Inspection on 05/05/06 for 56 Sycamore Grove

This inspection was carried out on 5th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 5th May 2006 09:15 Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 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.V289076.R01.S.doc Version 5.1 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.V289076.R01.S.doc Version 5.1 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.V289076.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only one named female service user over 65 years of age. Date of last inspection 12th October 2005 Brief Description of the Service: 56 Sycamore Grove is home for up to three people with a learning disability. It is one of a number of care homes 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. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included two visits to the home. One, which was unannounced took place on 5 May 2006 (between 9.15 am and 1.30 pm) and a second visit which took place on 17 May 2006 at 1.15 pm. Service users and staff members were met with during the visits. The service users were not able to communicate their views of the home. The manager was met with on 25 May 2006, when feedback was given about the inspection. Staff recruitment records were seen on 16 May 2006 at the OLPA office. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • • Each of the service users’ close relatives has completed a ‘comment card’ about the home. Comments have been received from the service users’ care manager on behalf of professionals from the Community Team for People with a Learning Disability. The manager has completed a pre-inspection questionnaire about the running of the home. Reports and notifications received by the Commission from the home since the last inspection. The judgements contained in this report have been made from evidence gathered during the inspection, including the visits to the home. What the service does well: What has improved since the last inspection? New staff have been appointed, which has reduced the need for agency carers and should result in more consistent support for service users. Refurbishment of the bathroom has nearly been completed. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 6 What they could do better: The three service users have lived together for several years, although behaviour and incompatibility between service users has affected their quality of life. Service users are not sharing the home with people they get on with and there have been regular incidents involving one service user’s physical aggression towards another. Efforts have been made by the manager and staff to reduce the number of incidents, although these have not been successful in producing a safe environment for each service user. Further discussions are taking place, which will need to result in service users having a better and safer home life. Much of the manager and staff team’s attention has focussed on the prevention of incidents between service users, which has reduced the opportunities for more developmental and individual work. New guidelines and records have been produced in response to the incidents and to help with monitoring behaviour and the service users’ needs. However, much of the other assessment and care plan information is in need of reviewing and updating. The manager is relatively new in post and has spent much of her time in a support worker role. The time for management and administrative tasks appears to be very limited. There are concerns about how well the deployment of staff is meeting the needs of service users, particular after 6pm when staff work alone until the following morning. The staffing arrangements need to ensure that service users receive the support they require with achieving their goals. The goals need to focus more on personal development and new activities, rather than on confirming the need for personal care and on-going support with daily tasks. There is a lack of internal monitoring and quality assurance, which would help identify areas for improvement and give information about how well the home is meeting the needs of service users. The manager has produced a business plan for the home and this needs to be developed so that it is more focussed on outcomes for service users. The licence agreements for service users need to be agreed and signed by the appropriate parties. 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 from having the use of another area where they can take part in more stimulating and recreational type activities. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 7 New staff members have not necessarily had previous experience of working in a learning disability service. They get to know the service users and OLPA’s procedures in a planned way, but are not given the opportunity to undertake an accredited programme of induction. This would provide new staff members with a more comprehensive introduction to working in a learning disability service. 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.V289076.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Standard 2 did not apply at the time of the inspection. Quality in this outcome area is poor. This judgement has been made from evidence gathered before and during 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 a third party EVIDENCE: No new service users have moved into the home in recent years. A requirement has been made at previous inspections about the need to have individual service user contracts in place. The Commission has been informed of discussions about contracts that have continued between OLPA and Wiltshire County Council since the last inspection. It is of concern that individual contracts for the service users have not yet been agreed between OLPA and the funding authority. The Commission has also raised this with Wiltshire County Council. OLPA has produced license agreements for service users, which include a number of terms and conditions. One of the service user’s personal files contained the agreements for the three service users. This was brought to a Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 10 staff member’s attention, in order that the agreements can be kept separately and appropriately filed. The service users do not have the capacity to understand the contents of such an agreement. It was recommended at the last inspection that a third party, usually the service users care manager, is involved in agreeing and signing the agreements. This recommendation has not been met. 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 do not include all the items that are specified under Standard 5.2 of National Minimum Standards. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visits to the home. Changing needs and personal goals are not well reflected in the service users’ plans. Arrangements in the home and a lack of resources have impacted on the service users’ progress and their opportunities for development. Service users are encouraged by staff to take an active role in the home, however their participation and choice is reduced because of safety factors and the behaviour of others. EVIDENCE: The service users’ files included records of ‘Shared Action Planning’, which involved the discussion of wants and needs and the setting of personal goals. The process had last been completed in 2004, with some inconsistent monitoring and more recent goals identified since then. Some specific and individual goals had been identified. A good example was a goal to have meals on the menu that reflect one service user’s cultural background. However many of the goals related to core values and basic care needs, rather than on Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 12 developing new experiences and activities. The ‘Date Achieved’ was often stated as ‘on-going’. It was not always clear how achievement was being assessed, whether the goals had been met and what further action was needed in order to fully meet a goal. The lack of a key worker and the high use of agency staff had been recorded as the reasons why certain goals had not been met. The manager and staff spoke about the difficulties that can arise when the service users are together in the home during the day. Views were expressed about an underlying incompatibility between the three service users and the need to ensure that service users are not adversely affected by the actions of another. This was influencing the day to day arrangements in the home and reduced the independence and freedom of movement that service users could exercise within the home. Incidents involving service users have been the subject of notifications to the Commission during the last year. In her comments, the service users’ care manager has stated that a number of the professionals’ involved in the reviewing and assessing of individual needs have experienced a reluctance from the home to implement recommendations, although reasons have been given for the service’s inability to follow these. Service users were not able to express their views directly in a meeting situation. Instead, staff members were taking the lead and using a ‘Tenants Discussion’ form to record relevant issues concerning the service users. Some of these ideas had been prompted by staff, based on recent events. This appears to be a good means by which matters affecting service users can be discussed and followed up. In addition to the Shared Action Planning records, the service users’ files included a range of assessments and guidance on personal routines. One service user had a support plan, dated April 2006, that referred to a range of personal care needs. A similar plan was not available for the other two service users and the manager said that these were to be completed. A timescale for this was agreed. The content and organisation of the files was inconsistent; the manager said that it was also the intention to improve these. Much of the assessment and care information on file dated back to 2003 and 2004 and had not been updated since. There was evidence of risk assessments that had been carried out concerning the service users’ activities and individual routines. A number of different recording formats were in use. Some assessments had been completed in 2006; others had been completed in previous years although not consistently reviewed. For example, the use of the bath hoist had been assessed in 1999 and review dates of January 2004 and January 2005 had been identified. The 2004 date had been ticked, but there was nothing to indicate whether a review had taken place in 2005 and what the outcome was. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 13 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, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visits to the home. Service users have well established routines, which include regular community activities and contact with relatives. Service users are encouraged to treat the home as their own. However, the benefits for service users are reduced the lack of compatibility between service users. Service users are provided with a varied menu. 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 for trips out. Service users were attending some planned activities that were timetabled to take place each week. Other activities were arranged on a more spontaneous basis according to the service users’ feelings and interests at the time. During Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 14 the visits, one service user was attending a day centre, which was their usual occupation for four days a week. The other service users were mainly homebased and had more unstructured time. With no fixed time to get up by they were able to have a more relaxed start to the day. Much of their time was spent in 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 consideration is given to providing another facility, which would offer service users the opportunity for different activities and experiences. Arrangements during the visits were flexible, with decisions made at the time about service users going out on some local trips for shopping or as a change from being in the home. The home has its own vehicle, which takes a wheelchair. This vehicle is of a relatively old design; the manager and staff said that they would prefer to have a different type of vehicle, which would draw less attention to the service users and the support they need. When in the lounge, service users were offered drinks, which were made for them. Service users contributed in small ways to the domestic routines, for example when a meal is served and cleared away. Service users were not excluded from the kitchen, although safety considerations and the service users’ ability meant that the staff member was taking full responsibility. Mealtimes could be difficult because of the behaviour between service users although guidelines and a seating plan had been produced to help with this. As previously reported, incidents have arisen between service users when together in the lounge. The staff spoken with recognised the limitations that this has on the service users’ quality of life. During the visits, staff were finding opportunities to support individual service users with things they enjoy in the home. This included for example giving one service user a pedicure and providing a quiet and relaxed time for listening to music, which was best done when another service user was out of the home. Each service user had a close relative who they were in regular contact with. In their comment cards, the relatives stated that they are made welcome in the home and can visit in private. Information about the service users’ family contacts and important people in their lives was recorded in their personal files. During the meals, staff sat with service users at the dining table to give some physical assistance and verbal prompting. This was done in an individual and friendly manner. The service users’ records included written guidance and information about diet and individual needs. It was recommended at the last inspection that the information about eating and dietary needs is updated and recorded using a single format. Some mealtime guidelines have been produced but these do not refer to all relevant items, for example they do not cross-reference to the risk assessment for choking. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 15 A record of the meals served was being kept each day. This showed a varied range of dishes and some individual choices made. Sandwiches were popular at lunchtime. Staff were monitoring one service user’s food intake and there was a list on display in the kitchen showing what fillings had been prepared in a service user’s sandwiches for their packed lunch and how much had been eaten. This was good practice. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 16 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): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visits to the home. The service users’ health and personal care needs are met. Service users receive the support that they need with their medication. EVIDENCE: Each service user had a personal file containing a range of guidelines for staff about their individual support and preferred routines. As reported under ‘Individual Needs and Choices’, care plans have not been consistently completed for each service user. Some new guidelines and monitoring records have been produced during the last year in connection with the behaviour and health of service users. The files also included more historical guidelines that had been produced in previous years. The guidance was not being consistently reviewed and it was unclear whether it had been superseded or was in need of updating. In their comment cards, the service users’ relatives confirmed that they are satisfied with the overall care provided. The service users’ files included medical and health sections, where staff had recorded and reported on appointments with heath care professionals. An exception to this was appointments with chiropodists; it was recommended at Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 17 the last inspection that these are also recorded in the health section, rather than in the service users’ personal diaries. The records showed that the service users have had recent contact with G.P.s, dentists, physiotherapist and other health care professionals. The service users’ health needs had received particular attention during the last year, involving hospital appointments and specialist support. A medical profile was available for each service user. Staff members were managing medication for the service users, who cannot do this themselves. The administration of medication records were up to date. Staff members were preparing some medication in advance in order that agency carers could administer this later in the day. This was necessary because of the agency’s policy on how their carers can administer medication. Staff members were recording their involvement with this. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 18 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): 22 and 23 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, after and during the visits to the home. The home is working closely with other agencies, however two service users continue to be at risk and to be harmed by the actions of another. The service users have very limited understanding of the complaints procedure and are dependant on others to raise concerns on their behalf. EVIDENCE: The Commission has been kept well informed of incidents that have taken place involving one service user’s physical aggression towards the others service users and occasionally staff. Initially, these incidents were the subject of referrals under the vulnerable adults procedures. Case conferences and review meetings have since taken place and the home has worked closely with the local Community Team for People with a Learning Disability and with other professionals. The incidents have continued in spite of this and these have been of a similar nature during the last year. 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. In their comment cards, two relatives have stated that they are aware of the home’s complaints procedure and one has stated that they are not. Each relative reports that they have made a complaint in the past, with one person commenting that complaints have been Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 19 made verbally to the staff and manager and been resolved without using the complaints procedure. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 20 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): 24 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visits to the home. The accommodation is homely and domestic in character. The bathroom has improved. The home looked clean and tidy. 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. There is one W.C. for use by the service users and staff. This is in the bathroom, which was being refurbished at the time of the visits. The accommodation looked clean and tidy. Laundry is carried out in the kitchen, with bins for dirty linen kept outside. A written procedure for the Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 21 movement of laundry has been produced, as recommended at the last inspection. Guidance on infection control was included in the home’s file for agency carers. Since the last inspection, OLPA have followed up a concern that was raised with them about the level of heating in the home and how this affected one service user. OLPA responded to this by monitoring the heating and keeping records, which showed that the required temperatures were being maintained. The staff and manager said during the visits that they felt a good temperature had been maintained in the colder months. The heating was discussed further with the manager; action is to be taken to conclude this, by following up the particular needs of the service user in question. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 22 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): 32, 33, 34 and 35 Quality in this outcome area was poor, with signs of improvement. This judgement has been made from evidence gathered before, during and after the visits to the home. The deployment of staff has not been sufficient to fully meet the needs of service users. The situation is improving with the appointment of new staff, although there is a lack of flexibility after 6pm. New staff members get to know OLPA’s procedures, but do not receive the recommended induction for working with people in a learning disability service. There is a well established programme of in-house training. Further developments are taking place, which will be of benefit to service users. Service users are protected by the organisation’s recruitment practices. EVIDENCE: The staff rotas showed that at least one person was working in the home at all times. Additional staff were being deployed during the day until 6 pm, when the staff member on duty worked alone. At 8pm an agency carer started work and provided waking cover until the following morning. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 23 As reported under the ‘Individual Needs and Choices’ section, there have been shortcomings in the staffing arrangements that have meant that some of the service users’ goals have not been achieved. In their comment cards, one relative stated that, in their opinion, there are always sufficient numbers of staff on duty; another stated that there were for ‘90 ’ of the time. The third relative did not feel that there were always sufficient staff on duty and was concerned that there is only one member of staff on after 6pm. In her comments, the service users’ care manager has referred to occasions when the staff rota could not accommodate some of the recommendations that have been made when the service users’ needs have been reviewed. The employment of a new permanent member of staff had reduced the need for agency carers and relief staff to be deployed during the day. The manager and staff were positive about the impact that this would have on the staff team and felt that there was the opportunity to establish a settled staff team. One of the staff members met with had started employment during the last month. She said that she had attended an Induction day at the OLPA office and completed an in-house induction. Time had been spent shadowing other members of staff. She felt that she had been given the information she needed for working in the home. The manager confirmed that Learning Disability Award Framework accredited training is not available; new staff members are therefore not receiving an induction that meets the expected standard and is consistent with national policy for learning disability services. The new staff member was due to attend some OLPA arranged training events during the coming month. This included medication and the staff member said that she was not yet involved in its administration to service users. Another staff member confirmed the training that she had received through OLPA, which included abuse awareness and a range of in-house health & safety related courses. All staff are reported to hold a current first aid certificate. Staff members attend mandatory training that is provided by the OLPA training officer or by a service co-ordinator. An external trainer is used for first aid. Some new subjects have been included in the OLPA in-house training programme for the year ahead. This should be beneficial in developing the staff team’s knowledge of learning disability and care related subjects. In recent months there had also been the opportunity for staff to attend training events outside OLPA, for example ‘Death, Dying and Bereavement’. This is good practice and further training events involving specialist trainers and outside professionals should continue to be sought. Three staff were reported to have achieved NVQ level 2 or above. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 24 Recruitment was discussed with the OLPA personnel officer and service coordinators at the OLPA office. The main employment records are held centrally, with copies of documentation also kept in the home. It was agreed that future arrangements could include inspection of the records at the office and the need to keep records in the home would be removed. However a recruitment checklist would need to be available for inspection in the home. The employment records for a number of OLPA support staff were looked at. Each staff member had an individual file. There was some inconsistency in the files’ contents and in the completion of an employee information form, which is used as a checklist during recruitment. It is recommended that this form is updated, as a number of new recruitment checks, for example POVA / C.R.B., have been introduced since the form was produced. The files showed evidence of appropriate recruitment practice, including copies of references, application forms and interview records. Documentation relating to C.R.B. disclosures and POVA checks was seen. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 25 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): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, after and during the visits to the home. The home’s manager knows the service users well and is gaining relevant qualifications. There are pressures on the manager’s time that may compromise standards in the home. There is a lack of quality assurance at an organisational level although the manager is developing this within the home. There are systems in place that help to safeguard the service users’ safety. However, an inconsistent approach to risk assessments may reduce their effectiveness. EVIDENCE: Mrs Gilmore has been registered as the home’s manager during the last year. Previously a support worker in the home, Mrs Gilmore said that this continued to be a significant part of her current role, as the ‘official’ time allocated for Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 26 management and administration tasks was eight hours a week. There was discussion with the manager about how the necessary tasks can be fitted into this time. (OLPA will be asked to provide the Commission with further information about the manager’s job description and her role in the home). Mrs Gilmore said that she is doing the Registered Managers Award and was expecting to complete this by the end of July 2006. Staff spoke positively about the support received from the manager and the day to day running of the home. OLPA has achieved the ‘Investors in People’ award. The OLPA policy on quality assurance referred to a number of internal and external devices by which the service is monitored. The policy did not show how these devices contribute to a cycle of planning-action-review, involving timescales and the production of improvement / action plan. A house development plan, dated January 2006, was a positive initiative, which the manager said had been produced following discussion at management and team meetings. The plan needs to be developed so that it is more focussed on outcomes for service users and shows how feedback from interested parties has contributed to its contents. Information about health & safety, including the maintenance and servicing of equipment was received from the home in a pre-inspection questionnaire. Staff members spoken with said that they received training in fire precautions. The home’s fire log book showed that fire drills and smoke alarm tests are taking place. There was a risk assessment file, which contained a range of assessment records concerning environmental hazards. Some of the risk assessments had been undertaken in 2006. Others had been completed in previous years and, as with the service users’ assessments, the records did not always show whether reviews had taken place on the dates identified. The minutes showed that health & safety is discussed at team meetings. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 27 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 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 28 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. The registered person must make arrangements to ensure that service users are not harmed or suffering abuse or being placed at risk of harm or abuse. Timescale for action 31/07/06 2. YA23 13(6) 25/05/06 3. YA33 18(1) The registered person must 25/05/06 ensure that staff members are deployed in sufficient numbers to ensure that the service users’ needs are fully met. The Registered Person must devise and implement an effective quality assurance system. (Requirement identified at previous inspections – met in part since last inspection). 30/08/06 4. YA39 24 Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 29 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, 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 the service users’ have personal goals which reflect a wider range of individual activities that they may wish to experience. That the service users’ personal files are reorganised to ensure that the contents are up to date and continue to be relevant. That the risk assessment pro-formas are amended to provide clearer section for the recording of review dates and the outcome of the reviews. That the opportunity for recreational and therapeutic activities within the home are reviewed, with consideration given to the provision of a new facility. That all relevant information, including the risk assessment for choking, is cross-referenced to the guidance on mealtimes, to ensure that this is readily available to staff. That chiropody appointments and their outcome are recorded in the health section of the service users’ personal records. 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. That the employment checklist is updated to include all aspects of the recruitment process. 2. YA5 3. YA6 4. YA6 5. YA9 6. YA12 7. YA17 8. YA19 9. YA22 10. YA34 Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 30 11. 12. YA35 YA39 That Learning Disability Award Framework accredited training is available to new staff members. That the policy on quality assurance is amended to include the arrangements made for annual development and for the production of an improvement plan. Sycamore Grove (56) DS0000028338.V289076.R01.S.doc Version 5.1 Page 31 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.V289076.R01.S.doc Version 5.1 Page 32 - 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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