Inspection on 21/06/05 for 56 Sycamore Grove

This inspection was carried out on 21st June 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

56 Sycamore Grove 18/04/07

56 Sycamore Grove 24/10/06

56 Sycamore Grove 05/05/06

56 Sycamore Grove 12/10/05

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 21st June 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 (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 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 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 Margaret Jean Kemp Care Home 3 Category(ies) of LD Learning Disability (2) registration, with number LD(E) Learning Disability - over 65 (1) of places Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Only one named female service user over 65 years of age Date of last inspection 2nd March 2005 Brief Description of the Service: 56 Sycamore Grove is registered to provide care for up to three adults with a learning disability. 56 Sycamore Grove is one of a number of care homes 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 domestic style and detached bungalow, which provides single room accommodation. 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 two staff members deployed at particular times. One waking staff member works during the night. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 4.30pm and took place over two hours. The main purpose of the inspection was to follow up requirements that were identified at the previous inspection. The three service users were met with although verbal communication on an individual basis was very limited. An agency staff member was working at the time, together with the acting manager, Mrs J. Gilmore. Mrs Gilmore’s application for registration as manager was being processed at the time of the inspection. Some of the home’s records were looked at. What the service does well: What has improved since the last inspection? What they could do better: Requirements concerning the safety of service users were identified at the last inspection. It is a matter of serious concern that OLPA have not met these requirements by the required date. This is a significant shortcoming and the organisation needs to follow up why the appropriate action was not taken within the identified timescale. An immediate requirement was made to complete the outstanding requirements by 27 June 2005. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.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 (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.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 (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.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 EVIDENCE: Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.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) 8 Service users are encouraged to take an active role in the home. However, such involvement is greatly limited by safety factors and by the service users’ ability to participate. EVIDENCE: It was seen that service users contribute in small ways to the domestic routines, for example when the tea meal is served and cleared away. Service users were not excluded from the kitchen although safety considerations and the service user’s ability meant that the staff member was taking full responsibility. The agency staff member present said that she had been given good information about what the service users were able to do. Service users are not involved in the development of policies and procedures and would not be able to contribute within the setting of a formal, structured meeting. A relative spoken with during the inspection felt that staff had a positive approach to involving service users in different aspects of the home. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 10 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) 13 and 15 Service users have well established routines which include regular community activities and contact with relatives EVIDENCE: 56 Sycamore Grove is situated in a residential area of Trowbridge and is within walking distance of some local shops. The home has it own vehicle for trips out. Staff members support service users with shopping and with using local amenities. Service users have planned activities that are timetabled to take place during the week. Other activities are arranged on a more spontaneous basis according to the service users’ feelings and interests at the time. The relative spoken with was a frequent visitor to the home. The service user concerned benefited from trips out and from having regular contact with a close relative. Through donations and fundraising. OLPA have been able to purchase a caravan that service users can now use for holidays and short breaks. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 11 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 Service users receive a high level of physical care although an individual approach is compromised by the lack of guidance about how personal care is provided. EVIDENCE: There is written guidance about the areas in which service users require personal care. The agency staff member spoken with confirmed that this information was available to her. Previous inspections have found that the home does not have a detailed policy and procedure regarding how personal care is provided. A requirement was made at the last inspection to address this matter, for the protection of service users and staff, by the end of June 2005. There is a brief policy headed ‘Provisions of Support’ although this does not directly address the issue of personal care given to service users by staff of the opposite gender. Mrs Gilmore said that there had been no change in OLPA’s position and if service users do not express a preference then male and female staff will provide personal care to any service user. In practice, agency staff members may provide personal care to service users of the opposite sex who are not able to make an informed choice about who provides their personal care. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 12 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 Two service users are being harmed by the actions of another service user EVIDENCE: The Commission has been informed, through Regulation 37 notifications, of incidents that have taken place involving one service user’s physical aggression towards the other two service users. These have been followed up through referrals under the vulnerable adults procedures. The home is working with the local Community Team for People with a Learning Disability to find ways of ensuring that service users receive the support they need and are not at risk. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 13 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) 24 and 28 The accommodation is homely but service users are at risk from a lack of attention to health & safety requirements. EVIDENCE: The home is an ordinary detached bungalow in a residential area. The accommodation is decorated and furnished in a homely and domestic manner. There is a spacious sitting room, which also contains a dining area. The home has a front and rear garden and there is some car parking at the front of the property. Requirements were made at the previous inspection concerning safety matters. These have not been completed within the required timescale (see ‘Conduct and Management of the Home’ section, Standard 42). Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 14 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 The service users’ needs cannot be met from within the permanent staff team. Consistency and continuity of support for service users is affected by the continuing use of agency and relief staff. EVIDENCE: An agency staff member and the home’s Acting Manager were working in the home until 6 pm. After this time there was lone working by the agency staff member. Agency staff members are deployed to provide waking staff cover during the night. New staff members need to be recruited in order to ensure that there is an effective permanent staff team who can meet the service users’ needs. Recruitment was taking place for new support workers, which will strengthen the permanent staff team. The relative spoken with during the inspection had experience of the home over several years and felt that this was a relatively settled period in terms of the running of the home. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 15 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) 42 Service users are at risk from a lack of attention to health & safety requirements EVIDENCE: Requirements were identified at the last inspection concerning the need for a fire risk assessment and a risk assessment in respect of the unguarded radiators. These areas had not been assessed by the required date of 31 May 2005. An action plan for the covering of the remaining uncovered radiators had also not been produced. An immediate requirement notice was issued confirming completion of these assessments and outstanding requirements by 27 June 2005. Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 16 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x x Standard No 11 12 13 14 15 16 17 x x 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore Grove (56) Score 2 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 17 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 1 Regulation 6 Requirement The Registered Person must ensure that the Service User’s Guide contains all information required by regulations and standards. The timescale of this requirement, identified at the last inspection, has not elapsed The Registered Person must ensure that each service user is supplied with a costed contract, identifying terms and conditions, in a format and language that is appropriate to their needs.This was identified at the last inspection and although it is noted that OLPA is awaiting updated local authority contracts, other aspects could progress alongside this. The timescale of this requirement, identified at the last inspection, has not elapsed The Registered Person must devise and implement an effective quality assurance system. The timescale of this requirement, identified at the last inspection, has not elapsed The Registered Person must Timescale for action BY 07/10/05 2. 3 5 BY 31/07/05 3. 39 24 BY 31/07/05 4. 42 13 BY Version 1.30 Page 18 Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc 5. 42 13 ensure that there is a documented risk assessment for all remaining uncovered radiators, with an action plan for the guarding of those still needing this. This is outstanding since the last inspection The Registered Person must ensure that a fire risk assessment is developed This is outstanding since the last inspection 27/06/05 BY 27/06/05 6. 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 18 Good Practice Recommendations 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 Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Grove (56) D51_D01_S28338_SYCAMOREGROVE(56)_v234806_210605Stage4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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