Care Home: Sydmar Lodge

Similar services:

• Henry Nihill House
• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)
• Queen Elizabeth House

What the care home does well The home is clean and furnished to a high standard. There are no offensive odours. Residents interviewed are happy with their accommodation and facilities provided.The meals provided are well balanced, varied and those interviewed said they are generally satisfied with these meals. Kitchen staff consult daily with residents regarding their meal preferences and this is being responded to. The care provided is client centred and effort is being made to address the specific care needs and preferences of residents. The manager regularly visits residents and consults with residents and their representatives regarding care needs and concerns. The home has a varied and good range of activities which are appropriate for residents. This ensures that residents are provided with social and mental stimulation. A detailed record of activities engaged in is kept. Jewish holy days and festivals are celebrated at the home. Staff are caring and competent and highly regarded by both residents and relatives. There is an ongoing programme of training to ensure that staff are able to meet the needs of residents. Relatives and other visitors are made welcome at the home. They are given the opportunity to meet with the managers of the home at regular meetings and are invited to a number of formal social events held at the home. What has improved since the last inspection? Improvements have been made in assessments carried out and they contained the required information. Care plans give detailed guidance to staff on how to meet the needs of residents. The arrangements for the administration of medication were satisfactory. Requirements made by the Environmental Health Officer had been responded to and the kitchen has received a 5 star rating. Fire risk assessment had been carried out on residents who wish to keep their bedroom doors open during the day and this is formally recorded in their care plans. This ensures the safety of residents. Appropriate signage is displayed on doors to communal areas including toilets, bathrooms, lounges and the dining room to assist people with a diagnosis of dementia access those parts of the building. The laundry had been cleaned and redecorated to minimise the risk of cross infection. Arrangements had been made to ensure that staff receive essential training A safety inspection of the home`s water supply had been carried out by a competent person to minimise the risk of legionella. What the care home could do better: The dates when complaints are received and responded to must be recorded. This is to ensure that complaints are promptly responded to. Window restrictors in residents` bedrooms must be engaged unless a risk assessment indicates otherwise. This is to ensure the safety of residents. To ensure that fire doors are in working order, weekly checks of the fire doors must be carried out. This is to ensure the safety of residents and all those in the home. Fire training must be provided for all staff. This ensures that staff are fully aware of action to take in the event of a fire. The fire risk assessment must be updated at least once a year or when there are changes affecting fire safety in the home. This is to ensure the safety of residents and all those in the home. A risk assessment must be carried out in relation to the garden shed and the immediate area around it. This is to ensure the safety of residents and visitors to the home. There should be a policy on the use of funds raised by the "Friends of Sydmar Lodge" group. This is necessary to ensure that the fund is not used to purchase items or services which are part of the contractual responsibility of the home. CARE HOMES FOR OLDER PEOPLE Sydmar Lodge 201-205 Hale Lane Edgware Middlesex HA8 9QH Lead Inspector Daniel Lim Unannounced Inspection 8th September 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydmar Lodge Address 201-205 Hale Lane Edgware Middlesex HA8 9QH 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) 020 8931 8001 020 8931 8003 European Care (GB) Ltd Malgorzata Guillen Care Home 57 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 57 11th June 2007 Date of last inspection Brief Description of the Service: Sydmar Lodge is a purpose built care home that is registered to provide personal care for a maximum of fifty-seven service users over the age of sixtyfive. Service users with either dementia or physical frailty may be accommodated. The home is owned and managed by European Care. The company also owns numerous other care homes in this country. The aims and objectives of the home are to offer personalised, individual care to people who live there and to assist them to live as they wish within any constraints placed on them by their physical or mental frailty. The home is a three storey detached house. There are forty-seven single bedrooms and four double bedrooms. These are located across all three floors. All bedrooms have en-suite facilities (a shower, toilet and wash hand basin). There is a lift, which provides access to all floors. On the ground floor, there is an office, a large lounge, a small lounge, diner, bathrooms, communal toilets and residents’ bedrooms. On the first floor, there are communal bathrooms, toilets and residents’ bedrooms. More bedrooms are located on the second floor. The kitchen and laundry room are located in the basement. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 5 There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is situated in a residential area of Edgware with easy access to public transport, shops, restaurants and other community services. The fees of the home range from £730 to £850 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 6 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. This inspection was carried out on 8 September 2008 and took a total of eight and a half hours to complete. A second visit was made on the next day to view documents not examined or available on the first day. We were assisted by the registered manager, Ms Malgorzata Guillen and the programme manager, Mr Chris Ashton. Six residents, two relative and a healthcare professional were interviewed. The feedback received from them was positive and indicated that they were satisfied with the care provided. Completed questionnaires were received from 14 residents, 2 staff and 4 professionals. These were on the whole, positive and indicated that residents were well cared for. Statutory records were examined. These included six residents’ case records, the maintenance records, accident and incident records, financial records, complaints’ records and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen, garden and communal areas were inspected. Six staff were interviewed regarding the care of residents and other areas associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB disclosures, references, supervision and training records were examined. In addition, the minutes of residents meetings were examined. These indicated that residents had been consulted and informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form (AQAA) was received by CSCI. Information provided in the assessment was used for this inspection. What the service does well: The home is clean and furnished to a high standard. There are no offensive odours. Residents interviewed are happy with their accommodation and facilities provided. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 7 The meals provided are well balanced, varied and those interviewed said they are generally satisfied with these meals. Kitchen staff consult daily with residents regarding their meal preferences and this is being responded to. The care provided is client centred and effort is being made to address the specific care needs and preferences of residents. The manager regularly visits residents and consults with residents and their representatives regarding care needs and concerns. The home has a varied and good range of activities which are appropriate for residents. This ensures that residents are provided with social and mental stimulation. A detailed record of activities engaged in is kept. Jewish holy days and festivals are celebrated at the home. Staff are caring and competent and highly regarded by both residents and relatives. There is an ongoing programme of training to ensure that staff are able to meet the needs of residents. Relatives and other visitors are made welcome at the home. They are given the opportunity to meet with the managers of the home at regular meetings and are invited to a number of formal social events held at the home. What has improved since the last inspection? Improvements have been made in assessments carried out and they contained the required information. Care plans give detailed guidance to staff on how to meet the needs of residents. The arrangements for the administration of medication were satisfactory. Requirements made by the Environmental Health Officer had been responded to and the kitchen has received a 5 star rating. Fire risk assessment had been carried out on residents who wish to keep their bedroom doors open during the day and this is formally recorded in their care plans. This ensures the safety of residents. Appropriate signage is displayed on doors to communal areas including toilets, bathrooms, lounges and the dining room to assist people with a diagnosis of dementia access those parts of the building. The laundry had been cleaned and redecorated to minimise the risk of cross infection. Arrangements had been made to ensure that staff receive essential training Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 8 A safety inspection of the home’s water supply had been carried out by a competent person to minimise the risk of legionella. 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. The summary of this inspection report can be made available in other formats on request. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken by the manager or a sufficiently skilled member of the company. This ensures that the home is able to meet the needs of residents. EVIDENCE: The manager stated that prospective residents had been fully assessed prior to admission and these assessments were kept in their case records. The preadmission assessments which were examined were noted to be appropriate and comprehensive. The assessments included details of the personal, mental, Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 11 cultural and spiritual needs of residents. Risk assessments together with strategies for minimising identified risks had also been prepared for residents admitted to the home. The home’s AQAA indicated that residents and their relatives are usually involved in these assessments. This is to ensure that they understand the decisions made. The home manager further stated that relatives and prospective residents are given the opportunity to visit the home prior to admission. Residents in the home were noted to be clean and appropriately dressed. The four residents who were interviewed informed us that they were well cared for and their care needs had been attended to. This was reiterated by two visiting relatives who were interviewed and in completed questionnaires received by us. Comments made by residents included the following : “very friendly and welcoming showing round on first visit” ”difficult to find fault, staff extremely patient and kind”, “well cared for” and “They do a lot more for us than is needed”. The manager stated that the home does not provide intermediate care. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for meeting the healthcare and personal care needs of residents are satisfactory and these are recorded in residents’ care plans. Residents are protected by the home’s satisfactory arrangements for the administration of medication. EVIDENCE: The issue of health and personal care was discussed with residents. They indicated that staff took good care of them and had attended to their personal and healthcare needs. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 13 When interviewed, they indicated that they could see a doctor if they needed to. The manager stated that the GP visits weekly and reviews the medication and treatment of residents. Case records which were examined, contained evidence that residents had access to other healthcare professionals such as the chiropodist, GP and optician. Individual care plans had been prepared for residents. A sample of six care plans which was examined was found to be well prepared. There was documented evidence of regular care reviews. Residents and relatives interviewed indicated that they had been consulted regarding the care provided. Appropriate risks assessments had been prepared for residents. These were of a good standard. We noted that one of the residents whose needs cannot be fully met at the home needed to be transferred to a nursing home. The manager reassured us that arrangements were being made for the transfer. Documented evidence was provided. The medication charts of four residents were examined. These indicated that medication had been administered as prescribed and signed for. The temperature records of the room where medication was stored had been recorded daily. These were satisfactory and no higher than 25 C. This ensures that medication is stored correctly. The manager reassured us that regular medication audits are carried out by her to ensure that medication is administered properly. A visiting healthcare professional was interviewed in the home. She stated that the home maintained closed liaison with her and her instructions regarding the specific care of her clients are followed. The home’s AQAA stated that none of the residents have a pressure sore and there had been fewer falls in the past twelve months. In addition, the home’s AQAA indicated that the home is committed to an anti-discriminatory culture and residents are being cared for with respect and dignity regardless of their background. This was confirmed by relatives and residents interviewed Comments made included: “Yes, staff they are respectful” “They have a good understanding of Jewish culture.” and “Staff treat me with dignity and respectful.” Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience an excellent outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life, meal arrangements and routines of residents are well organised. The views of residents and their relatives are being actively sought when planning the home’s activities and routine. People using the service are given the opportunity to take part in wide range of activities that are imaginative, appropriate and varied. They also have opportunity to maintain important family relationships. EVIDENCE: The home had a varied and comprehensive programme of weekly social and therapeutic activities. The programme was available for inspection and on display along the corridor on the ground floor. The activities’ organiser spoke to us and indicated that the programme of activities had been carefully planned to suit the preferences and needs of residents. She was supported by two volunteers. Activities provided included Jewish religious services, quiz, Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 15 slide shows, exercise sessions, discussion groups, entertainment sessions, and arts and crafts sessions. The home had an activities newsletter. Comments made by residents included the following: “I have been impressed by the enthusiasm of the resident activities organiser and the variety in what is offered.” “Staff are absolutely amazing” “good activities” Residents’ case records included a social care plan with a diary of activities that they had participated in. Jewish religious services and celebrations were regularly held at the home. The manager stated that these were organised by the local rabbi or members of the local Jewish community. Residents interviewed were satisfied with the programme and of the opinion that the activities were appropriate. The activities organiser stated that a men’s group had been organised for male residents and this appeared to be popular. Photos of various activities sessions and pictures painted by residents were printed in the home’s newsletter. The kitchen had been redecorated. It was clean and well equipped. A record of fridge and freezer temperatures had been kept. These were satisfactory. The head chef was knowledgeable regarding her responsibilities and the dietary preferences of residents. She informed us of an area of good practice in which residents are consulted daily by her or her staff regarding their meal preferences and their individual choices are responded to. This was also confirmed by a relative. The minutes of a residents’ meeting indicated that residents were also consulted regarding the meals provided. The menu examined was varied, balanced and reflected the Jewish cultural and religious preferences of residents. The dining area was well organised and spacious. Flowers were placed on individual tables and this made it a pleasant environment for meals. Residents interviewed indicated that they were generally satisfied with the meals provided. The dining room had been provided with air conditioning. The chef informed us that the kitchen had been inspected recently by the local environmental health officer and awarded 5 stars. The manager informed us of another area of good practice in which residents could have their breakfast in bed if they wanted to and breakfast time was flexible and served over a period of two hours (730am – 930 am). Residents confirmed that they had been visited by friends and relatives. Two relatives who were interviewed said they had been well treated and staff were respectful towards them and residents concerned. They further confirmed that Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 16 staff had been sensitive towards residents and they had been kept informed of matters affecting their relatives. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection are on the whole, satisfactory. The required policies and procedures for safeguarding residents were in place and give clear and specific guidance to staff. EVIDENCE: The six residents who were interviewed indicated that they were well treated and they knew who to complain to if they were dissatisfied with the care provided. The home had an adult protection procedure. It included information on examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CSCI. The manager and her staff who were interviewed were aware of the home’s policy and procedures for the protection of vulnerable adults. There was evidence that most staff had been provided with the required training. Several complaints were recorded in the complaints book. There was evidence that these had been responded to. However, the dates when complaints had been responded to or resolved were not always recorded in the book. This is Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 18 needed to provide the required information. The manager agreed that this would be attended to. The activities organiser informed us that relatives and residents had made contributions to a fund set up by the “Friends of Sydmar Lodge”. The fund had been used to purchase various additional items, including pots of flowers for the rear garden. A visitor to the home however, remarked that the purchase of pots of flowers for the garden should have been the responsibility of the home. This was discussed with the activities organiser and manager who agreed that there should be a policy on the use of such funds raised by the group. This is necessary to ensure that the fund is not used to purchase items or services which are part of the contractual responsibility of the home. A recommendation is made for this to be done. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 People who use this service experience an excellent outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean, tidy and furnished to a high standard. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of people who live there. The necessary equipment and adaptations for supporting residents are available. Residents are allowed to personalise their bedrooms. Overall, the home provides a pleasant, comfortable and attractive environment to live in. EVIDENCE: Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 20 All residents interviewed stated that they were happy with the accommodation provided and their bedrooms had been kept clean. Comments made by them and their relatives included the following : “The housekeeping team keep the home beautiful and always smell pleasant.” “Spotless, smart – more like a private hotel” “The laundry is exceptional” “Kept awfully clean!” “It feels more like a five star hotel” The bedrooms, lounges, and other communal areas were found to be clean and cheerfully furnished. No offensive odours were detected. The home has a maintenance person on site. The home’s AQAA stated that new carpets had been provided in some bedrooms communal areas of the ground floor and window frames on the ground floor had been repainted. Armchairs had been professionally cleaned and air conditioning had been provided in the dining room. Bedrooms inspected have en-suite facilities and appeared cosy and comfortable. They had been personalised by residents with their own pictures and ornaments. The manager stated that the floorings in some bedroom had been changed to suit the needs and preferences of residents. Various specialist equipment for the care of residents was available. These included hoists, assisted baths, raised toilet seats, toilet handrails, wheelchairs, special cups and a call system. There is now a new sound system (loop) in the dining room. The gardens had benefited from recent work carried out. It was attractive, colourful and seating had been provided. Pots of flowers were on display. A new path had been laid around the garden. The manager stated that this enabled residents to walk around it and have exercise. The laundry was inspected and we note that it had been redecorated. Laundry staff reported that care staff followed procedures for ensuring that soiled linen and clothes are put into the appropriate bags when sending them to the laundry. Soiled laundry items are subject to a special sluice cycle before being washed further. This ensures effective infection control and protects the health of residents. The required safety inspection had been carried out on the gas, electrical installations and portable appliances and documented evidence was kept in the home’s maintenance folder. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 21 From the complaints record examined, we noted that there had been some plumbing and central heating problems in a bedroom of the home. The manager and programme manager however, reassured us that this had been resolved. No further such complaints were noted. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The service has a good recruitment procedure that is followed in practice. The manager recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are generally satisfied with the staffing arrangements. EVIDENCE: The duty rota was examined. It indicated that in addition to the manager and her deputy, there was normally 8 care staff on the morning shifts, 6 staff on the afternoon and evening shifts and 4 waking night staff. The home also employs support staff including a head chef, kitchen staff, a housekeeper and domestic staff. The manager is aware of the need to keep staffing numbers under review to ensure that the home can continue to meet the changing needs of the people living there. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 23 Six staff who were on duty were interviewed individually on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. There was documented evidence in staff records to indicate that staff had been provided with essential training relevant to their area of work. Five staff records examined (including 3 new staff) indicated that the required recruitment standards and procedures such as obtaining satisfactory CRB disclosures and references had been followed. There was documented evidence of regular formal staff supervision. This was also confirmed by staff interviewed. The supervision notes indicated that staff had opportunity to discuss any work related problems, issues related to the care of residents and their training. The issue of equalities and diversity was discussed with the manager and her staff. Staff demonstrated an understanding of the need to treat all residents sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. They were aware that they must not discriminate against residents and they indicated that this was stressed to them during their induction and regularly by their manager. The four residents who were interviewed indicated that they had been treated with respect and dignity by staff. This was also confirmed by relatives interviewed. Some staff had not attended training in adult protection. The registered manager reassured us that training had been booked. She provided documented evidence of this during the inspection. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People living in the home can be assured that the home is well run and the manager has skills and ability to deliver a good quality of care. Residents and their representatives are consulted regarding the care provided and the management of the home. EVIDENCE: Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 25 The registered manager was found to be knowledgeable regarding her role and responsibilities. She had received her RMA (Registered Manager’s Award). Residents, relatives and staff were of the opinion that the home is well managed and the manager is approachable and caring. There was evidence that residents are consulted regarding the management of the home. Regular residents’ and relatives’ meetings had been held. The minutes of the latest residents’ meeting were examined. It indicated that residents were informed of progress in the home and their concerns had been responded to. Positive comments regarding the management of the home was noted. A relatives’ survey had been carried out recently and there was evidence that they were generally satisfied with the management of the home. The manager stated that to improve the quality of care provided, occasional random checks are also carried out by her during the night to ensure that the needs of residents are being attended to. In addition, the manager stated that she regularly talks with residents and their representatives. This was also confirmed by relatives and staff who were interviewed. Weekly fire alarm checks and regular fire drills had been documented. The home had a fire risk assessment. The fire risk assessment had however, not been updated in the past eighteen months. This is required to ensure that the assessment is up to date. The accident records were appropriately filled in and the CSCI had been informed of significant accidents and incidents. No fire training had been organised in the past eighteen months although new staff had been recruited in this period. This is required to ensure that staff are fully aware of action to take in the event of a fire. The manager agreed that training would be organised. Checks had been made to ensure that the electromagnetic doors were working. However, these had not been done on a weekly basis since 17 July 2008. Weekly checks are necessary to ensure that any malfunctioning is readily identified and repaired. The home had a current certificate of insurance. The financial records of three residents were examined. These were noted to be well maintained. Receipts had been obtained for transactions made on behalf of residents. On a tour of the premises, it was noted that window restrictors were not engaged in three of the bedrooms. These must be engaged to ensure the safety of residents. This was brought to the attention of the manager and programme manager who agreed to ensure that windows are restricted unless a risk assessment indicates otherwise. A visitor informed us that the garden shed and the area around the garden shed posed a health and safety risk to residents. The garden shed contained Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 26 garden furniture and was not locked. The area around it had some excess items and brambles. This was brought to the attention of the manager and programme manager. They agreed to carry out a risk assessment and ensure that the area is made safe. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X X 3 X x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 2 Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 28 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 OP16 22 The dates when complaints are received and responded to must be recorded. This is to ensure that complaints are promptly responded to. 2 OP38 13(4)(6) Window restrictors in residents’ bedrooms must be engaged unless a risk assessment indicates otherwise. This is to ensure the safety of residents 3 OP38 18(1)(c) 23(4)(d) To ensure that fire doors are in working order, weekly checks of the fire doors must be carried out. This is to ensure the safety of residents and all those in the home. 4 OP38 18(1)(c) Sydmar Lodge Standard Regulation Requirement Timescale for action 13/10/08 13/10/08 13/10/08 13/11/08 Fire training must be provided DS0000065700.V371400.R02.S.doc Version 5.2 Page 29 for all staff. 23(4)(d) This ensures that staff are fully aware of action to take in the event of a fire. 5 OP38 18(1)(c) 23(4)(d) The fire risk assessment must be updated at least once a year or when there are changes affecting fire safety in the home. This is to ensure the safety of residents and all those in the home. 6 OP38 13(4)(c) A risk assessment must be carried out in relation to the garden shed and the immediate area around it. This is to ensure the safety of residents and visitors to the home. 13/10/08 20/10/08 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. OP16 Refer to Standard Good Practice Recommendations There should be a policy on the use of funds raised by the “Friends of Sydmar Lodge” group. This is necessary to ensure that the fund is not used to purchase items or services which are part of the contractual responsibility of the home. Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sydmar Lodge DS0000065700.V371400.R02.S.doc Version 5.2 Page 31 - 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!