Inspection on 08/11/06 for 45 Sycamore Grove

This inspection was carried out on 8th November 2006.

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 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 7 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 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 Malcolm Kippax Key Unannounced Inspection 8th November 2006 2:30 Sycamore Grove (45) DS0000028260.V319594.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.V319594.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.V319594.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.V319594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: 45 Sycamore Grove is home for up to three people with learning disabilities. It 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 situated in a well established residential area of Trowbridge that is close to the town centre. Trowbridge College is nearby and there is a convenience store at the end of the road. Each service user has their own room. The communal rooms consist of a lounge and a dining room. There is a domestic style kitchen, with a separate laundry and utility room. The home has a manager and a staff team of four support workers. At least one person works in the home throughout the day, with additional staff deployed at certain times. One staff member sleeps-in during the night. The fee level at the time of this inspection was £900 a week. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home that took place on 8 November 2006 between 2.30 pm and 6.00 pm. A second visit took place on 13 November between 9.30 am and 12.00 am. The home’s manager was met with at the home on 24 November 2006. The three service users who live at 45 Sycamore Grove were spoken with during the visits. Evidence was also obtained through: • • • • Discussion with staff members and with the home’s manager. Observation. A tour of the home. Examination of some of the home’s records, including the three service users’ personal files. Other information has been received and taken into account as part of this inspection: • • • The manager completed a pre-inspection questionnaire about the home. The service users, with support from staff, completed surveys about what it is like to live at 45 Sycamore Grove. Four of the service users’ relatives have commented about their experience of the home. The judgements contained in this report have been made from the evidence gathered during the inspection, including the visits to the home. What the service does well: The service users have meetings together and with staff, which gives them the opportunity to talk about matters that affect them. Some of the service users’ individual needs and wishes are recorded as personal goals, which helps to highlight the areas in which each person will require support in the future. Service users receive support from staff with family relationships, which enables them to keep in touch with and visit their close relatives. Service users help to chose the menus, which means that they can have meals that they like. Staff have information about the service users’ dietary requirements so that alternatives can be provided to meet individual needs and preferences. The service users’ health is monitored by staff and outside professionals are involved to ensure that their individual needs are met. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 6 Staff members provide good support with keeping the accommodation clean and tidy, which means that the service users have a pleasant and homely environment to live in. Service users benefit from the attention of individual staff, who were seen to be supporting service users in a friendly and positive manner during the visits made to the home. What has improved since the last inspection? What they could do better: The service users have very different needs and routines within the home. The way in which one service user is being supported has an impact on the freedom and independence of the other service users. Service users are not wholly protected from harm. The home needs to find ways in which the needs of service users can be met without compromising their rights and opportunities for a more independent lifestyle. Service users are listened to within the home although they and their representatives cannot feel confident that their concerns will be followed up promptly and appropriately by the organisation. Changes need to be made in how the organisation responds to a complaint to ensure that it meets its obligations and the terms of its own complaints procedure. There is a system in place for identifying personal goals, although the benefits for service users are reduced because of how the system is used and a lack of consistent recording. It was not always clear how achievement of the goals would be measured and what action should be taken, and by whom. This is important, in order to ensure that service users make good progress with achieving their goals and that the need for any additional support is readily identified. The service users’ individual plans for personal support were in need of updating, to ensure that that staff have good information about the service users’ current needs and the support that they require. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 7 Changes need to be made in the home’s medication procedures, as service users have not been wholly protected by the way in which their medicines have been administered. There needs to be better forward planning in how staff members are deployed to ensure that service users receive support at the time it is needed. Agency carers and relief staff are regularly used; the home should aim to reduce their use, as service users would benefit from having the consistent support of a permanent staff team. However the use of agency carers and relief staff will increase because of the time it takes to recruit a new staff member. There needs to be better evidence kept of the recruitment process to show that service users are protected from unsuitable staff. A quality assurance report needs to be produced, which shows how the views of service users and stakeholders have been taken into account and contributed to improvements in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sycamore Grove (45) DS0000028260.V319594.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.V319594.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): 2 Standard 2 did not apply at this time as no new service users have moved into the home. EVIDENCE: Sycamore Grove (45) DS0000028260.V319594.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. There is a system for supporting service users with their personal goals. Individual goals are being identified, although the benefits for service users are reduced because of how the system has been used. Service users can make decisions about their lives. However, there are procedures in the home that have an impact on the service users’ rights and their opportunities for an independent lifestyle. EVIDENCE: The service users’ files contained records of ‘Shared Action Planning’ (S.A.P.), which is the system used for identifying the service users’ wants and needs and their personal goals. Individual goals had been identified and recorded. These reflected a range of interests, such as photography, woodwork and going on a train. Other goals were more concerned with relationships and personal development. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 11 Forms were available for recording the different stages of S.A.P., however information and the service users’ progress was inconsistently completed. There were gaps in the records, which meant that it was not clear how achievement was being measured and what stage the service users were at with meeting their goals. Service users had chosen how to personalise their rooms. One service user’s room was well decorated with posters and personal possessions. In contrast, another service user had very few personal items on show but said that this was how they wanted it. There was a lock on the door but the service user said that they did not want to have a key. Another service user did have a key to their room. Service users had been given the minutes of the last ‘tenants’ meeting, to keep in their rooms. The most recent minutes seen were for a meeting that took place on 12 September 2006. At this meeting, the service users had been told about some changes that were being made to resource centres, which would affect when they could attend. It was recorded that two service users were unhappy about this and had written letters of complaint (with support). The manager said that the ‘tenants’ meetings were going to be held monthly. Guidelines had been written in connection with one service user’s behaviour in the home. These included the need for a staff member to be present when two service users are using the lounge, because they could not be left with each other. Access to items in the kitchen was restricted because of locks on the cupboard doors. This was something that was reported to be necessary because of the actions of a service user. A staff member said that the need for service users to be more closely supervised when in the home had meant that there was less support available to accompany service users outside the home. Sycamore Grove (45) DS0000028260.V319594.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 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. Service users have individual lifestyles, which are reflected in their occupation and daily routines. Service users receive support with their family relationships, which enables them to keep in touch with and visit their close relatives. Service users have different needs, which can make it difficult to for each person to exercise choice and independence in the home. Service users help to choose the menus and alternatives are provided to meet individual needs and preferences. EVIDENCE: One service user had planned activities during the week, which included four days at a resource centre and one day attending a yoga session at a nearby Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 13 college. Another service user also had a place at the resource centre although he was choosing to stay in the home, rather than to attend. A third service user had a more varied week, which included attending college on two days (for sessions on woodwork and media studies), working at a garden centre for one day and two home-based days. This person returned home from the garden centre during the visit on 8 November 2006 and spoke about their work there, which he enjoyed. The service user had also been on a shopping trip with a staff member before coming home and was pleased with some videos and CDs that he had bought and could add to his collection. One service user was not leaving the home regularly and therefore had limited contact with the local community. A staff member said that this person needed support from two staff when outside the home and that his behaviour meant that they were quite restricted in what activities could be attended. This aspect of the service user’s needs was well documented in their personal records. This service user was visiting a family member each week and also spent time with a Church group, which included going on an annual outing. The service user had a photograph of the most recent outing and he was pleased to have this on display in his room. The service users’ individual files included information about their family relationships and contact details. Each service user regularly saw one of their close relatives. In their comment cards, the three relatives confirmed that they are welcome in the home at any time and can visit in private. Two people stated that they are kept informed of important matters affecting their relative in the home; one person reported that this was ‘sometimes’ the case. In their comment card, one relative questioned whether service users are given too much free choice in the home and gave the example of whether it was in a service user’s best interests frequently to stay in bed all day. As reported under ‘Individual Needs and Choices’, some routines in the home were geared around meeting the needs of one service user in particular, which affected how independent the other service users can be. A menu was written with service users each week. This showed a varied range of meals throughout the week. The main meal was prepared in the evening. During the visit on 8 November, a staff member was preparing salmon and mushroom pasta. Other meals on the menu for the week included chicken with noodles and fish and chips. Information about one service user’s dietary needs was included in their personal file. Some foods were avoided and the record of meals showed when the service user had had something different as a result. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including the visits to the home. There is a lack of up to date guidance for staff, which means that service users may not receive the support that they require. The service users’ health is monitored, with the involvement of health professionals. Service users have not been wholly protected by the way their medicines are administered in the home. EVIDENCE: The service users’ individual files included guidance for staff about their personal and healthcare needs. Statements on the provision of personal care had been written in January 2006. Each service user had a ‘Personal care support plan’, which was dated February 2005. The plans did not reflect the service users’ current needs and did not refer to guidelines on support that had been more recently produced. Records were kept of the service users’ health related appointments, including visits to dentists and chiropodists. Staff members were supporting service users with particular health needs at the time of the inspection. This included Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 15 a skin condition, which had been referred to a dermatologist. The district nurse was visiting to provide support with another health need. The service users’ health needs were discussed in staff meetings. A physiotherapist had been invited to attend one of the meetings in order to advise on a home exercise regime for one service user. There was a file containing guidelines and information about one service user’s behaviour and how this should be responded to in the home. In their comment cards, two of the service users’ relatives stated that they are satisfied with the overall care provided and one stated that they are not. A medication file was kept in the office. This contained a medication profile for each service user, together with information about their prescribed medication. None of the service users looked after their own medication and staff kept medicines safely in a locked cupboard. Medication records were looked at on 14 November 2006. A staff member had initialled the record of administration to show that medication had been given to a service user at 8 am on that day. However the record was blank in respect of one medicine that the service user was due to receive at that time. The staff member present could not confirm whether this medicine had been given. The staff member attempted to contact the staff member who had administered the other medication but had since gone off duty, to check what had happened. Incident reports had been completed in connection with two other medication errors that had occurred since the last inspection. These incidents, the most recent of which was on 2 October 2006, had been followed up by the manager although not reported to the Commission at the time. One service user had medication that was prescribed, 1 – 2 tablets, as required (P.R.N.). There was guidance for staff about the circumstances in which this medicine should be administered. This did not refer to the dose to be given and the records did not show whether one or two tablets had been administered. The medication details on one service user’s record of administration had been changed, although the hand written amendment had not been signed. Staff members received ’in-house’ training from a service co-ordinator in OLPA’s procedure for dealing with medication. It has previously been recommended that an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage. This has not been followed up. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including the visits to the home. Service users are listened to within the home. However service users and their representatives cannot feel confident that their concerns will be followed up promptly and in accordance with the organisation’s complaints procedure. Service users are not wholly protected from harm. EVIDENCE: As reported under the section ‘Individual Needs and Choices’, ‘tenants’ meetings were being held, which gave service users the opportunity to raise any concerns or issues directly with staff. Minutes were kept and at a meeting in April 2006, there was a discussion with service users about the home’s complaints procedure. OLPA has produced a written complaints procedure, which provides guidance on how to make a complaint and the time it will take to respond to a complainant. The home’s manager reported in the pre-inspection questionnaire that no complaints had been received during the last 12 months. The Commission has received information about one complaint that was made in writing to the OLPA Chief Officer in July 2006. The complainant received no response to their original complaint and wrote further letters to the Chief Officer about this. The complainant wrote to the Commission on 31 August 2006 to report that their complaint had not been acknowledged or investigated. Following Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 17 correspondence, OLPA’s Chief Officer informed the Commission in October 2006 that a delay in responding to the complainant was due to a combination of sickness and annual leave. Each service user had regular contact with a family member. In their comment cards, one relative confirmed that they are aware of the home’s complaints procedure. Another relative did not confirm this, but commented that they ‘have never asked’; the third relative stated that they were due to attend a meeting with OLPA to discuss a large complaint concerning lots of issues. A staff member confirmed that she had attended OLPA ‘in-house’ training in abuse awareness. The staff member said that training about the prevention of abuse was also going to be covered in their LDAF training. There was guidance in the home about the reporting of allegations and what constitutes abuse. OLPA has produced a range of relevant policies, including whistle blowing. There was a file in the home that contained monitoring forms and guidelines for responding to incidents of aggression from a particular service user. A staff member said that there had been occasions when she felt scared when responding to such incidents. There was a record of an incident in September 2006 when two staff members had locked themselves into the office for 30 minutes when this service user was reported to have become very agitated and had started to shout. This action was in accordance with written guidance in the home, which instructed staff to take service users to the office and to lock the doors as soon as possible when this service user’s behaviour ‘escalated’. The guidance stated that a 999 call should then be made and the OLPA on-call manager informed of the incident. The manager said that the behavioural nurse had been consulted about this guidance. Incidents involving one service user’s aggression towards another has been the subject of a vulnerable adults investigation since the last inspection. Guidance has been produced which states that the two service users could not be present in the same room without a staff member present. One of the service user’s relatives has said that they are particularly concerned about a service user’s behaviour and the impact that this has on other people in the home. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. The accommodation is homely and well personalised. Service users are well supported with keeping the home clean and tidy. EVIDENCE: 45 Sycamore Grove is an ordinary detached bungalow in a residential area. The home has a front and rear garden. The accommodation was decorated and furnished in a homely and domestic manner. There was a spacious sitting room and a separate dining room. Each service user had their own room, which was close to a bathroom and a separate W.C. There was a well kept kitchen and a small utility room where the laundry was done. Files and records were kept in an office / staff sleeping-in room, where they did not intrude on the service users’ accommodation. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 19 During the visits, service users spent time in the lounge and in their own rooms. The service users’ bedrooms varied in size. The smallest room had been well personalised, but had very limited space for socialising and for items of furniture. However it appeared that the service user liked the privacy and often preferred to use their own room, rather than the lounge. Service users had a choice of communal rooms for different activities. The lounge was well decorated and comfortably furnished. Service users were watching television in the lounge with a staff member present. The dining room was available for quieter activities. The front garden was in need of some tidying up and better upkeep, in order to give a better first impression of the service users’ home. The main area of garden was at the rear of the property. A certificate was displayed in the home for ‘best hanging baskets’ in the OLPA garden competition. Service users had discussed at a ‘tenants’ meeting what they wished to do with the competition prize money. Radiator covers have been fitted in several locations. A cover had been fitted to the radiator in the bathroom since the last inspection. The home looked clean and tidy. Cleaning schedules had been produced for different areas of the accommodation. There was a no-smoking policy operating in the home. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 20 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, 33, 34 and 35 Quality in this outcome area is poor with improvements evident in the training of staff. This judgement has been made using available evidence including the visits to the home. Service users benefit from the attention of individual staff. The effectiveness of the staff team and the benefits for service users are reduced by a lack of forward planning. The use of relief and agency carers is likely to increase because of the home’s recruitment practices. Service users benefit from the checks that are made prior to the appointment of new staff. There was a lack of evidence that the recruitment process protects service users from unsuitable staff. Service users will benefit from developments that are taking place in the induction and training of staff. EVIDENCE: Staff were responding to service users in a friendly and supportive manner at the time of the visits. An example of this was the way in which a staff member when arriving at the home was heard to greet service users and to acknowledge immediately the positive things that they were doing. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 21 There were guidelines for staff to follow when supporting service users on each shift. Staff members demonstrated an awareness of the guidelines and of the strategy for supporting service users when they were together in the home. Much of the guidance highlighted the need for service users to receive consistent support and for their health and welfare to be monitored and kept under review. Staff meetings were held, which included discussion about the service users’ needs and progress. However the permanent staff team could not cover all the shifts that were needed and relief and agency carers were regularly used. Staff rotas were written by the manager for the month ahead. The rotas showed at least one staff member working throughout the day, with additional staff deployed at specific times. During the visit on 13 November there was lack of staff to support service users individually, which meant that one service user had to stay at home, rather than attend a planned session at a local college. The staff members present had appreciated the problem and spent time to trying to find a solution, which included a phone call to the OLPA service co-ordinator. The problem appeared to have arisen because the monthly rota had not been amended when it was known that additional support would be needed on this particular day. In their comment cards, two relatives confirmed that in their opinion there were always sufficient numbers of staff on duty; one relative stated that in their opinion there were not. One of the staff members met with on 13 November said that she was working her last day after being employed with OLPA for several years. Staff mentioned that one of the immediate outcomes of this would be that the home would be short of a driver to support service users with their activities outside the home. The vacancy was discussed with the manager, who said that a new support worker had not been recruited and this was not likely to happen until the new year. The manager acknowledged that this would result in the increased use of relief and agency carers. Staff recruitment and employment records were seen at the OLPA office where they were kept centrally. The OLPA Personnel Officer was met with at the time. Staff members had individual files, which contained original documentation relating to their employment. The files showed evidence of appropriate recruitment practice, including copies of references, application forms and interview records. Records of Criminal Records Bureau (C.R.B.) disclosures and Protection of Vulnerable Adults (POVA) checks was looked at. In the case of the records relating to one staff member, there was a discrepancy between the information provided on the application form and what was recorded on their C.R.B. disclosure. This raised a question about how the inconsistency had been addressed with the staff member and what Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 22 assessment had been made of their suitability in the light of the C.R.B. disclosure. The Personnel Officer said that this had been discussed with OLPA’s Chief Officer but not documented. Induction and training was discussed with a staff member who had been appointed since the last inspection. The staff member had had a probationary period of six months, which was followed by an appraisal. Their induction had included Learning Disability Award Framework (LDAF) accredited training. The LDAF was a new development, which has been recommended at previous inspections. The staff member said that she had attended events as part of OLPA ‘s programme of training for support workers. To date, this had included food safety, drug administration, person centred planning and abuse awareness. Individual training records for staff were kept in the home. Other training provided for staff during the last year had included ‘freedom, rights and responsibilities’, health and safety, makaton, mental health awareness and first aid (appointed persons course). The most recently appointed staff member had not yet attended a first aid course with OLPA but said that she had completed a course prior to her employment. It has been recommended at previous inspections that the training programme is developed to include more learning disability specific training events and to give staff the opportunity to receive training from outside professionals and specialists. There have been some positive developments, with the introduction of LDAF and the inclusion of some new subjects within the OLPA in-house training programme. One staff member has achieved a National Vocational Qualification (NVQ) in care at level 2 and another staff member was undertaking the same NVQ. The standard of 50 of care staff with NVQ at level 2 or above was not yet met. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. Service users benefit from a manager who knows them well and is undertaking relevant qualifications. There is a lack of management cover at times, which may reduce the benefits for service users. Service users have the opportunity to contribute their views although these are not yet reflected in a quality assurance report. There are systems in place that help to safeguard the service users’ safety. EVIDENCE: Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 24 The manager, Keri Hendy is an experienced manager who has worked in a number of care services. Keri Hendy said that she had started the registered managers award in 2004 and was expecting to complete this before the end of 2006. She also said that she had started NVQ in care at level 4. Keri Hendy said that she spent 15 hours a week on management tasks and the remaining hours on providing direct support to the service users. The manager’s hours were included on the monthly staff rotas, which showed time spent in the home on weekdays and at weekends, often involving a long shift with a ‘sleep-in’ in between. A combination of the manager’s days off and annual leave resulted in the home regularly being without management cover for several days in a row. This was discussed with Keri Hendy, who said that one advantage of this way of working was that it enabled her to be familiar with the services users’ needs and to monitor practice in the home. There was an on-call system, by which staff could contact an OLPA manager outside office hours or when the home’s manager was not working. Staff used this when the manager was not present on 13 November, although it was not successful in sorting out the problem. Keri Hendy acknowledged that in this case, the home had needed to be more pro-active in ensuring that support was available to service users with their daily plans. The manager had produced a development plan, which identified areas that could be improved within the home. This included for example, decoration and having internet access. The plan had been discussed with staff at a team meeting. OLPA have carried out a survey of service users and stakeholders, which has given some indication of standards within the services that the organisation provides. The results of the survey had been collated although a report of the action to be taken had not yet been produced. The manager was advised of the amendment to Regulation 24 of the Care Homes Regulations, which concerns the type of report that must be produced. Health and safety records included a maintenance file and a file with information about the Control of Substances that are Hazardous to Health (C.O.S.H.H.). A maintenance inspection had been carried out on 27 October 2006. A general fire risk assessment had been reviewed on 1 October 2006. The housing association, which owns the property, had recently written concerning the need to address each service user’s need for evacuation as part of the fire risk assessment. The manager said that the OLPA health and safety officer was due to visit the home during January 2007 in connection with this. A record was kept of fire drills and checks of home’s fire precaution systems. There was a requirement at the last inspection for a record of fire instruction to staff to be maintained in the fire log book. The staff team had received instruction since the last inspection although this was recorded under general Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 25 training, rather than in the log book. It was agreed with the manager that the details of the instruction would be added to the fire log book. Staff members spoken with said that they had received training in fire precautions. Risk assessments concerning the service users were recorded on their individual files. Other information about health & safety, including the maintenance and servicing of equipment was received from the manager in a pre-inspection questionnaire. During the visits it was seen that there were records in use for the recording of hot water temperatures and carbon dioxide checks. The staff team meeting minutes referred to occasions when health & safety matters had been discussed. Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 26 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 1 23 2 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 1 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 x 3 x 2 x x 3 x Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 27 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 YA18 Regulation 15(2) Requirement The registered person shall keep the service user’s plan under review. In order to show compliance with this regulation, the service users’ personal support plans must be updated and reflect their current needs. 2. YA20 13(2) The registered person shall make 25/11/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In order to show compliance with this regulation, the registered person must ensure that: • Staff initial or enter the appropriate code on each occasion when medication is administered to service users. • The dose is recorded on each occasion that medication is administered to service users. • That staff sign when they have amended the preprinted record of Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 28 Timescale for action 31/12/06 • administration. That the Commission is notified of medication errors, in accordance with Regulation 37 of the Care Homes Regulations 2001. 25/11/06 3. YA22 22(3) 22(4) The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. In order to show compliance with this regulation, there must be evidence that: • The person who made the complaint has been informed within 28 days of the action to be taken. • The complaint has been appropriately investigated. 4. YA23 13(6) The registered person shall make 31/01/07 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. In order to show compliance with this regulation the arrangements being made for managing service users’ behaviour in the home must be reviewed with the appropriate professionals. The arrangements made as a result of the review will need to ensure that service users are not being placed at risk of harm or abuse and are not having their rights and freedoms restricted. 5. YA33 18(1)(a) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure DS0000028260.V319594.R01.S.doc 25/11/06 Sycamore Grove (45) Version 5.2 Page 29 that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. In order to show compliance with this regulation, there must be sufficient staff deployed to ensure that service users receive the support that they need attending their planned activities outside the home. 6. YA34 19(1)(a) The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home. In order to show compliance with this regulation, there must be written evidence that: • Any concerns about a prospective staff member have been discussed with that person. • The risk to service users of employing that person has been suitably assessed. 7. YA42 23(4) A record of fire instruction to staff must be maintained in the fire log book (outstanding from last inspection). 31/12/06 25/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 30 1. 2. YA6 YA33 That the system of Shared Action Planning is consistently completed with each service user. That the way in which the staff rota is produced is reviewed with the aim of ensuring that day to day changes in the service users’ activities and need for support can be quickly responded to. That the process of recruiting a new member of staff is started at the earliest possible opportunity in order to reduce the need for agency carers and relief staff to be deployed. That staff members have the opportunity to attend more external training events and training courses which include the contribution of outside agencies. That the way in which management cover is arranged in the home is reviewed in order to ensure that cover is provided in a way that best meets the needs of service users and staff. 3. YA33 4. YA35 5. YA37 Sycamore Grove (45) DS0000028260.V319594.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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