Inspection on 15/11/07 for 45 Sycamore Grove

This inspection was carried out on 15th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

45 Sycamore Grove 03/05/07

45 Sycamore Grove 08/11/06

45 Sycamore Grove 23/01/06

45 Sycamore Grove 05/07/05

45 Sycamore Grove 10/03/05

45 Sycamore Grove 28/01/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Sycamore Grove (45) 45 Sycamore Grove Trowbridge Wiltshire BA12 9LE Lead Inspector Sally Walker Unannounced Inspection 15 November 2007 09:10 th Sycamore Grove (45) DS0000028260.V349557.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 Sycamore Grove (45) DS0000028260.V349557.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. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Grove (45) Address 45 Sycamore Grove Trowbridge Wiltshire BA12 9LE 01225 760956 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) Ordinary Life Project Association Mrs Keri Hendy Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 Brief Description of the Service: 45 Sycamore Grove is one of a number of care homes in Wiltshire that are run by the Ordinary Life Project Association (OLPA). 45 Sycamore Grove is a detached bungalow in a residential area of Trowbridge. Trowbridge College is nearby and there is a convenience store at the end of the road. Each service user has their own room. There is a lounge and a dining room for communal use. The home has a domestic style kitchen, with a separate laundry and utility area. Service users receive support from a manager and permanent staff team. There is at least one person working in the home throughout the day. Extra staff are deployed at certain times. Information about the service is available in the home’s ‘Statement of Purpose’. Information about current fee levels can be obtained directly from the home. Copies of inspection reports are available from the OLPA head office at Beckford House, Gipsy Lane, Warminster, Wiltshire, BA12 9LR. They are also available through the Commission’s website: www.csci.org.uk Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 15th November 2007 between 9.10am and 2.05pm. We completed the site visit on 19th November 2007 between 9.15am and 11.45am. Mrs Hendy was present during the inspection although on the first day she had two appointments. We spoke with two service users and three staff. We made a tour of the building. Two service users showed us their bedrooms. We looked at service users files, staff training and recruitment files, risk assessments, medication administration records and menus. As part of the inspection process survey forms were sent to the home to gain the view of service users, families and healthcare professionals. Comments are to be found in the body of this report. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Service users are encouraged to contribute to goal planning. Service users make decisions about what happens from day to day. Staff record good details about what service users have achieved during the day. Service users are well known to staff. Service users follow their own routines and have separate activity programmes. Service users make good use of local facilities and plan their weekly activity and leisure programme. Service users choose their weekly individual menus with staff encouraging a healthy diet. Care plans show good evidence that service users are encouraged to communicate and make decisions about their daily lives. Service users maintain regular contact with family. Concerns about service users healthcare needs are promptly referred to relevant healthcare professions. Health and medication is regularly reviewed. Staff are familiar with the local Safeguarding Adults policy on reporting allegations of abuse. Service users bedrooms are decorated and furnished to reflect their individual personality. Their private space is respected by staff. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Different aspects of service users care plans should relate to each other. There should be clear cross-referencing detail. Risk assessments must be clear about whether service users can bath alone or whether they must never be left alone when bathing. Handwritten entries in the medication administration record should be witnessed, signed and dated by two staff. If a medication is prescribed to be taken only when required, the care plan must state what circumstances trigger an administration. The medication file could contain the section of the medication policy that states what to do if an error occurs. The home must tell us if there are any occurrences in the home that affect the service users. This relates to the break down of the central heating boiler. As well as the training provided by the organisation, staff should have access to external training related specifically to working with people with learning disability. A checklist to accompany copies of documents and information about staff recruitment should ensure that Mrs Hendy knows that new staff have undergone Criminal Records Bureau and Protection of Vulnerable Adults list checks. Please contact the provider for advice of actions taken in response to this Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 7 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. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 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 Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 did not apply at the time of this inspection as no new service users had moved to the home. Quality in this outcome area is not able to be determined. This judgement has been made using available evidence including a visit to this service. Current service users have lived at the home for more than 4 years. Service users experiences of being provided information when moving in were mixed. EVIDENCE: In a survey form one service user said that they had been asked if they wanted to move into the home. Another service user said no to the question. To the question about whether they received enough information about the home before they moved in order to decide if it was the right place for them, one service user said yes and one said no. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 10 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users contribute to goal planning. They are supported to make decisions about their lives. Risk assessment does not restrict service users from experiencing a full and active lifestyle. EVIDENCE: Action had been taken to address the recommendation that the system of Shared Action Panning is consistently completed with each service user. A new system had been introduced entitled ‘Person Centred Planning’. Keyworkers are allocated one to one time with service users to discuss the different aspects of their care and support. This also meets the recommendation that one to one time activities are consistently maintained so that service users participation can be accurately monitored. Mrs Hendy monitors the reports that keyworkers make of this time with service users. Mrs Hendy told us that changes to care plans were discussed at staff meetings. Each file had a review sheet to show regular review of the plans. Each file had a good pen picture of Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 11 the service users’ history and current needs. There was a list of areas staff should consider when care planning with service users. This included: healthy body, expressing individuality, friendships, learning opportunities, leisure, choice and communication. The daily records showed good details of what service users had been involved in during the day. There were detailed records of meals taken, conversations and decision-making, visits and trips in the locality and leisure activities. Although needs were set out in the plan, there was not necessarily always clarity or cross-referencing with other elements of the plan. For example, one care plan stated “needs boundaries” but it was not clear what this meant. There was an isolated statement that staff must “restrict bedtime”. It was only by looking through all of the different sections of the file that these statements were clarified. We had discussions with Mrs Hendy about different formats for recording and rationalising information about service users needs and how they are to be met and monitored. We found good guidance on how service users communicate. Some service users used Makaton gestures. It was clear from daily reports that service users are encouraged to communicate and make decisions about their daily lives. Service users decided how they spent their day if they were not involved in work or college. Staff supported service users to plan their week of activities and leisure time. Mrs Hendy was in the process of reviewing all the individual risk assessments. These included use of equipment, going out without staff, bathing and use of the kitchen. There were locks on bedroom doors although not all current service users wanted to have their own key. In the survey form service users were asked if they make decisions about what they do each day. Both said they sometimes decided. In a survey form one of the relatives wrote: “Actions agreed at annual review meetings are not always carried out.” Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 12 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 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are involved in their own different, separate activities, some they achieve with staff support. Service users make good use of community facilities. Service users retain close contact with family. Service users retain some responsibilities for their daily lives. Staff uphold service users rights. Service users are encouraged to follow a healthy diet. EVIDENCE: Each service user has a weekly programme of activities which is kept in their bedroom. They plan what they are going to do each week. Service users refer to their programme each day so they can prepare for any outside activities and visits. The programmes were either written or took the form of photographs or pictures of the different activities. Mrs Hendy said she was looking at expanding service users range of opportunities for activities. One service user Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 13 told us they were going to a class at the local college that afternoon. Another service user told us that they caught the bus to their work in a garden centre. Staff supported service users with going to these activities. One service user told us that they liked to go to the cinema and visit their family. One service user told us about their holiday to Spain last summer. Mrs Hendy said that all service users have the option of going on an annual holiday. The organisation has a caravan at the seaside on the south coast which is available to service users. Mrs Hendy said that if service users would not manage a long period of time in unfamiliar circumstances, they would have a home based programme of specific activities for a holiday alternative. One service user told us about their job and what they were working on that week. They said they were going Christmas shopping later in the week on their day off. There was a record of what activities service users had been involved in each day. The record showed all of the local facilities service users went to. Staff record how much time they spend one to one with service users. Mrs Hendy reviews these forms to ensure all service users have an equitable time of individual staff support. Service users regularly made visits to their families or their families visited them. Service users and families also kept in contact via the telephone. At the last inspection we recommended that service users are given more opportunity to take responsibility for managing their own money. We gave the example of a cash card so that service users could withdraw their own money. Mrs Hendy said that this suggestion had been considered. However current service users would not necessarily have the capacity to remember PIN numbers. Service users money was brought to the home each week and kept safe on their behalf. Service users had access to their money at any time. Records and receipts were kept of all transactions. The records and money was regularly audited by Mrs Hendy. Service users were encouraged to save with their own individual savings accounts. One service user told us that they liked the meals and would help with preparation and cooking. They said they liked to cook spaghetti and sausages. Staff said service users also baked cakes; one service user always baked the Christmas cake. There was a large bowl of fruit in the kitchen. There was guidance in care plans about supporting service users to choose healthy options for their packed lunches. Special diets were followed where recommended by a dietician. Service users told us that they regularly went out for meals. Meals for the week are planned with service users on a Sunday. Staff said service users choose different meals and although individual choices were respected, service users were encouraged to follow a healthy diet. All the ingredients were fresh and made to a recipe from scratch. There is a board in the kitchen showing the daily menu. Service users choose their own breakfast. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 14 The main meal is taken during the evening. Service users have a light snack at lunchtime or take a packed lunch if they are working or going to day services. In the survey form service users were asked if they could do what they wanted to do during the day. Both answered yes. They were also asked if they could do what they wanted to do during the evening. Both answered yes. Service users were asked if they could do what they wanted to do at the weekends. One answered yes and the other answered no. In a survey form one of the relatives wrote: “Service users always appear content. More physical activity could be encouraged – eg swimming, badminton. None of the staff can drive. Although public transport is used, the lack of a driver must restrict activities.” Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good support and encouragement from staff. Service users have good access to relevant healthcare professionals. None of the current service users manage their own medication. Systems are in place to ensure safe administration of medication. EVIDENCE: Each service users had a file containing a great deal of information about their care and support needs. There was a list of significant contacts. The pen picture gave details of medical history. Further information had been gained from the internet about medical conditions or diagnoses. The care plans did not always cross reference with different sections relating to different healthcare needs. One care plan about regular weight monitoring stated that there were “restrictions in place”. It was not clear what they were. However a letter from a dietician in another part of the file clarified a restricted diet due to medical conditions. There was information in another part of the Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 16 care plan relating to food supplements. Service users were regularly weighed and significant gains or loss referred to relevant healthcare professionals. There was good guidance on how service users communicated, how behaviours were managed, how skin conditions were managed and how nutrition and eating was monitored. It was clear that service users healthcare plans were discussed with them regularly. Where needed service users had regular visits to either the chiropodist, dentist or optician. Records were kept of outcomes of appointments. Service users had good access to specialist healthcare professionals. It was evident that referrals were made when concerns noted. Behaviour management plans were in place. Staff recorded any incidents together with circumstances surrounding occurrences. The behavioural nurse was reviewing their clients when we visited. Action had been taken to meet the requirement that risk assessments relating to activities undertaken by service users are kept under review. Action had also been taken to implement safety measures as indicated in these assessments. Mrs Hendy was in the process of reviewing the individual assessments. They included: use of the kettle, going out without staff support, using taxis and public transport, behaviours and bathing. We advised that there must be a record of whether service users bathe alone or whether they must never be left in the bath alone. Guidance was available on safe moving of service users and use of the bath hoist. None of the current service users had been assessed as able to manage their own medication. The supplying pharmacist puts up a monitored dosage system. Staff are trained in administration of medication as part of their induction. This is carried out by the organisation’s training officer. Continued competency is assessed each year. We looked at the medication administration records. We advised that any handwritten entries on the medication administration record should be witnessed, signed and dated by two staff. We also advised that all medication prescribed to be taken only when needed, should be recorded in the care plan. This should say what triggers the medication to be given. There was however good guidance in that if paracetamol is given, a cold remedy containing the drug should not also be given. There was good guidance on the administration of medication prescribed by a psychiatrist. The care plan identified a list of triggers for an administration. We advised that the medication policy should be included in the medication administration record so that staff could immediately know what action to take if an error occurs. Service users do need medication if they are out for the day. If medication is needed when service users go home, it is put in a smaller monitored dosage pack and recorded on the medication sheet. Action had been taken to meet the requirement that staff initial or enter the appropriate code on the medication administration record. This related to two Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 17 occasions where agency staff had failed to record medication administrations. Concerns about agency staff’s competence to administer medication had not been taken up with the agency. The same agency continues to be used by the home if only rarely now that vacancies are being filled. Mrs Hendy said that agency staff would not be expected to give medication, as the home now has at least two staff, trained in medication administration, on duty during the waking day. The medication is always given by the home’s own permanent staff. Mrs Hendy said that she intended to take up the supplying pharmacist’s offer to provide training to staff. In a survey form one of the relatives wrote: “Day to day care excellent – always clean and well-dressed.” Another relative wrote about meeting service users’ needs: “Now it does, there was a time when things were different. I don’t like the fact that [the service users are] allowed to sniff aerosols and perfumed oils. I was told it was up to [the service user]. This relates to essential oils. The service users are not sniffing harmful substances as indicated above. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 18 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have good opportunities for discussing any concerns they may have. Staff are aware of the local Safeguarding adults procedure and how to use it. EVIDENCE: The organisation had a complaints procedure a copy of which had been placed on service users files. Mrs Hendy said she was looking at producing the procedure in pictorial format to be more accessible to service users. She showed us copies of the draft. Mrs Hendy showed us a pictorial leaflet entitled “your views” where service users can discuss any issues they had with the service, amongst other things. Mrs Hendy went on to say that staff were encouraged to talk with service users about issues in their keyworker meetings. Mrs Hendy had considered the recommendation made at the last inspection that service users could take a more active role in managing their money and to be independent with finances. We suggested cash point cards. Mrs Hendy said that this suggestion was not discounted for any future service users. However current service users would not necessarily have the capacity to remember PIN numbers. She went on to say that service users could access their monies at any time. Records and receipts were kept of all transactions in the accounts kept of service users money. Service users had their own wallets Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 19 for their money with the remainder kept in safekeeping. Service users were also encouraged to save in their own named savings accounts. The home works to the local policy on Safeguarding Adults. This was available in the home. Mrs Hendy said she planned to introduce the amended local policy at the next staff meeting. Staff were asked about how they must report any allegations of abuse. They were familiar with the policy on who to inform. Staff said they had been given a copy of the booklet on Safeguarding Adults entitled “No Secrets in Swindon and Wiltshire”. In the survey form service users were asked if they know who to speak to if they are not happy. Both answered yes. The survey form asked if service users know how to make a complaint. One ticked always and one ticked hardly ever. In a survey form one of the relatives wrote about the complaints procedure: “I’m sure this could easily be found out should the need arise.” Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and clean home. EVIDENCE: Service users have their own single bedrooms which are decorated to reflect their different personalities. There is a sitting room, dining room, kitchen, bathroom and separate toilet. The accommodation is well decorated and homely. Two of the service users showed us their bedrooms. They had been decorated and furnished to reflect their different personalities. Keys were available for service users to lock their bedrooms if they wanted to. When we arrived at the home the central heating boiler was not working. There was a frost that morning. We were told the boiler had been out of action since the previous Friday. We had not been told about this under Regulation 37 notifications. Various attempts had been made by different engineers to solve the problem. There was still hot water from the emersion tank. Portable Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 21 heaters had been proved and there was a gas fire in the sitting room. The following day Mrs Hendy told us that the housing association that owned the building had given her assurances that the boiler would be mended in four days time. She told us that additional heaters had been provided and she would assess the situation over the weekend. The weather temperature over the weekend improved and there was no frost. The housing association had provided additional heaters. Mrs Hendy had assessed the use of the portable heaters. When this inspection was concluded the home was warm. The floor coverings in the bathroom and toilet had been replaced as discussed at the last inspection. Action had been taken to address our recommendation that the diary sheets in the kitchen are consistently completed. This is to ensure that the standards of food hygiene and cleanliness in the kitchen are well monitored. Staff were working to the format supplied by the local Environmental Health department. Cleaning schedules were in place. Service users were encouraged to become involved in some cleaning and tidying of their bedrooms. Staff supported service users to launder their clothing and linen. The home was clean and no unpleasant odours were detected at any time. Protective clothing and disposable gloves were available to staff if needed. Grab rails had been installed to pathways to aid access in the grounds. Service users took part in regular fire drills and evacuation of the building. A portable smoke detector was used as an object of reference so that service users could confirm that a drill was taking place if they were distracted by the noise of the alarm. The fire risk assessment had been reviewed in January 2007. In the survey form service users were asked if the home is fresh and clean. Both said always. In a survey form one of the relatives wrote: “House is always clean.” Service users and their clothing frequently smell ‘institutional’ – I don’t know why this should be in such a small group.” It was not possible to establish what this meant. All service users personal clothing and linen is washed in their own separate load. The home used laundry products and cleaning agents bought from supermarkets, rather than industrial products. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 22 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from having a more permanent staff team. At least two staff on duty enables service users to be better supported with different aspects of their lives. The organisation had not confirmed to the manager that they had checked all staff’s suitability to work with vulnerable people. Staff have good access to internal training. Staff would benefit service users by having a wider experience of relevant training. EVIDENCE: The staffing rota provided for a minimum of two staff on duty throughout the day, during the week. At weekends this may be reduced to one, depending on whether service users go to their families. There is one member of staff sleeping in at night. The rotas are compiled according to the needs of the service users and any training staff may be involved with. All but one of the staff vacancies had been filled. There was less reliance on agency staff. One of the staff told us about their previous experience of working with people with learning disabilities in care homes and in the community. They said that Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 23 they had good access to training. They said they had medication updates every year. They had also completed training in moving and handling and fire safety. Another staff told us of their experience of working in other homes within the organisation and in other care settings. They talked about their current training. At the last inspections of 8th November 2006 and 3rd May 2007 we recommended that the process of recruiting a new member of staff is started at the earliest opportunity. This was to reduce the use of agency staff and give more continuity to service users. This is now addressed as staff from another home in the organisation have transferred to this home. There is only one full time vacancy left to fill. Mrs Hendy said the process would be completed in the new year. The vacant shifts were covered by permanent staff. Mrs Hendy said that service users were involved in interviewing potential staff. Most of the documentation and information in relation to recruitment, required by regulation was on file. However there was no evidence that checks had been made on the Protection of Vulnerable Adults list or of negative Criminal Records Bureau certificates before staff had commenced duties. Mrs Hendy said that all documents regarding staff recruitment were kept at the organisation’s head office. Copies of the documents and information required by regulation are forwarded to the home once an applicant is appointed. Mrs Hendy said she awaited copies of documents for those staff who had recently transferred from another home in the organisation. We recommended that a checklist should accompany each recruitment file. This could show the dates when each check was made and the date on which suitability to work with vulnerable people was confirmed. All new staff are inducted into their role. They undertake some specific induction training with the organisation’s training officer. All staff have access to the Learning Disability Qualification. This gains credits towards the NVQ qualifications. Currently three staff have NVQ Level 2. Staff said they had supervision every month with minutes kept. Some action has been taken to meet the recommendation made at previous inspections that the training programme is developed so that more learning disability specific training is accessed. It was also recommended that staff had the opportunity to access training from external professional specialists. Mrs Hendy reported that some specialist training was to be provided by the local Community Team for People with Learning Disability. The staff training files showed that the majority of training is carried out by the organisation. However one staff attended a course from an external provider on death and dying. Staff said they were asked about their training needs during supervision. They said there was a list of available courses for the year. Mrs Hendy confirmed that training was part of the home’s development plan. They also said that if they saw relevant external courses they applied to the Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 24 organisation for agreement. One staff said they wanted to attend the course in Makaton. Staff said they were regularly kept up to date with mandatory courses; for example, health and safety, risk assessment, hazardous chemicals, abuse, moving and handling, shared action planning, infection control, fire safety, first aid and food safety. In the survey form service users were asked: Do the staff treat you well? Both service users ticked always. They were also asked: Do the carers listen and act on what you say? One ticked always and one ticked sometimes. In a survey form one of the relatives wrote: “staff welcoming. I think it is unfortunate that there are no longer any male members of staff.” We discussed the possibilities of specifically advertising for male staff taking into consideration any exemptions under equal opportunities legislation. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 25 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 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from Mrs Hendy’s style of management. She knows service users very well and is keen to promote their interests. Mrs Hendy has nearly completed NVQ Level 4 in care and management. Service users contribute to quality assessment of the service. Staff are trained in health and safety. Systems and checks of the environment and tasks are in place to ensure service users health and safety. EVIDENCE: Mrs Hendy said she had completed the Registered Managers Award and had submitted the remaining units of the NVQ Level 4 in care and management. Mrs Hendy was also undertaking as a Learning Disability Nurse. Mrs Hendy was asked about whether she was provided with study leave for these Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 26 qualifications. The organisation provided no support in this area. Mrs Hendy is allowed 15 hours each month for administrative work. She works with service users and carries out the sleep in duty. Any course work was done in her own time. Action had been taken to address the recommendation that a policy on improvement and annual development is produced. Mrs Hendy had completed the Annual Quality Assurance Assessment we asked for. This is a document in which we ask homes to assess the quality of different aspects of their service. they also tell us what they plan to do in the future. Mrs Hendy said that she intended to develop the home’s quality assurance monitoring in discussion with staff at the next team meeting. She went on to say that the organisation carries out quality monitoring with findings being fed back to her through her line manager. Mrs Hendy was having supervision with her line manager on the first day we visited. Regular meetings are held with service users to discuss events happening in the home and to plan visits. Regular staff meetings are held with minutes kept. These meetings feed back information from managers meetings within the organisation and any information from the Annual General Meeting. A record was kept of all accidents together with separate monitoring of any falls. There was not a high incidence of accidents. Risk assessments had been carried out on the environment and use of equipment. Individual risk assessments with service users were part of their care plan. Sycamore Grove (45) DS0000028260.V349557.R01.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 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 N/A 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 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 3 3 X 3 X 3 X X 3 X Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 28 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 YA9 Regulation 17 Requirement Timescale for action 15/11/07 2 YA6 3 YA42 4 YA34 The person registered must ensure that care plans and risk assessments state whether service users can bath alone or whether they must never be left alone when bathing. 17 The person registered must 15/11/07 ensure that different aspects of the care planning process should relate to each other. 37 The person registered must 15/11/07 ensure that the Commission is notified without delay of any events in line with the Regulation. 17 & The person registered must 15/11/07 19(10)(a)&(b) ensure that the registered manager is informed that all new staff have undergone Protection of Vulnerable Adults list checks and that Criminal Records Bureau certificates have been received. Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 29 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 YA35 Good Practice Recommendations The person registered should ensure that staff members have the opportunity to attend more external training events and training courses which include the contribution of outside agencies. (Recommendation from previous inspections) The person registered should ensure that any amendments to service users care plans are dated for monitoring purposes. The person registered should ensure that handwritten entries in the medication administration record are witnessed, signed and dated by two staff. The registered person should ensure that all PRN medication [prescribed to be taken only when required] should be detailed in the care plan. Guidance should be recorded as to what circumstances trigger an administration. The registered person should consider including the section of the medication policy relating to medication errors in the medication administration record. 2 3 4 YA41 YA20 YA20 5 YA20 Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Sycamore Grove (45) DS0000028260.V349557.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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