Inspection on 12/10/05 for 56 Sycamore Grove

This inspection was carried out on 12th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

56 Sycamore Grove 18/04/07

56 Sycamore Grove 24/10/06

56 Sycamore Grove 05/05/06

56 Sycamore Grove 21/06/05

56 Sycamore Grove 02/03/05

56 Sycamore Grove 14/01/05

56 Sycamore Grove 26/02/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Sycamore Grove (56) 56 Sycamore Grove Trowbridge Wiltshire BA12 9LR Lead Inspector Malcolm Kippax Unannounced Inspection 12th October 2005 10:25 Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sycamore Grove (56) Address 56 Sycamore Grove Trowbridge Wiltshire BA12 9LR 01225 763056 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 Judith Anne Gilmore Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only one named female service user over 65 years of age. Date of last inspection 21st June 2005 Brief Description of the Service: 56 Sycamore Grove is home for up to three people with a learning disability. 56 Sycamore Grove is one of a number of care homes that are run by the Ordinary Life Project Association (OLPA). The home is situated in a residential area of Trowbridge. There is a convenience store nearby and Trowbridge provides a range of amenities and town centre shops. The home has its own vehicle for trips out. The property is a domestic style and detached bungalow. Each service user has their own room. There is a large sitting room with a dining area. Staffing levels are maintained at a minimum of one staff member throughout the day, with additional staff members deployed at certain times. An agency carer provides waking cover during the night. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 10.25 am and took place over 4½ hours. The three service users were at home at the time and receiving support from two staff members. A third staff member was out shopping and returned later. The service users are not able to comment directly on the care that they receive. There was discussion with the staff members and their interactions with service users were observed. There was a tour of the accommodation. Care plans, meeting minutes, menus and medication records were looked at. Mrs Gilmore’s application to be the registered manager has been approved since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Additional facilities could be provided in the home for the benefit of service users who have specialist needs. The lounge is a comfortable sitting area, although service users may enjoy having a more recreational and stimulating area that encourages interaction and involvement, in contrast to the more passive activities that take place in the lounge. The medication records need to be changed to ensure that staff members keep an accurate record of when they remove medication from the original packs. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 6 This has become necessary because staff members need to fit in with how agency carers wish to administer medication when they work in the home. Changes made to the service users’ care plans could be better shown in their individual records. It should be evident from the records that all areas of need have been reviewed as part of an individual plan at least every six months. 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 (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 (56) DS0000028338.V257123.R01.S.doc Version 5.0 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): 2 and 5 Prospective service users are likely to benefit from the home’s admission arrangements. Service users do not understand the terms and conditions that have been produced and should receive support with this from a third party EVIDENCE: No new service users have moved into the home in recent years. There is a written admissions procedure. This includes the need for a community care assessment to be received in respect of the prospective service user. The procedure states that the OLPA service co-ordinator will carry out an appropriate assessment in the absence of a community care assessment. A prospective service user will make an initial visit to the home, with further visits being made to suit individual needs. The placement is reviewed after four weeks and confirmed after twelve. License agreements produced by OLPA were seen on the service users’ files. The home’s manager had signed the agreements and a relative had signed one of them. An appropriate person who is independent of OLPA had not signed the other two agreements. The service users themselves do not have the capacity to understand the contents of such an agreement. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 9 Such a terms and conditions statement is useful, as there are on-going difficulties between OLPA and Wiltshire County Council, which have resulted in a lack of agreement about the terms of individual contracts. However the licence agreements should be agreed with a third party acting on the service user’s behalf and cover those items which are specified under Standard 5.2 of National Minimum Standards. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 (Standard 8 was inspected and met at the last inspection.) Service users benefit from the detailed guidelines that are available to staff in particular areas of support. Service users benefit less from the way in which care plans and personal goals are reviewed and recorded. Service users receive support from staff with decision making. Risk assessments are helping to ensure that service users can participate safely in activities. EVIDENCE: Each service user had a personal file containing a range of guidelines about their individual support and preferred routines. Several of these were very detailed and provided comprehensive and up to date information about the service users’ needs in particular areas. Guidelines and monitoring in some areas had increased during recent months, in response to incidents in the home involving service users. Guidelines and information had been recorded in different formats. They had been produced over recent years and some were not dated. It was not clear Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 11 whether these were part of an original care plan and what the review process consisted of. It should be evident from the records that all areas of need have been reviewed as part of an individual plan at least every six months. The service users’ files included goal sheets as part of ‘Shared Action Planning’. The most recent goals were recorded in 2004. Some of the goals were ‘ongoing’, including 1: 1 time with staff, the opportunity to make choices and ‘being pampered’. The service users’ personal diaries were identified as the means of recording these goals. A separate form would be a clearer method of monitoring the goals and show what activities have taken place and their frequency. Service users are not able to express their views directly in a meeting situation. Instead, staff members take the lead and use a ‘Tenants Discussion’ form to record relevant issues concerning the service users. Examples of these included ideas for a birthday party, the need to change seating arrangements and things that service users have enjoyed doing. Some of these ideas had been prompted by staff, based on recent events. This is good practice and appears to be a very worthwhile means by which matters affecting service users can be discussed and followed up. A discussion had taken place on 22 September 2005 and another was due to be held on 25 October 2005. Records of risk assessments were included in the service users’ files. These had been produced over recent years in connection with the service users’ different activities and needs. In May 2005, a risk assessment had been carried out concerning the service users’ safe use of the home’s minibus. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 and 17 (Standards 13 and 15 were inspected and met at the last inspection.) Service users have well established routines which include community activities and unstructured time in the home. Service users are encouraged to treat the home as their own and to be involved in the daily routines. Service users are provided with a varied menu. EVIDENCE: Each service user had a programme of regular weekly activities. One service user attends a resource centre for four days a week. The other two service users had few regular activities and staff members said that new opportunities were being sought. These service users spend more time in the home and going out with staff. During the inspection, service users had unstructured time in the home and were mainly sitting in the lounge. Staff members said they may be a trip out in the afternoon. The lounge is mainly arranged as a comfortable sitting area with a television and a music centre. It is Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 13 recommended that consideration is given to how other facilities can be set up, which will offer service users the opportunity of a more stimulating experience. Service users are not able to contribute to, or be independent in, the usual household tasks for reasons of safety and understanding. It was evident during the inspection that staff members encourage service users to be involved in small ways and to take an interest in what is happening within the home. Staff members sat with service users at the lunch table. Two service users received support with eating. The service users’ records included information about diet and eating. Guidelines on mealtimes had been written in September 2005 for one service user. Information about other service users was available, some of which dated back to 1999. Information was recorded under various headings such as ‘Daily Routines’, ‘Mealtimes’ and ‘Eating’. It is recommended that a more consistent approach is taken in how this information is recorded and when the service users’ needs in this area are reviewed. Staff members said that the meals are chosen, as far as possible involving the service users, on each Sunday night for the week ahead. Sandwiches are popular at lunchtime. A list was on display in the kitchen showing what fillings had been prepared, in order to help ensure that variety is provided. A record is kept of the meals served on a daily basis. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 (Standard 18 was inspected and almost met at the last inspection.) Service users receive good support with their healthcare and medication. However following a change in policy, there is a shortcoming in the recording of medication. EVIDENCE: The service users’ files included ‘Medical and Health Appointments’ forms that are completed by staff. An exception to this was appointments with chiropodists that are recorded in the service users’ personal diaries. The forms showed that service users have had contact with various healthcare professionals and specialists. Entries had been made in October and one service user left during the afternoon for a hospital appointment. Another service user had seen her GP recently. One service user’s health needs have been assessed since the last inspection with the involvement of different healthcare professionals. Records are kept of regular weight checks. A medical profile was available for each service user. Staff members manage medication for the service users, who cannot do this themselves. The Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 15 administrative records were up to date. Staff members said that they have to prepare some medication in advance, for agency carers to administer later in the day. This is as a result of the agency’s policy on how their carers can administer medication. This involvement by staff was not being recorded; it is important to do this because of the need for accountability when medication is administered. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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 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 23 was looked at during the last inspection and met.) EVIDENCE: Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 17 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): 27 and 30 (Standard 24 was inspected and almost met at the last inspection; standard 28 was met.) Service users will benefit from changes that are due to be made in the bathroom. The accommodation is kept clean and tidy. EVIDENCE: There is a bathroom with WC. This is the only facility for use by service users and staff. A member of staff said that plans were in hand to refurbish the bathroom and to fit a new suite. There is a ceiling hoist for the bath. This was originally installed for a former service user and is now being used by one of the current service users. The involvement of an occupational therapist would be beneficial at this time, to advise on the most appropriate aids in the bathroom to meet the service users’ needs. The suitability of the ceiling should be considered, as a different type of a bath hoist/chair may now be more suitable. The accommodation looked clean. Laundry is carried out in the kitchen, with storage bins kept outside. The staff member spoken with was aware of the risk of cross-infection and said that the practical tasks were kept as separate as possible. There was no written guidance about the arrangements, which Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 18 should be considered for the benefit of agency staff and others who are less familiar with the home. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 19 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): 35 (Standard 33 was inspected and almost met at the last inspection.) The appointment of new staff members has been beneficial. Training is provided through in-house activities but the benefits for service users are reduced by the lack of an accredited programme of induction for new staff. EVIDENCE: The two staff members present at the start of the inspection said that they had started working in the home since the last inspection. This has reduced the need for agency and relief staff. Agency carers still provide waking cover during the night. New staff members had participated in an OLPA programme of induction. However, Learning Disability Award Framework training is not provided. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 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): These standards were not looked at on this occasion. (Standard 42 was inspected and not met at the last inspection. Requirements identified at the time have since been met.) EVIDENCE: Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 21 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 3 X X 2 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore Grove (56) Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000028338.V257123.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes. The provision of individual contracts for service users (Requirement 1) is being discussed further. The implementation of a quality assurance system (Requirement 2) was not looked at during this 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. Standard 1 YA3 Regulation 5 Requirement Timescale for action 31/07/05 2 YA39 24 3 YA6 15 4 YA20 13 The Registered Person must ensure that each service user is supplied with a costed contract. The ‘Timescale for action’ refers to the date that was identified at the inspections on 02.03.05 and 21.06.05. The Registered Person must 31/07/05 devise and implement an effective quality assurance system. The ‘Timescale for action’ refers to the date that was identified at the inspections on 02.03.05 and 21.06.05. Individual service users’ plans 13/10/05 must be reviewed at least every six months and updated to reflect changing needs. A record must be kept of all 13/10/05 occasions when medication is taken out of its original containers in advance of its administration to service users. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 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 2 3 4 5 6 7 8 9 10 Refer to Standard YA5 YA5 YA6 YA6 YA12 YA17 YA19 YA27 YA30 YA35 Good Practice Recommendations That a third party, usually the service users care manager, is involved in agreeing and signing any terms and conditions statements. That the licence agreements include all items that are specified under Standard 5.2 of National Minimum Standards. That changes to a care plan are more clearly identified. That a separate form is used for the recording of activities that take place in connection with the service users’ personal goals. That the opportunity for recreational and therapeutic activities within the home are reviewed, with consideration given to the provision of a new facility. That the information about eating and dietary needs is updated and recorded using a single format. That chiropody appointments and their outcome are recorded in the health section of the service users’ personal records. That advice is taken from an occupational therapist about the provision of aids and equipment in the bathroom. That a written procedure is produced concerning the movement of soiled laundry and the risk of cross-infection. That Learning Disability Award Framework accredited training is available to new staff members. Sycamore Grove (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 24 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 (56) DS0000028338.V257123.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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