Inspection on 24/10/06 for 56 Sycamore Grove

This inspection was carried out on 24th October 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 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 05/05/06

56 Sycamore Grove 12/10/05

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 Key 24th October 2006 10:50 Sycamore Grove (56) DS0000028338.V316099.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 (56) DS0000028338.V316099.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 (56) DS0000028338.V316099.R01.S.doc Version 5.2 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 Vacant 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.V316099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only one named female service user over 65 years of age. Date of last inspection 5th May 2006 Brief Description of the Service: 56 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). 56 Sycamore Grove is situated in a residential area of Trowbridge. There are some shops nearby. The home has its own vehicle for trips out. The property is a 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. The range of fees at the time of this inspection was £899.47 - £1028.63 Sycamore Grove (56) DS0000028338.V316099.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, which took place on 24 October 2006 between 10.50 am and 1.05 pm. A second visit took place on 7 November 2006 between 1.00 pm and 4.30 pm. The OLPA service coordinator was met with at the home on 20 November 2006. The three service users who live at 56 Sycamore Grove were met with during the visits, although they were not able to communicate their views about living at 56 Sycamore Grove. The home was without a manager at the time of this inspection. Evidence was obtained during the visits through: • • • • Discussion with staff members and with the OLPA service co-ordinator. Observation. A tour of the home. Examination of some of the home’s records, including the three service users’ personal files. Information from the previous inspection of the home, which took place in May 2006, has also been included in this report. Other information has been received and taken into account as part of the inspection: • • Comments were received from a local authority care manager. Two of the service users’ relatives completed comment cards about 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: Service users are encouraged by staff to make choices and take an active role in the home. Staff talk to service users about things they would like to do. Some of the service users’ individual needs and wishes have been recorded as personal goals, which helps to highlight the areas in which each person requires support. Service users receive support with their relationships and have regular contact with family members. This helps service users to keep in touch with the wider community and with events outside the home. Service users enjoy the meals. Mealtimes are arranged in an individual way, which takes account of the service users’ needs and preferences. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 6 Service users receive the support that they need with their medication and are protected by the home’s procedures. The home is located in an ordinary residential area, where service users can be part of a local community and are close to a range of facilities and amenities. The accommodation is generally homely and domestic. There is a spacious lounge and the service users have their own rooms nearby. Individual staff members respond flexibly and are keen to develop the service for the benefit of service users. During the visits, staff members were seen to be providing support in a positive and friendly manner. The views of service users and their representatives are being sought. Service users benefit from the regular discussions that staff have about their current needs and welfare. What has improved since the last inspection? What they could do better: The home was without a registered manager at the time of this inspection. The OLPA service co-ordinator and the manager from another OLPA home were spending time in the home. This was providing some useful management input into the home and the areas in need of attention were being prioritised. Risk assessments and care records were being reviewed at the time of the visits, although it is of concern that these were only now being addressed as they were in need of updating at the last inspection. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 7 The appointment of a new permanent manager is a priority to ensure that OLPA meets its legal responsibilities and so that service users can benefit from a period of stability in the running of the home. The staffing level resulted in a lack of flexibility as to when service users could receive individual support with activities. There are concerns about how the needs of service users are being met, particular from 8 am – 9 am and after 6pm, when a staff member or agency carer works alone until the following morning. Service users were assessed as needing one to one support in some areas of their lives and personal care, although the way that staff are deployed meant that it would be difficult to provide this without compromising the heath & safety of other service users. The deployment of staff needs to ensure that service users receive support in accordance with their assessed needs and the home’s guidance on the provision of personal care. Individual contracts for service users have not been agreed between OLPA and the funding authority. OLPA have produced license agreements for service users, however these have also not been agreed between the appropriate parties. Service users do not have the capacity to understand the contents of the agreements and should receive support from an appropriate person outside the home, to ensure that their rights are protected. The agreements include a statement that a service user may be required to move to a different bedroom in the home, however no information is given about the circumstances in which this could happen. The agreements should not only be signed by the appropriate parties, but also appear fair and be updated to ensure that they include all relevant items. Although there is a system (Shared Action Planning) in place for identifying personal goals, the benefits for service users are reduced because of how the system is used. Better information could be recorded about some of the service users’ personal goals. It was not always clear how achievement of the goals would be measured and what action should be taken, and by whom, in order to ensure that service users make good progress with achieving their goals. One service user did not have a current Shared Action Plan. Timescales had been identified within the service users’ support plans and assessments for when different areas of support needed to be reviewed. These timescales were not always being met, for example support with eating was not being reviewed monthly, as stated in the plan. Reviews need to be undertaken within the identified timescales to ensure that the risk to service users has not changed and that service users receive the appropriate level of support. Service users would benefit from changes to the home environment, which would provide some new facilities and the opportunity for different activities. 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 it has previously been recommended that service users may benefit Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 8 from having the use of another area where they can take part in more stimulating and recreational type activities. The garden should be tidied up and better maintained in order to make the most of the new features that are being created. Internally, the home was generally clean and tidy, although one domestic area was unhygienic and in a poor condition when seen during the first visit to the home. This area was much improved when seen on 20 November, although it highlighted the need for checks and arrangements to be in place, which will ensure that an area of the home is not allowed to get into a poor state. The views of service users and their representatives are being sought but are not well reflected in the home’s most recent development plans. OLPA has conducted a survey of stakeholders, which has been useful in providing feedback about standards across the organisation as a whole. This process could be usefully developed in a way which will provide feedback about the standards within the individual homes. 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 (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 9 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.V316099.R01.S.doc Version 5.2 Page 10 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): 5 Quality in this outcome area is poor. This judgement has been made using available evidence including the visits to the home. Individual contracts for service users have not been agreed between OLPA and the funding authority. Service users do not understand the terms and conditions that OLPA have produced and should receive support with this from an appropriate person. EVIDENCE: It was reported at the last inspection that discussions about contracts were continuing between OLPA and Wiltshire County Council. During this inspection, the OLPA service co-ordinator, Ms Beavan, said that individual contracts for the service users had not yet been agreed between OLPA and the funding authority. OLPA had produced license agreements for service users, which include a number of terms and conditions. The service users did not have the capacity to understand the contents of such agreements and it has previously been recommended that a third party signs the agreements. The agreements included a statement that a service user may be required to move to a different bedroom in the home. However, no information was given about the circumstances in which this could happen. Another recommendation Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 11 has previously been made that the licence agreements include all items that are specified under Standard 5.2 of National Minimum Standards. Standard 2 did not apply at this time as no new service users have moved into the home in recent years. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 12 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 was adequate. This judgement has been made using available evidence including the visits to the home. There is a system is in place for identifying personal goals although the benefits for service users are reduced because of how the system has been used. Service users are helped by staff to participate in the home. However, safety factors and the availability of support have an impact on what the service users can do. Changes in occupancy have been agreed since the last inspection, in response to the service users’ needs. EVIDENCE: The service users’ files contained records of ‘Shared Action Planning’ (S.A.P.), the system used for identifying the service users’ wants and needs and their personal goals. Forms were being used for recording the different stages of S.A.P., however the information had been inconsistently completed. There were gaps in the records, which meant that it was not clear how achievement Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 13 was being measured and what stage the service users were at with meeting their goals. One service user did not have a current Shared Action Plan. It was recommended at the last inspection that the goals reflect a wider range of individual activities that the service users may wish to experience. Many of the goals continue to relate to core values and basic care needs, rather than on developing new experiences and activities. This was discussed with the OLPA service co-ordinator, who said that this was important in order to highlight the importance of physical care and support in meeting each service user’s needs. It was also the intention to introduce a new system of Person Centred Planning, to replace S.A.P. It was reported at the last inspection that there was an underlying incompatibility between the three service users, which affected the independence and freedom of movement that service users could exercise within the home. Following review meetings a decision has been made that one service user will be moving from the home when a suitable residence has been found. The service users were not able to express their views directly in a meeting situation. Instead, staff members were taking the lead, using a ‘Tenants Discussion’ form to record relevant issues concerning the service users. The records of a discussion in September were looked at. There had been a discussion about various matters, including travelling in the minibus, swimming and family relationships. The current needs of each service user had been commented on and decisions made about how particular matters would be followed up and who would be responsible for doing this. These occasions appeared to be a useful time to focus on matters affecting individual service users. It was recommended at the last inspection that the service users’ personal files are reorganised to ensure that the contents are up to date and continue to be relevant. The organisation of the service users’ files has improved and the care and assessment information was more clearly presented. Some general risk assessments involving facilities in the home were being updated at the time of the inspection. Some new assessments had been undertaken since the last inspection. These concerned the safety of service users when undertaking particular activities in the home and in the community. The assessments provided guidance for staff about the level of support required by service users. The service users generally required a high level of individual staff support and supervision with many daily activities. It had been assessed that the three service users cannot travel together in the home’s minibus. The deployment of staff at particular times of day meant that there was a lack of flexibility as to when service users could receive support with certain activities. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 14 During the visits, staff members were seeking to involve service users in some of the domestic routines. A staff member prepared lunch. Service users with an interest in what was happening were able to spend time in the kitchen, under supervision. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 15 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 was adequate. This judgement has been made using available evidence including the visits to the home. Service users have established routines during the day. However, the level of support and facilities that are available limit flexibility and the opportunities for personal development. Service users are part of the local community. They receive support with their family relationships. Service users enjoy their meals. Mealtimes are arranged in an individual way, which takes account of the service users’ needs and preferences. EVIDENCE: 56 Sycamore Grove is situated in a residential area of Trowbridge and is within walking distance of some shops. The home had its own vehicle, which takes a wheelchair. This vehicle is of a relatively old design. It was reported at the last inspection that the manager and staff had said that they would prefer to Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 16 have a different type of vehicle, which would draw less attention to the service users and the support that they need. One service user attended a resource centre for much of the week. Another service user’s timetable showed only two regular activities attended outside the home each week. Other activities were arranged on a more spontaneous basis according to the service users’ interests on the day and the staff support available. Two service users in particular had unstructured time during the week and spent a lot of this time in the home. During the visits, service users were using the lounge, which is mainly arranged as a sitting area with a television and a music centre. It was recommended at the last inspection that the opportunity for recreational and therapeutic activities within the home is reviewed, with consideration given to the provision of a new facility. Ms Beavan said that she would like to see the lounge used in different ways, although resources were not readily available for this. Ms Beavan also raised concerns about the impact that changes in the provision of day care in the community would have on the service users. Staffing levels reduce to one person working after 6pm, which limits what the service users are able to do in the evenings. In response to a question about what the home could do better, one relative commented on the need to keep the service users from being bored. Information about the service users’ family contacts and important people in their lives was recorded in their personal files. Each service user had a close relative who they were in regular contact with. In the comment cards received from two relatives, one person stated that they are made welcome, but did not respond to a question about whether they can visit in private. The other relative had responded with ‘Not Applicable’ to the questions about visiting. Ms Beavan said that she regularly met with one service user’s parents to keep them up to date with events. The staff member said that a menu is written each Sunday for the week ahead and that service users had their main meal either at lunch or at tea, depending on who was at home. Lunch was observed. The two service users ate together, receiving support from the staff member who had prepared the meal. Lunch was a freshly prepared, cooked meal of cottage pie and vegetables. The menu for the week showed a varied range of meals, which included roast, take-away, curry and other dishes that were known to be popular with the service users. Service users received some physical assistance and verbal prompting with eating. This was given in individual and friendly manner. Guidelines for meal times and assessments about support with eating have been produced. As reported under ‘Personal and Healthcare support’ some assessments had not been reviewed within the required frequency. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 17 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 was poor. This judgement has been made using available evidence including the visits to the home. There has been an improvement in the service users’ support plans. These now provide better information for staff about the service users’ needs although service users are at risk because of a lack of review in particular areas. The deployment of staff means that there are times of day when service users cannot receive personal care in the way that they require. Service users receive support with accessing health care; some individual needs were responded to at the time of the inspection. Service users receive the support that they need with their medication and are protected by the home’s procedures for its administration. EVIDENCE: Each service user had a Daily Care Plan file which contained guidance for staff about the service users’ personal care needs. A requirement was made at the last inspection that each service user has a care and support plan that is up to Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 18 date and comprehensive. The service users’ care plan files have since been reorganised and had much of the contents updated. The files contained details of the service users’ personal care needs in areas such as bathing, foot care, care of eyes and dressing. Areas of need were highlighted where service users required one to one support from staff. These included assistance with eating because of a risk of choking, and supervision with toileting and bathing because of the risk of seizures. Timescales had been identified within the service users’ support plans and assessments for when different areas of support needed to be reviewed. These timescales were not always being met, for example support with eating was not being reviewed monthly, as stated in the plan. Guidance for the provision of support had been written since the last inspection, which stated that two people will be on duty when female service users are receiving personal care. The staff rota showed that there is lone working by staff from 6 pm until 9 am the following morning. The way that staff are deployed meant that it would not be possible to provide service users with the individual support they require at particular times of day without compromising the heath & safety of other service users. In their comment cards, the service users’ relatives confirmed that they are satisfied with the overall care provided, although one commented on the shortage of staff. One service user had an Epilepsy Management Plan, dated September 2005. This was due to be reviewed in September 2006, although a review had not taken place. This was brought to the service co-ordinator’s attention, who immediately followed it up by contacting the Community Team for People with Learning Disabilities. A record of seizures was being kept. Seizures have occurred at different times of day, including when there has been lone working by staff. One service user had a hospital appointment at the time of the visit on 24 October because of an injury arising from a fall during a seizure. The same service user was attending hospital again during the visit on 20 November because of another injury, although the cause of this one was not known at the time. The service users’ files included medical and health sections, where staff recorded and reported on appointments with heath care professionals. Appointments with chiropodists are now also recorded in the health section, rather that in the service users’ personal diaries, as recommended at the last inspection. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 19 Staff members were managing medication for the service users, who cannot do this themselves. A medical profile had been written for each service user. Health professionals were involved in reviewing the service users’ medication. There had been a change in staff routine. The agency carer on night waking duty no longer administers the morning medication at the end of their shift; the support worker who comes on duty at 8 am now did this. The medication arrangements were looked at during the visit on 24 October. Medication was kept in its own cabinet within a larger office cupboard that was mainly used for the storage of files. The office cupboard was lockable, but the inner cabinet was not, which meant that the medication was not secure when the files were being used. This had received attention before the home was visited again on 20 November 2006. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 20 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 was adequate. This judgement has been made using available evidence including the visits to the home. The service users have very limited understanding of the complaints procedure and are dependant on others to raise concerns on their behalf. Service users are benefiting from a reduction in harmful incidents that arise from a service user’s behaviour. EVIDENCE: OLPA has produced a complaints procedure, which includes contact details for people outside the home. The service users were dependant on other people to raise concerns on their behalf. It was recommended at the last inspection that a check is made with the service users’ relatives and other interested parties to ensure that they have a copy of the home’s complaints procedure. In their comment cards, the relatives stated that they are aware of the home’s complaints procedure. It was reported at the last inspection that incidents had taken place involving one service user’s physical aggression towards the others service users and occasionally towards staff. The service user’s care manager commented that the unpredictable and high risk behaviours have dissipated. The staff member and service co-ordinator also confirmed that these incidents were now less frequent; the reason for this was unclear, although it was thought that having separate dining arrangements had helped. As reported under ‘Individual Needs and Choices’, one service user will be moving from the home when a suitable residence has been found. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 21 Training in abuse awareness is provided ‘in-house’ as part of the OLPA programme of staff training. The home has had experience of making a referral under the vulnerable adults procedures. One service user had an unexplained injury, the cause of which was followed up by Ms Beavan and staff during the visit on 20 November 2006. The service user’s care manager was contacted, with a view to an adult protection investigation being undertaken. The Commission has since received a Regulation 37 notification about this. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 22 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 was mainly adequate, but poor in one particular area. This judgement has been made using available evidence including the visits to the home. The accommodation is homely and domestic. Service users would benefit from changes to the home environment, which would provide some new facilities and the opportunity for different activities. The home was generally clean and tidy, although one domestic area was unhygienic and in a poor condition when the home was first visited. 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, with a dining area in one corner. The home has a front and rear garden and there is some car parking at the front of the property. A sensory area is being developed in one area of the garden, which staff said was particularly beneficial for one service user. Other features, such Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 23 as wind chimes, have been placed around the garden. Parts of the garden were overgrown and in need of tidying up and better upkeep. There is one W.C. for use by the service users and staff. This is in the bathroom, which has been refurbished since the last inspection. The accommodation generally looked clean and tidy. Clothes washing was carried out in the kitchen. A procedure had been written for the movement of laundry to reduce the risk of cross-infection. Guidance on infection control was included in the home’s file for agency carers. The home’s garage was seen on 7 November 2006. This was being used as an additional domestic area, with a freezer and a tumble drier. Most of the garage was taken up with storage of various household objects and items that were waiting to be disposed of. There was no clear separation between the domestic and the storage areas in the garage. Cobwebs had built up in the area around the freezer and tumble drier and there was a build up of debris, as there was a lack of extraction from the tumble drier. The area was much improved when seen again on 20 November. The tumble drier had been replaced and the area had been given a good clearout and tidy up. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 24 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 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including the visits to the home. Individual staff members respond flexibly and are keen to develop the service for the benefit of service users. However the deployment of staff results in a lack of individual support at particular times of day, which puts service users at risk. Service users will benefit from the developments that are taking place in the induction and training of staff. (Standard 34 did not apply at the time of this inspection). EVIDENCE: The staff rotas for October and November 2006 showed at least one person working in the home at all times. Two people were deployed between 9 am and 6 pm. Occasional more staff were working at a particular time of day. There was lone working from 6 pm in the evening until 9 am the following day. An agency carer was employed to provide waking cover from 8 pm until 8 am. Guidance for the provision of support stated that two people will be on duty when female service users are receiving personal care. As reported under ‘Personal and Healthcare Support’, service users have been assessed as Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 25 requiring one to one support in particular areas. The deployment of staff meant that any personal care and one to one support would be need to take place between 9 am and 6 pm, without compromising the heath & safety of other service users. During the visits, staff members were engaged in a range of tasks. Staff members appeared aware of risks to service users within the home. At times, one staff member supported a service user outside the home, leaving the other staff member to support two service users while also preparing a meal. Staff members appeared to be responding flexibly to different situations, including supporting a service user who needed to have a hospital appointment at short notice. In their comment cards, one relative stated that staff do the best they can in the circumstances. No new staff members had been appointed since the last inspection and employment records were not looked at on this occasion. Staff training was examined at the last inspection. A recommendation that Learning Disability Award Framework (LDAF) accredited training is available to new staff members, has since been met. Staff attendance on first courses was checked. All staff members except one, have attended an appointed person’s course in first aid. One person was booked to attend a course in December 2006. A member of staff had recently started their National Vocational Qualification in care at level 2. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 26 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 mostly adequate and poor in particular areas. This judgement has been made using available evidence including the visits to the service. The management arrangements have not ensured that good standards are maintained in the home. The appointment of a new permanent manager is a priority to ensure that OLPA meets its legal responsibilities and so that service users can benefit from a period of stability in the running of the home. The views of service users and their representatives are being sought but are not well reflected in the home’s development plans. There are systems in place that help to safeguard the service users’ safety. However, an inconsistent approach to risk assessments may reduce their effectiveness. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 27 EVIDENCE: The home was without a registered manager at the time of this inspection and there was not acting manager in place. The previous manager had given notice of her leaving although the Commission did not receive notification at that time. Ms Beavan reported that she is overviewing the management of the home. Ms Beavan, as service co-ordinator, was spending additional time in the home and Ms Godsell, the manager from another OLPA home was also providing support with administration. Staff members had been delegated tasks in the home. There was no timescale for the appointment of a new manager. OLPA had conducted a survey of stakeholders, which has been useful in providing feedback about standards across the organisation as a whole. This process could be usefully developed in a way that will provide feedback about the standards within the individual homes. OLPA has achieved the ‘Investors in People’ award. There was a House Development Plan, dated January 2006. This included a range of objectives for the year ahead. It was not clear how the views of service users and their representatives had been taken into account when the plan was produced. Changes in the Care Homes Regulations were discussed with Ms Beavan, as they relate to the home’s system for evaluating the quality of the services provided at the care home. There was a health & safety file, with risk assessments and C.O.S.H.H. information filed separately. It was reported at the last inspection that there was an inconsistent approach to risk assessments. This was also evident when the records were looked at on 24 October 2006. Although some new risk assessments had been undertaken, others had not been reviewed on the dates identified. The health & safety file was in need of attention in order to update the contents and to ensure that checks are carried out and consistently recorded. Risk assessments and care records were being reviewed at the time of the visits. This included the home’s fire risk assessment. Ms Beavan said that several doors in the home were going to be upgraded to fire resisting doors. Mrs Beavan and Ms Godsell were prioritising the assessments and records that needed to be reviewed. Some of the records had been reviewed and updated when they were seen on 20 November 2006. Ms Godsell was reorganising the storage for C.O.S.H.H. related substances. There was no regular health & safety check being made of the home environment and Ms Godsell said that this was going to be started. The home’s fire log book was up to date. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 28 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 1 34 N/A 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 3 x N/A x 2 x x 2 x Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 29 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 YA6 Regulation 15 Requirement The registered person must ensure that a comprehensive and up to date care and support plan is produced in respect of each service user. (Requirement made at the last inspection and has been met in part). In order to show compliance with this requirement, the care and support plans, and related risk assessments must be reviewed, in accordance with the timescales identified and updated to reflect the service users current needs. 2. YA33 18(1) The registered person must 21/12/06 ensure that staff members are deployed in sufficient numbers to ensure that the service users’ needs are fully met. (Requirement brought forward from last inspection). In order to show compliance with this requirement, the registered Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 30 Timescale for action 21/12/06 provider will need to demonstrate that the deployment of staff throughout the day is meeting the service users’ assessed needs and is consistent with the home’s written guidance on the provision of personal care. 3. YA37 8 Regulation 8: ‘The registered person shall appoint an individual to manage the care home’. The Commission must be informed of arrangements being made for the appointment of a new manager and a proposed timescale for this. 4. YA39 24(2) The registered person must supply the Commission with a report based upon the home’s system for evaluating the quality of the services provided at the care home and includes those matters that are referred to under Regulation 24(2) of Care Homes Regulations 2001. 15/12/06 31/01/07 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 YA5 Good Practice Recommendations That a third party is involved in agreeing and signing any terms and conditions statements. (Recommendation outstanding from last inspection) 2. YA5 That the licence agreements include all items that are specified under Standard 5.2 of National Minimum DS0000028338.V316099.R01.S.doc Version 5.2 Page 31 Sycamore Grove (56) Standards. (Recommendation outstanding from last inspection) 3. 4. YA6 YA6 That the system of Shared Action Planning is consistently completed with each service user. That the service users’ have personal goals which reflect a wider range of individual activities that they may wish to experience. (Recommendation outstanding from last inspection) 5. YA12 That the opportunity for recreational and therapeutic activities within the home are reviewed, with consideration given to the provision of a new facility. (Recommendation outstanding from last inspection) 6. YA9 That the risk assessment pro-formas are amended to provide clearer section for the recording of review dates and the outcome of the reviews. (Recommendation outstanding from last inspection) 7. YA39 That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. (Recommendation outstanding from last inspection) 8. YA42 That the home’s health & safety file is reorganised to ensure that the information is up to date and that the outcome of checks is consistently recorded. Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Grove (56) DS0000028338.V316099.R01.S.doc Version 5.2 Page 33 - 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. 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