Version 5.3 care are sought. This is to ensure the service being provided by the home is continuing to meet service users` needs and expectations. Key inspection report CARE HOME ADULTS 18-65 Sycamore Lodge 54 Greenheys Road Wallasey Wirral CH44 5UP Lead Inspector Helen Carton Key Unannounced Inspection 19th October 2009 10:00 Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Address 54 Greenheys Road Wallasey Wirral CH44 5UP 0151 638 7625 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) cath.keenan@alternativefuturesgroup.org.uk Alternative Futures Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with Nursing- code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of people who can be accommodated is: 12 Date of last inspection 30th September 2008 Brief Description of the Service: Sycamore Lodge is a single storey building separated into two units. Both have their own lounge, kitchen and bathroom areas. Specialist lifting and bathing equipment is available for use by service users. All bedrooms are single occupancy. There is a car park area to the front of the building and two separate garden areas at the rear for service users use. A copy of the most recent Care Quality Commission (CQC) report is available from the manager of the service. Alternative Futures who own and run Sycamore Lodge will provide information about inspections on request. The current weekly fee to live at Sycamore Lodge is £1080.00. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. As part of the inspection process we sent the manager of Sycamore Lodge an Annual Quality Assurance Assessment (AQAA) document, which was completed prior to our visit to the home. This document was to provide information about the service at the home and to tell us where they felt they had made improvements to the way they support service users and the staff team. As part of this process surveys were sent to six service users and eight members of the staff team a total of ten responses were received. We visited Sycamore Lodge to enable us to look at records and to discuss how the home supports service users in all aspects of their lives. Part of this process involved speaking with the manager, members of the staff team and spending time with service users to find out their views on living at the home. We spent approximately eight hours at the home. What the service does well: Before a person is offered a placement at Sycamore Lodge an assessment of their needs and personal expectations are made to make sure the home can meet them. Prospective service users are encouraged to visit prior to moving in so they have the opportunity to test drive the home. As much as possible service users are involved in the development of their care plans and risk assessments and are supported to play an active role in reviewing their care and support at regular intervals. Records show each service user has an activity plan and calendar, which provides information about activities enjoyed and actual activities undertaken on a weekly basis. Activities include daily living skills such as grocery shopping, domestic duties and attendance at specialised day services. Routines are flexible to support service users make decisions about what activities they wish to take part in Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 6 Records show service users are supported to access health care services to maintain their physical and mental wellbeing. Records also show that guidance and support are sought from specialist services when specific care needs are identified. Policies and procedures are in place that gives clear guidance and direction to the manager and staff team on how to report allegations of abuse, neglect or poor care practices. The physical environment of the home is appropriate to the specific needs of service users the building is well maintained. The manager and the company who own and run Sycamore Lodge support the staff team to access training to enable them to provide appropriate care and support. There are management systems in place, which promote the safety and welfare of service users. What has improved since the last inspection? What they could do better: More detailed information about service users nursing care needs must be included in support plans this is to ensure their healthcare needs are effectively and safely managed. We discussed with the manager the need to review some of the quality assurance systems currently being used. To make sure the views and opinions of service users, their representatives and other professionals involved in their Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 7 care are sought. This is to ensure the service being provided by the home is continuing to meet service users needs and expectations. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 8 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 Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ needs and lifestyle choices are assessed prior to an offer of a placement being made this enables them to be confidant Sycamore lodge can meet their holistic needs. EVIDENCE: The statement of purpose provides good information about the facilities prospective service users can expect to receive if they decide to move into Sycamore Lodge. The service user guide is in an easy read format with photographs used as prompters to support service users in their understanding of the information. Prior to a person moving into the home a full assessment of their needs and lifestyle choices is undertaken by a member of the management team. The admissions process looks at the skills, qualifications and experience of the staff team to ensure they are able to support a prospective service user safely and appropriately. An important part of the assessment process is the identification Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 10 of nursing needs and the compatibility with those people already living at Sycamore lodge. Since the last inspection visit two people have moved into the home with documentation showing full and detailed assessments took place prior to an offer of a placement being made. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users preferred routines, lifestyle choices and mental wellbeing is supported by the homes care planning and risk management strategies. Resulting in service users being treated as individuals and living in an enabling environment. EVIDENCE: A sample of support plans were viewed and found to be person centred and where possible agreed with service users. Information held in these plans overall provided good information about how service users wish to be supported including their social and emotional needs. However there was little detailed information regarding the nursing needs of service users and the level and type of nursing care being provided. We discussed this issue with the manager and deputy manager advising them nursing care needs must be Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 12 clearly identified with specific guidance provided to ensure service users receive appropriate and safe treatment and support. Detailed information is held about other professional’s input and support to ensure service users are supported in a consistent and safe way. Where necessary risk assessments are carried out with management support plans produced and reviewed regularly to ensure service users are supported to undertake activities safely and to enable them to remain as independent as possible. Service users have a key worker who is involved in the development and reviewing of their support plans. As part of this process key workers spend time with service users to ensure the support being offered is meeting their changing needs and lifestyle choices. We discussed with the manager the need to streamline some of the information held in care files to ensure the most up to date information is easily accessible to the staff team. We received an email on the 27/10/09 to confirm the work to review how information is stored has commenced. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 13 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): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ care needs and lifestyle choices are being proactively met resulting in service users being confident their daily experiences of living at Sycamore Lodge will be positive. EVIDENCE: Records show service users have activity plans and calendars, which provide information about activities enjoyed and actual activities undertaken on a weekly basis. Activities include daily living skills such as grocery shopping, domestic duties and attendance at specialised day services. Routines are flexible to support service users make decisions about what activities they wish to take part in. We spent time with service users and observed members of the staff team supporting them to make choices about their daily routines. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 14 Service users are supported to remain as independent as possible and to maintain and in some instances develop daily living skills such as preparing food for meals, making themselves drinks. Activities are planned on a daily basis with key workers involved in the planning and risk management of activities to ensure service users are supported appropriately while out in the community. For those service users who are physically frail support is offered to ensure they are involved in stimulating activities within the home. Social and leisure activities promote a therapeutic environment that encourages service users to develop positive relationships with fellow service users and the staff team. Members of the staff team spoken with during the visit made the following comments: “We are supporting service users to be more active in the community which they are enjoying and it is giving them more confidence in everything they are doing”. “We spend much more quality time with those service users who are more physically frail which I think is making a big difference to their emotional wellbeing”. Service users support plans and person centred plans have detailed information about the significant relationships in their lives and the role the staff team play in supporting them. Sycamore Lodge employ catering and domestic staff to ensure service users receive good quality food and their environment is clean and tidy. Each service user has a menu plan which provides detailed information about food likes and dislikes and meals they enjoy. Special diets are catered for with information from dieticians and other healthcare services available for the nursing staff to access if required. The manager told us service users are supported by their key workers to raise issues regarding the running of the home and are visited regularly by the area manager to ensure their needs and expectations are being met. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users personal and healthcare needs are met by a supportive and flexible care service. EVIDENCE: Service users receive support with their personal care needs using a person centred approach with specialist healthcare and dietary needs recorded in individual health action plans. However support plans detailing nursing care support and monitoring are limited and do not provide clear information or guidance for the staff team to follow. This issue was discussed with the manager and deputy who agreed to discuss this issue with senior managers from the organisation and review the content of the current healthcare plans. Records show all service users are regularly reviewed by their GPs, optician podiatrist and psychiatric services based at Ashton House. Daily records Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 16 provide brief information about any healthcare concerns and appointments attended and direct staff to individual healthcare files. Members of the staff team in surveys returned to us made the following comments: We provide effective person centred care for people with a learning disability and complex physical and mental health problem. We find creative ways to support people. “We are given up to date information about the care needs of the people we support. There is detailed information held in support plans about how service users like to be supported with their personal care including preferred shampoos, deodorants and the type of clothes they like to wear. This supports the staff team to promote service users rights to receive an individualised care service and to have their decisions and lifestyle choices respected. Qualified nurses administer service users medication. We looked at a sample of medications and the accompanying Medication Administration Record sheets, overall they were well maintained. On a small number of occasions medication received into the home had not been fully documented. The manager told us this issue would be discussed with individual members of staff team. The medication is securely stored with a clear procedure for the staff team to follow whilst administering medication. Information sheets about all medication administered is available as reference material. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies, procedures and working practices are in place to ensure service users rights as citizens are promoted and protected. This results in service users living in a safe environment that respects their individual needs and lifestyle choices. EVIDENCE: The statement of purpose and service user guide provides information about the complaints procedure and the responsibility of the provider to provide a safe environment. Since the last site visit the management team have produced a DVD providing service users, families and friends with information about the complaints procedure. All members of the staff team including the manager have undertaken safeguarding adults training within the last 12 months. Policies and procedures are in place that gives clear guidance and direction to the manager and staff team on how to report allegations of abuse, neglect or poor care practices. There have been two formal complaints made to the home, which have been satisfactorily resolved, and 17 safeguarding referral made since the last inspection visit to Sycamore Lodge. The management team have ensured all Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 18 correct reporting and investigating procedures have been carried out to maintain the safety and welfare of service users. Detailed records are kept at the home of all complaints and allegations with outcome information held at the company head office. The Care Quality Commission has been kept informed of all issues and outcomes of investigations. Where shortfalls have been identified the management team and the company have acted appropriately and in the best interest of service users. There has been no deprivation of liberty safeguarding referrals made by the home or any other agencies regarding the welfare of service users living at Sycamore Lodge. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sycamore Lodge provides an adequate living environment for service users, which meets their physical and social needs. EVIDENCE: The physical environment of the home is appropriate to the specific needs of service users the building is well maintained. The communal areas are pleasantly decorated and furnished to a good standard with photographs of service users and arts and craft work completed by them being displayed. Each service user has their own bedroom, which is personalised to reflect their hobbies and interests. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 20 Health and safety information regarding the environment is easily accessible to the staff team including infection control policies and procedures and emergency contact numbers for utilities and equipment. The service is split into two units with each having a lounge/ dining area and separate specialised bathing facilities. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by a skilled and competent workforce resulting in them receiving person centred support in an environment that respects and values them as individuals. EVIDENCE: Records show and discussions with the manager and comments made in returned surveys that the staff team are supported to undertake training to enable them to offer appropriate care and support to service users. Training records show the company and the manager remain committed to support the staff team to undertake internal and external training courses including National Vocational Qualifications in care. The staffing rota indicates the manager is using the nursing and care staffing hours effectively and flexibly to meet the needs of service users. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 22 The recruitment and selection procedures in place provide safeguards to service users to ensure they are supported by suitably skilled and competent people. We discussed with the manager the need to hold detailed records regarding nursing students who carryout placements at the home. This is to ensure service users safety and wellbeing is protected and promoted. Members of the staff team spoken with during the visit made the following comments: “Since J came as manager things have really improved the communication between us and the management team has really improved”. “Since J came to work here I am now enjoying my work again and I believe service users are benefiting from a more confident staff team”. We observed service users being supported by members of the staff team in a sensitive and caring manner. Service users appeared relaxed and comfortable spending time with members of the staff team. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems within the home promote the health, safety and wellbeing of service users. EVIDENCE: An application to register the manager with CQC has been received and is currently being processed. She has appropriate qualification and experience and has over 15 years experience in the nursing and care sectors. Records show she undertakes regular training to support both aspects of her role, managing the service and offering direct care and support to service users. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 24 There are management systems in place, which allows the running of Sycamore Lodge to be audited including national quality assurance systems, which seek out the views of other stakeholders. We discussed with the manager the need to look at ways to engage on a local level with professionals involved in supporting service users and visitors to the home to seek out their views. This is to ensure the service provided by the home meets service users needs and expectations. She agreed to look at this and discuss it with senior managers from the organisation. Health and safety records are well maintained with safety checks and inspections being carried out at the required intervals. Information gained from returned staff surveys indicates the staff team feel supported by the manager and feel they receive sufficient information to support service users safely in their daily lives. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 25 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 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Version 5.3 Page 26 Sycamore Lodge DS0000069979.V378057.R01.S.doc No 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 YA19 Regulation 15 Requirement Service users nursing care needs must be fully documented with clear guidance provided to the staff team to ensure they receive appropriate and safe support. The manager should ensure the placing organisation provides safety check information regarding student nurses undertaking a placement at the home. The in house quality assurance systems must be reviewed. This is to ensure information is gained from stakeholders involved in Sycamore Lodge rather than at an organisational level. This will ensure the person centred focus of the service is maintained. Timescale for action 30/12/09 2. YA34 18 30/12/09 3. YA39 24 30/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 27 No. Refer to Standard Good Practice Recommendations Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 28 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Sycamore Lodge DS0000069979.V378057.R01.S.doc Version 5.3 Page 29 - 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!