Inspection on 23/01/06 for 45 Sycamore Grove

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

45 Sycamore Grove 15/11/07

45 Sycamore Grove 03/05/07

45 Sycamore Grove 08/11/06

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 Malcolm Kippax Unannounced Inspection 23rd January 2006 12:45 Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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.V280752.R01.S.doc Version 5.1 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.V280752.R01.S.doc Version 5.1 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.V280752.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: 45 Sycamore Grove is registered to provide care for up to three adults with a learning disability. 45 Sycamore Grove is one of a number of care homes in Wiltshire run by the Ordinary Life Project Association (OLPA). The home is situated in a residential area of Trowbridge. There are some shops within walking distance. The home has its own vehicle for trips out. The property is a detached bungalow, which provides single room accommodation for service users. The communal rooms consist of a lounge and a dining room. There is a domestic style kitchen and a separate laundry and utility room. Staffing levels are maintained at a minimum of one staff member throughout the day. One staff member sleeps-in during the night. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 12.45 pm and 5.05 pm. It focussed on a number of key standards that were not looked at during the previous inspection. Each of the three service users was met, as well as a staff member and an agency carer. The accommodation was seen and records were examined, including risk assessments, personal guidelines, staffing, menus and health & safety. Service users vary in their communication skills and the extent to which they can comment on their experience of the home. The home’s manager was not working at the time but was spoken with after the inspection. What the service does well: What has improved since the last inspection? The appointment of a new support worker has meant that service users receive more support from permanent staff team, rather that agency carers and relief staff. There is a computer in the dining room, which it is hoped will be of interest to service user and that they will learn to use. The manager had produced a ‘House development plan’ which includes objectives that will enhance the service. The upkeep of the garden has improved. A bird table has been bought with money that was given as a prize in the OLPA garden competition. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 6 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. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not looked at on this occasion. Standard 2 did not apply at this time as no new service users have moved into the home. EVIDENCE: Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Service users can make decisions about what they want to do. Independence is encouraged, although risk factors affect the level of independence that can be achieved. (Standards 6 and 8 were inspected and almost met at the last inspection). EVIDENCE: The system of ‘Shared Action Planning’ is the main way in which service users can make decisions about their lives. Examples of the service users’ shared action plans, including their personal goals, had been looked at during the previous inspection. The service users meet together at ‘tenants’ meetings. The minutes of a meeting in November 2005 showed that service users had been asked about things that they would like to do before Christmas. They had suggested shopping trips, going to a carol service and going to the cinema. At an earlier meeting, two service users had said that they would like to go to a Gateway club. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 10 The service users’ files contained risk assessment forms that have been completed on an individual basis. Some involved generic hazards and others concerned more personal activities. The latter included using a shaver, road safety and spending time unsupervised in the kitchen. Many of the assessments had been undertaken in 2003, with review dates identified. Sometimes the review date had been initialled, although several dates in 2005 had not and no comment had been added to show whether a review had taken place on that date and what the outcome was. The care and assessment records contained guidance about some limitations that apply in what the service users are able to do. For example, decisions had been recorded that a service user would not be left alone in the home or go out alone. Other restrictions had been recorded about a service user not being able to have a front door key. The service user was able to have a key to their own room. Some dietary guidelines had been agreed in respect of another service user. These took into account their personal preferences and support with healthy eating. Guidelines had also been produced to enable a service user to make their own drinks safely in the kitchen. This involved the provision of some separate facilities. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Service users help to chose the menu and have meals that they enjoy. Guidance for staff helps to ensure that service users receive consistent support in connection with dietary and other needs. (Standards 12, 13, 15 and 16 were inspected and met at the last inspection). EVIDENCE: The staff member said that the menu is discussed with service users each week and their wishes are taken into account. The current menu was displayed in the kitchen. This, and the previous menus, showed that some meals are regularly repeated, with a relatively high number of chicken and pasta dishes. A service user said that he was happy with the meals. It appears that certain types of meals are particularly popular with the service users and are therefore frequently on the menu. The need for a more varied selection of meals should be kept under review. Examples of the service users’ files were looked at. Guidance had been produced in relevant areas, such as appropriate quantities, particular likes and dislikes, involvement in menu planning and whether there were any known Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 12 allergies. The file for agency staff contained guidelines on food and drink. These included a reminder to prompt one service user to have regular drinks and to offer a choice of drinks when doing this. Some agreed restrictions about food and use of the kitchen are in place, as reported under standard 9 Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users receive the support that they need with their medication. (Standards 18 and 19 were inspected at the last inspection. Standard 18 was almost met and standard 19 was met). EVIDENCE: These were suitable facilities in place for the safekeeping of the service users’ medication. None of the service users are able to look after their own medication and there is a central facility that is managed by staff. Records for the administration of medication were up to date. Stock records and records of disposal are being maintained. A medication file was kept in the office. This included a copy of the OLPA procedure for the administration of medication. The file contained drug information cards and medication profiles for the service users. There was other guidance for staff, such as the need to be aware of expiry dates and how to record changes in the administration of medication. The staff training records show that staff attend OLPA training in drug administration. The staff member confirmed the training that she had received. There is no training from an outside specialist and no external Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 14 courses have been attended. This is recommended in addition to the in-house arrangements. It was recommended at the last inspection that a statement on personal care is produced to include the organisations policy on gender and the provision of personal care. A ‘Provisions of Personal Support’ policy was seen during the inspection. This stated that staff can provide personal care regardless of their gender if they have provided evidence of current C.R.B. OLPA should develop a more comprehensive organisational policy that will reflect good practice and the range of factors that need to be taken into account. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users have the opportunity to raise concerns although would need the support of others if making a formal complaint. (Standard 23 was inspected and almost met at the last inspection). EVIDENCE: The tenants meetings are an opportunity for service users to raise concerns with staff on a regular basis. A service user said that he would talk to the manager if not happy with something. Another service user when asked, mentioned the inspector as being somebody who could be spoken to. It was not clear whether service users have the details of people who could be contacted outside the home. It would be worth checking what information service users have received about this. OLPA has produced a written complaints procedure. This is in the form of a leaflet although the format is unlikely to meet the needs of each service user. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home provides service users with suitable and domestic type accommodation. (Standard 28 was inspected and met at the last inspection). EVIDENCE: Service users were spending time in the lounge and in their own rooms. At the start of the inspection, one service user was listening to music in his room before going out later in the afternoon. This is a relatively small room with limited space for socialising and for items of furniture. However it appeared that the service user liked the privacy and often preferred to use his own room rather than the more spacious lounge. Another service user returned home during the afternoon and watched a video in his room before sitting in the lounge before tea. There is a separate dining room, which means that service users have a choice of communal rooms for different activities. There is a television in the lounge. A computer has been installed in the dining room where it can be used in relative quiet. The staff member said that it was hoped that service users would take an interest in the computer and be able to use it on a regular basis. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 17 The kitchen and the other areas seen during the inspection looked clean and homely. Laundry is carried out in a separate utility room. This means that the risk of cross infection can be better managed. There is a ‘Safe Laundry’ procedure, which was reported to be still current when last reviewed in February 2005. There is a garden at the rear of the property. The garden has one a prize in the OLPA garden competition. A bird table has been bought with money that was given. Fencing has recently been installed where the garden borders with a playing field. The staff member said that there had been difficulties with some people using the park, which affected the service users. However the fencing meant that service users no longer had a view over the field. Radiator covers have been fitted in several locations, although significantly not in the main bathroom. This was discussed with the manager following the inspection and it was agreed that a cover would be fitted in this location. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Staff members are working towards achieving the level of qualification that is expected. Service users benefit from the statutory training that OLPA provides. However there is a lack of an accredited programme of induction for new staff. Further information is needed to confirm that service users are adequately protected by the recruitment procedures. (Standard 33 was inspected and met at the last inspection). EVIDENCE: In addition to the home’s manager there is a staff team of three permanent support workers. Two support workers are undertaking NVQ at level 2. A third support worker has been appointed since the last inspection. The manager said that this support worker would be undertaking NVQ following completion of their OLPA induction programme. Learning Disability Award Framework accredited training is not being provided. This is recommended for staff who are new to working in a learning disability service and can be used to provide the underpinning knowledge for progress towards achieving NVQs. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 19 The manager said that the new staff member had started working in the home under supervision, before a C.R.B. disclosure was issued. In this situation, a POVA check would need to have been undertaken, through ‘POVA First’, before the staff member had started work. The manager could not confirm that this was the case and OLPA is asked to confirm the arrangements with the Commission. The staff training records show that staff members participate in a range of courses as part of the OLPA programme of training. This covers statutory areas of training well although it would be beneficial to develop the programme to include more specialist and learning disability related subjects. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home benefits from an experienced manager who shows a good commitment to her own professional development. Systems of quality assurance are not well established. (Standard 41 was inspected and not met at the last inspection). EVIDENCE: The manager, Keri Hendy is an experienced manager who has worked in a number of care services. She said that she was near to completing the registered managers award and is continuing with part-time studies leading to a nursing qualification in learning disabilities. A ‘Quality Assurance’ file was seen in the home. This refers to a number of internal and external ways in which the service is monitored, although there is Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 21 no overall plan for quality assurance which shows how they contribute to a cycle of planning-action-review, involving timescales and the production of improvement / action plan, as is expected under National Minimum Standards. The manager has produced a House development plan, which was discussed at a team meeting in November 2005. This is a positive development in identifying objectives which will enhance the service. It is not clear whether the views of service users and their representatives have been taken into account, or whether the House development plan is not designed to do this. Evidence needs to be available in the home that a system is in place for reviewing, at appropriate intervals, and improving the quality of care in the home. The system must include consultation with the service users and their representatives. Shortcomings in respect of standards 41 were identified at the last inspection are reported to have been met. Inspection of standard 42 was limited to an examination of risk assessments and the home’s fire log book. Risk assessments have been recorded covering a number of areas such as lone working, use of equipment, use of the house vehicle and fire. The fire log book showed an up to date record of checks of the alarm system and the emergency lighting. The fire fighting equipment was checked by outside contractors in December 2004. A record of a more recent check was not found. A further check may now be overdue. There are regular fire drills and the last one had taken place on 4 January 2006. The staff member said that the drills included some instruction in fire precautions. This instruction is not being reported in the fire log book. A record needs to be kept showing that staff members have received regular instruction in accordance with the required timescale. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 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 X 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 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 2 X X 2 X Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 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 YA24 Regulation 13(4) Requirement That a risk assessment is undertaken in respect of the bathroom radiator, prior to the fitting of a cover. That the Commission is informed of when a POVA check was completed for the most recently appointed staff member. The Registered Person must devise and implement an effective quality assurance system. (This requirement has been met in part since the last inspection). There must be evidence in the home that a system is in place which meets regulation 24 of the Care Homes Regulations 2001. A record of fire instruction to staff must be maintained in the fire log book. Timescale for action 28/02/06 2. YA34 19 28/02/06 3. YA39 24 31/03/06 4. YA42 23(4) 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 24 No. 1. 2. Refer to Standard YA9 YA18 Good Practice Recommendations That the risk assessment records show whether the assessment was reviewed on a particular date and the outcome of the review. That OLPA develop a more comprehensive organisational policy on gender and personal care, which will reflect good practice and the range of factors that need to be taken into account. That an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage. That a check is made to ensure that service users have the details of people who can be contacted outside the home if they have a concern. That L.D.A.F. accredited training is provided for staff who are new to working in a learning disability service. That staff members have the opportunity to attend more learning disability specific training events as part of the OLPA training programme. 3. 4. 5. 6. YA20 YA22 YA35 YA35 Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Grove (45) DS0000028260.V280752.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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