Care Home: Sylvandale

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What the care home does well Sylvandale care home provides a good level of care to residents accommodated. All residents spoken to and observed were happy with their care and appeared well cared for. Observed interaction between staff and residents was good. The home provides individualised programmes of care and underpins practices with a full range of policies and procedures based on best practice. In particular, the home has a very detailed, documented approach to the healthcare needs of residents to provide full care in this area. The premises are appropriate and there is a full management structure to support staff. What has improved since the last inspection? Since the last inspection the premises have undergone a full refurbishment programme which has led to a great improvement to the physical conditions of the premises. They are now decorated and furnished to a good standard with appropriate floor covering. In addition, the home has appointed more domestic staff which has resulted in a distinct improvement to the cleanliness of the premises. The home has developed activities for certain residents to enable them to access the local community based on individual wishes. What the care home could do better: Within the context of a greatly improved physical environment, the needs to provide extra chairs and lockable facilities in bedrooms so areas are fully suitable for residents. In addition, the activities for disabled residents must be developed so that they remain active in home that these some more the home.Within the context of a generally effective documentation system, the lack of regular reviews for some care plans is a deficit which means that they do not always reflect the current situation. Staff generally feel themselves well supported and trained. However, there is an inconsistency in the amount of formal supervision available that must be addressed for the better direction of staff. In addition, the lack of training documentation and indeed the lack of training in some instances must be rectified for the further development of staff. Most importantly the staffing establishment of this home remains deficient and inconsistent which is detracting from the consistency and reliability of the care being provided and must be resolved. CARE HOME ADULTS 18-65 Sylvandale 191 Spital Road Bromborough Wirral CH42 2AF Lead Inspector John Mullen Key Unannounced Inspection 24th November 2008 09:30 Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sylvandale Address 191 Spital Road Bromborough Wirral CH42 2AF 0151 334 0142 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) suelovato@wirral.gov.uk Metropolitan Borough of Wirral Susan Joy Lovato Care Home 23 Category(ies) of Learning disability (23) registration, with number of places Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate 5 (five) named people over the age of 65 in the category of Learning Disability (LD). 14th September 2007 Date of last inspection Brief Description of the Service: Sylvandale care home is a purpose built unit, owned and managed by Wirral Social Services. The home was opened in 1986 to accommodate up to 23 residents with a learning disability. The unit is located in a residential area and is within a fifteen 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 for single occupancy. In addition, there is a flatlet which the home uses to introduce residents to more independent living. At the time of the site visit the home was providing accommodation for 19 residents. There is a standard charge of £369.64 for permanent residents and £69.55 for residents receiving respite care. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key unannounced inspection of Sylvandale care home which included a site visit. All key standards were assessed in addition to a selection of other standards. This inspection encompassed information received since the last inspection. In addition it included information provided by the home through its preinspection questionnaire and supporting documents. Interviews took place with a manager, a senior care assistant and three care workers. Comment cards were sent to a random selection of staff and health professionals. Residents were spoken to and observed to the extent that their capacities allowed. The premises were inspected and a large amount of documentation examined. What the service does well: Sylvandale care home provides a good level of care to residents accommodated. All residents spoken to and observed were happy with their care and appeared well cared for. Observed interaction between staff and residents was good. The home provides individualised programmes of care and underpins practices with a full range of policies and procedures based on best practice. In particular, the home has a very detailed, documented approach to the healthcare needs of residents to provide full care in this area. The premises are appropriate and there is a full management structure to support staff. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Within the context of a greatly improved physical environment, the needs to provide extra chairs and lockable facilities in bedrooms so areas are fully suitable for residents. In addition, the activities for disabled residents must be developed so that they remain active in home that these some more the home. Within the context of a generally effective documentation system, the lack of regular reviews for some care plans is a deficit which means that they do not always reflect the current situation. Staff generally feel themselves well supported and trained. However, there is an inconsistency in the amount of formal supervision available that must be addressed for the better direction of staff. In addition, the lack of training documentation and indeed the lack of training in some instances must be rectified for the further development of staff. Most importantly the staffing establishment of this home remains deficient and inconsistent which is detracting from the consistency and reliability of the care being provided and must be resolved. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of information on residents means that individualised and appropriate care can be provided. EVIDENCE: An examination of files in the home found a full care needs assessment in each to provide a basis for work with residents. There was always the home’s own assessment which was detailed and appropriate and, with one exception, there was also a full care needs assessment from the referring agency to direct staff. Staff interviewed could give a clear picture of the needs assessments of each resident confirming a good knowledge. None agreed with the comment from a consultant psychiatrist that the home is accommodating residents for whom they are not capable of supporting and felt all residents were appropriately placed. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practices of the home produces an individualised and safe service for its residents. EVIDENCE: An examination of case files in the home found a care plan for each which was individualised and gave direction to staff on the work to be undertaken. However, not all the plans had been reviewed so in some cases their relevance was in doubt. Interviews with care workers found them well aware of the work to be undertaken with each resident and of their specific needs. Interviews with managers and the pre-inspection questionnaire confirmed that there was an individualised approach to care and this was confirmed by the site visit. The home uses a key worker to promote individualised care although interviews with staff confirmed that these had been rearranged recently meaning they are not yet well established in some cases. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 10 The pre-inspection questionnaire confirmed that it is the aim of the home that residents are encouraged to live independently within the context of their individual capacity. An interview with a senior care assistant confirmed that three residents have been moved into more independent living since March 2008 and one is currently being prepared for this possibility. Interviews with managers also showed that residents are encouraged to express choice in such areas as meals, furniture and clothes and could given evidence of these being exercised in such areas as their bedroom furniture. Conversations with residents found them content with their lifestyle although capacity varied considerably and their ability to express views were accordingly limited. An examination of files held by the home found a whole series of risk assessments in each which were specific to individual residents and were comprehensive and had been reviewed on a regular basis to confirm relevance. Interviews with managers and staff showed them very aware of the risk associated with individual residents. In particular, they were very knowledgeable about residents exhibiting challenging behaviour and could show how they were meeting these problems in a positive and effective manner. Only one service user is able to leave the home unescorted and none are self-medicating but the staff could given good reasons why this was the case in the context of individual safety. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an individual lifestyle for residents although activities for some need to be developed so that they are fully occupied in the home. EVIDENCE: The pre-inspection questionnaire stated that residents are engaged in various activities to encourage participation. Interviews with managers and documents seen confirmed that most residents attend a day centre with one resident going to college so that they are active during the day. There were only two residents who currently do not attend some form of day care because of their capacity. The capacity of residents means they are incapable of attending any occupation as only one can leave the home unescorted. Residents spoken to were happy with attending the day centres which they felt were a good outlet for their time. The pre-inspection material included a comment from a consultant psychiatrist that more structured activities for residents who remain in the home are required for their benefit. This Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 12 comment was supported by both the manager and care workers interviewed and borne out by the site visit which revealed some deficits in this area. One care worker stated that there were only two staff who can now drive the minibus and also that the staffing needs of some residents preclude some outside activities. However, the activities book did give examples of a number of activities being arranged although this does preclude some of the more disabled residents in the home. The pre-inspection material stated that residents use local facilities according to preferences so that they are part of the community. Interviews with managers and an examination of an activities folder confirmed that residents do go to local pubs and shops and other relevant facilities as they wish. There have been no reported incidents of local hostility to the home which managers said is well integrated into the local community. On the day of the inspection one resident was being escorted by a member of staff in her own car in the locality which confirmed an active approach. The pre-inspection questionnaire made no particular reference to family links and friendships although there was an emphasis on good relationships with the home confirming a positive approach. An interview with a manager, reinforced by interviews with care workers, confirmed that there are relatively few visits to the home from relatives and friends. The home has no specific rules to exclude families and friends and when the former do attend managers say they are welcomed as part of an overall approach to care. Pre-inspection comments from a consultant psychiatrist and a general practitioner confirmed that the home promotes the choices and responsibilities of residents within a safe environment. Interviews with managers showed that residents are given choices in areas such as food, furniture and clothes and on a tour of the premises specific choices within bedrooms were shown to have been made by residents. The capacity of residents invariably restricts their access to certain areas of the home which could be unsafe for them. However, within this context, examples were seen during the site visit of residents being encouraged to make choices in terms of their activities during the day which were respected by staff. The pre-inspection questionnaire showed that the home looks to promote healthy eating and individual choice in respect of food as part of the overall care provided. An examination of menus showed that choices were available for residents and those residents spoken to said they enjoyed the food in the home. The home has a number of small dining areas as well as a large communal dining room so that meals can be eaten in a number of places. Residents’ files examined showed that residents’ weight is taken on a regular basis as a part of an overall health plan. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good level of personal healthcare support although a greater continuity in the staff group is required to further this. EVIDENCE: The pre-inspection material, including comments from healthcare professionals, confirm that personal support is being provided to a good standard to promote individual care. The site visit confirmed that residents are encouraged to make choices and are dealt with individually and according to their needs. A tour of the premises also confirmed that the home is well equipped to assist residents overcome any physical disability. However, interviews with managers and care workers confirmed that there is a problem with the consistency of the staff group. The manager stated that there were 150 hours of vacancy which are being covered in a number of ways including the use of agency, bank and the home care service. In addition, interviews with care workers showed they had great concerns about the effectiveness of replacement staff in terms of their knowledge of individual residents and their familiarity with their particular needs. This was a widespread feeling amongst Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 14 the staff group and reflected an important concern about the continuity and consistency of care. The pre-inspection questionnaire stated that there were full policies in place to monitor the health needs of residents including a monthly health plan. The site visit confirmed this. Each case file examined had a very detailed document which gave full information on the medication and health needs of residents. Care workers have been given training in these matters and all staff interviewed felt that these arrangements ensured that the health care of residents was being promoted to a good standard. Files seen also confirmed that regular appointments are made with appropriate medical staff to ensure continuing attention to health needs. Comment cards received from a consultant psychiatrist and a general practitioner were complimentary about the home’s attention to the health care needs of residents. Medication sheets seen were correctly completed and a tour of the premises included an inspection of the medication room which was fully equipped and secure for the protection of residents. Incidents reported to the Commission of wrong administration of medicines have been dealt with thoroughly and properly to minimise the possibility of repetition. The home has a full medication policy, which is dated 2003 but is currently being reviewed by Wirral Council to reflect developments since then. An examination of training documents plus interviews with staff confirmed that all who administer medicines have been trained in this subject so that they are competent in this area. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures of the home result in a safe service for residents. EVIDENCE: The pre-inspection questionnaire stated that a full complaints’ procedure is in place and that there has only been one complaint over the past 12 months. The site visit confirmed this. The complaints’ book showed that the complaint had been recorded and fully dealt with according to good practice. No resident spoken to had any complaint to make to the extent that they were able to express their views. Evidence was seen in files that the home does use an advocacy service when necessary so that residents are safeguarded in this area. The pre-inspection questionnaire confirmed that full safeguarding policies are in place and that staff are being regularly trained in this subject for the protection of residents. The site visit showed that instances of safeguarding and of referral to the required authorities were fully documented and in accordance with correct procedure. The documentation seen in the home also showed that notifications on these issues are made to the Commission as required. Interviews with a manager showed that the home was fully aware of its responsibilities in this area which was confirmed by the documentation seen. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are now fully suitable so that residents can be accommodated safely and appropriately. EVIDENCE: The last key inspection was highly critical of the standard of the premises which it felt was not suitable for its purpose. Correspondence with the Commission since has confirmed that the home has been fully refurbished to address this. A tour of the premises found a good standard of decoration, floor covering and furnishing to record an improvement in standards. Externally, some trees have been removed to provide a brighter aspect. The home is divided into four units plus a flatlet and this means that residents are in more homely, smaller environments, which was the view of comment cards received from healthcare professionals. Residents spoken to expressed satisfaction with their accommodation and two in particular showed a degree of pride when showing their bedrooms. One deficit noted is that not all Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 17 bedrooms had both an easy chair and a lockable facility, which is necessary for the complete use of these areas. The pre-inspection questionnaire stated that the standard of hygiene has been significantly improved since the last key inspection. A tour of the premises found the home to be hygienic with appropriate cleaning facilities in place. The home has appointed extra domestic staff since the last inspection and now has four members of the domestic staff on rota, two of whom were on duty on the day of the inspection, which appeared sufficient. The home now presents as a clean, hygienic facility for the care of residents. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The training and formal support of care staff must be both increased and better documented so that they are supported in their work. EVIDENCE: An examination of staff files found that there was a thorough recruitment procedure in place in the home for the protection of residents. All files seen had full application forms, police checks, personal references and checks of identity to confirm a thorough process. Interviews with managers confirmed that this is a matter of routine and that all checks are taken as a matter of course. An interview with a recently appointed member of staff confirmed that she felt that this process was both fair and robust. The pre-inspection material confirmed that Wirral Council has all the required policies and procedures to underpin the process. The pre-inspection questionnaire stated that full training is taking place, including vocational training to underpin practice. Most, but not all, interviews with care workers bore this out with examples being given of core and refresher training being provided in most subjects to the satisfaction of staff. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 19 One care worker said that “training is always there”. However, training records were sparse within the home which meant that training frequency could not be entirely validated. Some care workers felt that they needed refresher training but were unclear about dates. In addition, a care worker appointed in June 2008 had received an induction and medication training but not in other core subjects, including moving and handling and safeguarding adults, which meant she was not fully prepared for her work. A discussion with the manager confirmed that accessing training has been a problem on occasions which meant that training can be delayed. The pre-inspection material made no mention of staff support and the frequency of formal supervision. Interviews with care workers found them happy with the level of support they received but also unsure of the amount of formal supervision they should have. When pressed they gave figures that showed clearly that they did not have formal supervision at the required intervals. An examination of staff files revealed a wide variation in the amount of formal supervision staff were receiving but, essentially, at a frequency that was below what was required to fully support them. In addition, the supervision records of one manager could not be accessed because the registered manager was not present. This is contrary to good practice as it means some records are dependant on individuals rather than processes. Evidence from the files did show that an appraisal system is in place, which, amongst other things identified training needs for the further development of staff. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed effectively for the safe accommodation of residents. EVIDENCE: At the time of the site visit the registered manager was not available and a senior member of staff was in charge of the home. However, since the last inspection the manager has been registered with the Commission and since that time there have been no concerns about the management of this home reported to us. The pre-inspection material confirmed that appropriate management structures are in place and that she is being supported in her role. The site visit confirmed that staff felt the home was being managed in a reasonable manner and that they were being supported consistently in their work. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 21 The pre-inspection material stated that the home wished to develop its quality assurance arrangements through the development of a relative/carer forum. The site visit found that this had not materialised but it did also show that residents’ meetings are taking place to ascertain their wishes. In addition, other elements of a quality assurance system are in place with regular external monitoring of the home to promote good practice. Documents seen show that there is a monthly audit of the home to provide some degree of quality control. The home has had limited input from families and friends but preinspection questionnaires from medical practitioners were very supportive of the home. A tour of the premises found the home a safe environment for the care of residents. A random check of water temperatures found them not too hot and the kitchen and laundry facilities were safe for the residents accommodated. The home had documentation to show regular kitchen inspections, health and safety inspections and checks on utilities to confirm a safe service. An examination of the fire book confirmed that there were drills taking place and a regular check of equipment for the same purpose. Staff interviewed have regular training in health and safety matters although some of these are in need of refreshing to keep them fully up to date. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 4 3 X 3 X 3 X X 3 X Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 18 Requirement The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. (Previous timescale of 31/10/07 not met). The residents’ plan must be regularly reviewed so that it remains up to date. More structured activities for residents during the day are required so that they remain active within the home. A training plan must be implemented and documented so that staff training needs can be assessed and met. Staff must be formally supervised regularly to provide greater direction in their work. Supervision records must be available so that staff support can be checked. Timescale for action 01/03/09 2. 3. YA6 YA12 15(2)(b) 16(2)(n) 01/02/09 01/04/09 4. YA35 18(1) 01/04/09 5. YA36 18(2) 01/04/09 Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 24 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 YA26 Good Practice Recommendations Each bedroom should contain a lockable facility and at least one comfortable chair so the space can be fully used by residents. Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection NW Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sylvandale DS0000035841.V362662.R01.S.doc Version 5.2 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!