Inspection on 05/07/05 for 45 Sycamore Grove

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

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 23/01/06

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 5th July 2005 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 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 Stationary 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) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 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 LD Learning Disability (3) registration, with number of places Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10TH March 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 and Trowbridge offers a range of amenities and town centre shops. The home has its own vehicle for trips out. The property is a detached bungalow, which provides single room accommodation. 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) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 2.05pm and 5.20pm. The three service users and a member of staff were met with. The communal rooms and two of the service users’ rooms were looked at. Examples of the service users’ care plans and other records were examined. There have been no changes in the home’s occupancy during the last year. What the service does well: What has improved since the last inspection? What they could do better: The home’s permanent staff team is not able to cover all duties that are needed in order to support service users. Continuity of care and opportunities for service users should improve with the recruitment of new staff and a reduction in the use of agency staff. The policies and procedures file needs to be reviewed to ensure that service users’ rights and best interests are protected. In particular, there is insufficient guidance about responding to allegations of abuse and the policy on personal care is short on detail. There is a lack of information about quality assurance and how the service users’ personal goals are followed up. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 6 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) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) These standards were not assessed on this occasion. Previous requirements concerning the home’s Statement of Purpose and Service User’s Guide are being followed up with the home’s manager, who was not present during this inspection. EVIDENCE: Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) 6 and 8 Service users benefit from the good information that staff have about their day to day support needs. A lack of up to date information about personal goals and progress with achieving these is likely to affect the quality of life that service users experience. EVIDENCE: The records included ‘daily routines’ guidelines and ‘personal care support plans’ which provide a summary of the service users’ needs and show how staff members need to be involved in their care. The staff member spoken with confirmed her knowledge of the service users’ day to day care needs. The same written information was available to agency staff in a separate file. A communications book and a home’s diary also contained information that helps staff to keep up to date about events affecting service users. A service user spoke positively about the support received from staff and each person looked well supported with their personal care. Service users spoke about their interests and how they spend their time. Two of the service users’ files included a ‘Shared Action Plan’, which is used to record personal goals and progress with meeting these. One of the action plans was produced in January 2004 and another in May 2004. Three monthly monitoring forms are used although these were not up to date. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 10 A ‘tenants’ meeting had taken place in April 2005, with the previous meeting haven taken place in May 2004. The April 2005 meeting had been an opportunity to discuss current affairs (included the general election), menus, the staffing situation and OLPA news, including a new caravan that was available for use by the service users. One service user was looking forward to using the caravan in July. OLPA had also produced a summer edition of a quarterly newsletter. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) 12, 13, 15 and 16 Service users have well established activities during the day. There is limited opportunity to participate in individual social events. Service users have regular contact with the local community and are encouraged to maintain contact with family and friends. Service users are not subject to undue restrictions and are supported to take an active role in the home. EVIDENCE: A written activities programme for the current week was seen in one service user’s room. This was up to date and showed participation in a mix of community and home-based activities during the week. This service user spent part of the week working at a garden centre. The other two service users attended day centres, one for four days a week and one for five. One service user said that he wished to have one home-based day and the staff member said that this was being followed up. Another service user said that he was keen to study photography at college. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 12 The staff member said that there were not enough staff to enable service users to attend social activities in the evenings. The records showed that some outings were taking place at the weekends. One service user spoke about the close contact he has with some family members. The staff member spoke about the support that service users receive with visits to relatives. The service users’ records included a section that detailed any restrictions that exist concerning personal freedom and rights. Some limitations were in place and safety issues are a factor in some cases. During the inspection service users were able to use the kitchen to make their own drinks with some supervision from the staff member. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) 18 and 19 Service users receive the personal care that they need although there is a lack of clarity about the choices they can make. Service users benefit from staff members’ awareness of their healthcare needs. EVIDENCE: A statement about personal care is included in the service user’s guide. This states that ‘it is respected that ideally you should choose who assists you to have a bath and support you to look your best. It may be a man or a woman who helps you to get ready at the start and end of the day and look after you while you sleep’. A requirement has been identified at previous inspections that a policy and procedure is implemented to cover gender and the provision of personal care. The staff member spoken with was not aware of a general OLPA policy about this. Details of appointments with GPs and other healthcare professionals were reported on a range of forms in the service users’ records. One service user’s dental appointments form showed that a check-up had not taken place since October 2004. The staff member said that it was likely that a more recent check-up had been arranged, but agency staff may not have had access to the form to record this. The service user’s personal diary included an entry about a dental appointment in June 2005. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 14 Chiropody is recorded on another form. One service user said that he received help from a family member with nail cutting although this was not shown on the form. The same service user had received good support from staff with a recent health condition. Appointments and care needs in connection with this were well recorded in the service user’s records and personal diary. A staff meeting on 3 June 2005 had included discussion about healthy diets and helping service users during heat wave weather. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) 23 Staff members receive training through O.L.P.A., although awareness of abuse and protection for service users is reduced by a lack of information in the home. EVIDENCE: The staff member spoken with said that she attended a training session about abuse. The O.L.P.A. operational file included a policy on abuse. This refers the staff member to a number of old Wiltshire Social Services documents which have since been replaced by more recent guidance. The documents referred to could not be located in the office. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 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 standard(s) 28 Service users have a choice of communal areas and enjoy using these. EVIDENCE: Services users have their own rooms but were choosing to spend time together in the lounge. The lounge was comfortably furnished and had a television and video player. There was a separate dining room with an outside door to a good sized rear garden. The dining room is next to a domestic style kitchen and there is a separate laundry / utility room. There is a no-smoking policy operating in the home. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 A permanent staff team with the regular use of agency staff meets the service users’ needs within the home. Opportunities for individual support with social activities outside the home are limited. EVIDENCE: The staff member spoken with said that staff members usually worked by themselves throughout the week. On occasions, for example because of a dentist appointment, arrangements are made for a second person to be working. This minimum staffing level means that any support with individual social activities in the community needs to be planned in advance. A written staff rota is maintained. The staff member said that although the permanent staff worked additional shifts, agency and relief staff members were regularly used in order to provide the cover needed. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 The records and written policies and procedures generally safeguard the service users interests, although some areas are in need of attention. EVIDENCE: OLPA have produced a file with organisational policies and procedures for implementation of the home. The staff member spoken with was familiar with the file, although not all the staff had signed the forms to confirm that they had read and understood the file’s contents. There is a separate file for agency staff, which contains a range of written procedures and information. Agency staff had signed a form to confirm that they have read the file when coming on duty. The contents of the file have not been prioritised for attention, for example to highlight particular emergency and health and safety information. A fire procedure was displayed by the home’s front door, although it was stated in the file that this could be found within the office / staff sleeping-in room. The administration of medication records were up to date. Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 2 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore Grove (45) Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x 1 x x D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 20 YES 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 23 Regulation 13 Requirement The policy and procedure on abuse must be amended to ensure that up to date and accurate information is available to staff in the home The Registered Person must devise and implement an effective quality assurance system.This was identified at the last inspection although the timescale of the requirement has not elapsed Each staff member must read and have knowledge of the homes policies and procedures file Staff must receive accurate information about the location of the fire procedure notice Timescale for action BY 31/08/05 2. 39 24 BY 31/07/05 3. 40 18 BY 31/08/05 FROM 06/07/05 4. 5. 42 23 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 6 Good Practice Recommendations That the service users progress in meeting their Shared D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 21 Sycamore Grove (45) 2. 3. 4. 5. 8 18 18 19 6. 40 7. 40 Action Plan goals is regularly monitored and recorded That the tenanants meetings are held on a more frequent and regular basis That details of all health care matters are recorded using the appropriate forms That support with nail cutting is recorded in the service users individual files That the statement on personal care is developed to include the organisations policy on gender and personal care and to provide details of any limitations and restrictions that may apply in the provision of personal care The Registered Person should ensure that all policies and procedures are reviewed so that all are up to date and relevant (recommendation outstanding from last inspection) That the contents of the relief staff file are reviewed and that the information is prioritised for attention by staff Sycamore Grove (45) D51_D01_S28260_SYCAMORE(45)_234903_050705_STAGE4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. 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