Inspection on 08/08/07 for Sycamore Care Centre

This inspection was carried out on 8th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sycamore Care Centre 09/08/06

Sycamore Care Centre 13/02/06

Sycamore Care Centre 16/09/05

Sycamore Care Centre 21/02/05

Sycamore Care Centre 08/10/04

Sycamore Care Centre 04/03/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sycamore Lodge Residential Home Nookside Grindon Sunderland SR4 8PQ Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 8th August 2007 10:00 X10015.doc Version 1.40 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 Lodge Residential Home DS0000015741.V347613.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 Older People. 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 Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Residential Home Address Nookside Grindon Sunderland SR4 8PQ 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) 0191 525 0181 0191 528 8908 sycamorelodge@slwltd.fsnet.co.uk SLW Limited Judith Dolan Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (40), Physical disability (4) Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: The home provides care to older people over the age of 65 years, eleven of who may have dementia or mental health needs and four places for people who may have a physical disability. This home does not provide nursing care any health needs are dealt with by the Community Nursing Services. The main part of the house is Victorian in construction and was previously owned by the social services department. The current owner bought the home several years ago and after extensive refurbishment reopened it to provide care for twenty people. Since then the owner has built an extension to the home with the provision of a two-storey building, in order to enable forty people to be accommodated. All areas of the extension offer disabled access but there are some restrictions on the upper floor of the main house. The home is detached and stands in its own grounds with well-established trees and is approached by a private drive. Although it is located in the heart of the Grindon community it has a feel of being in the country due to its location and large expanse of external space. There is a large garden to the front of the home that can be used by service users and their visitors. There is easy access to a bus service, which offers services into the City Centre, where there is a range of services and shops. A detailed Service User Guide has been developed by the home and a Home Brochure is available. These documents provide clear information about what the service offers. A copy of these and a copy of the previous inspection report are available in the entrance hall to the home. The fee level for the home is £372.00 or £387.00 per week depending on the individual assessed needs of the service users. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day in August 2007 and was a scheduled unannounced Key Inspection. The inspection included a separate look at the Annual Quality Assurance Assessment (AQAA) completed by the proprietor. The care experienced by a sample of service users was ‘case tracked,’ this is where the inspector focuses on the service provided for individual service users and time was spent chatting with service users and staff and observing life in the home. A tour of the building took place, and a sample of staffing and service users’ records was inspected. The inspector took a midday meal with service users. The judgements made in this report are based on the evidence gained from this process. What the service does well: Staff are courteous towards the service users. They encourage service users to actively make decisions about the care they receive. Service users said: “The girls are lovely, they explain to me what they are going to do” and “I like living here, I’m looked after well.” The home endeavours to address the diverse interests and social cultures of the service users living at this home. Each person’s individual interests and preferred way of life is respected and supported. One service user stated that they liked the home because there is always somewhere to sit on your own if you wish. Staff use light-hearted banter when interacting with service users who respond accordingly showing that they enjoy this approach. This creates a light and relaxed feel in the home. The manager knows all the service users well and interacts with them and the staff in a warm and sensitive way. Service users referred to the manager as: “A canny lass,” “She’s a goodin,” and “A fair lady.” Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 6 So that service users are cared for in a skilled and appropriate way there is an expectation in this home that staff are competent and qualified to do the job. The home takes responsibility for this by providing a wide range of training opportunities for all of the staff. The Company makes sure the home is decorated and furnished to a high standard and the domestic staff take pride in keeping the home clean and tidy. This provides an environment that is attractive, comfortable and fresh and that promotes a positive image of the people who live and work there. What has improved since the last inspection? What they could do better: The Service User Guide must include the range of fees charged by the home, so that service users and other interested persons receive the full information about the home. So that service users are aware of the full cost of their personal fees and how these are to be paid these should be included in their individual contracts. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 7 So that all service users receive consistent care staff are encouraged to continue to improve the quality of the care plans. There must enough detail in the care plan to guide staff in relation to how an individual task should be carried out and this must reflect the service user’s preferred way. If all staff follow the same guidance the service user will receive care that is consistent. So that there are enough care staff to address service users’ personal needs and at the same there is someone to organise activity in the home, serious consideration should be given to employing someone solely to organise and support activities in the home So that service users are supported by well-informed staff who are up to date with procedures regarding Safeguarding Adults, training in relation to this should be regularly updated. The staffing numbers needed to support service users should be regularly reviewed to ensure that service users’ changing needs are addressed. 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 Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good information about the service. This helps service users to make an informed choice about where they would like to live. A contract is in place that informs service users of the home’s terms and conditions. Preadmission assessments demonstrate service users’ needs and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 10 Both documents have recently been reviewed and updated to ensure that they include current information about the service. However the Service User Guide does not inform service users or interested parties of the range of fees charged by the home. Of the care files sampled individual contracts that describe the home’s terms and conditions were in place. However the area that informed the service user of the full cost of their fees and how these are paid was incomplete. Service users therefore do not have information that is rightfully theirs. The home has a policy that states that prior to anyone moving into the home as much information as possible about the person is received from the referring agency. The home also carries out their own assessment with the service user and their family. This and other information gathered by the home is used to develop the care plan and was included in the care files sampled. As well as a detailed assessment the home also gathers information about each individual’s life history. This is kept at the front of the file where it introduces the reader to the whole person including their background from which they came, the life they lived and the things they enjoyed. It also gives a positive synopsis of their current needs. This profile is an important piece of information for carers to refer to when working with the individual service user and assisting them to make decisions and choices about their lives. The care needs assessment is kept at the back of the care file so that it can be reviewed and adjusted when needs change. When the decision is made that the home can meet a prospective service user’s needs a letter is sent out to the person to confirm this and a copy is kept in the individual care file. This home does not provide intermediate care. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans that are progressing well and that are beginning to guide staff to appropriately support service users’ with individual care needs and to make choices about their lives, are beginning to be put in place. However if the information in them is not recorded in sufficient detail their is a risk that service users do not receive consistent care. Service users’ personal and healthcare needs are met in a flexible manner, in a way that promotes their dignity and acknowledges their right to privacy. Medication arrangements are appropriate to the needs of service users and they are managed safely and appropriately, ensuring that the welfare of the service users is safeguarded. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 12 EVIDENCE: A new care plan document has been developed by the home and this is used with the assessment document to ensure that the identified care needs and identified risks if relevant, are addressed. Some of the care plans have been developed in enough detail to guide staff in the appropriate and preferred way. However not all care plans are recorded in such detail. This was discussed with the manager and it was felt that as the new document is used more and staff gain more practice this will improve. Individual risk assessments are in place and clear risk strategies guide staff to minimise the identified risk. These are currently recorded away from the care plans. As an outcome of discussion the manager and staff agreed that these could be more effective if they were recorded directly with the care plan they relate to. Although staff are trained to carry out their role effectively and address their duties professionally they are aware of their limitations and gain further advice from specialist doctors and nurses, for example relating to dementia care and issues surrounding Huntingdon’s disease. Staff work closely with other healthcare professionals and a separate document in the care file records individual healthcare visits and appointments with the outcomes. The district nurse addresses medical issues such as administering insulin for diabetes, use of catheters and checking blood in relation to the use of medication. They also assess for equipment needed for pressure relief and are responsible for any medical dressings needed. Care plans are monitored monthly and evaluated six weekly when changing needs are addressed and care plans adjusted. Although all service users have a review meeting with the social worker and their family at the end of the first year of living at the home, following this there placement is only reviewed via a mail questionnaire from social services. It was suggested that the home carries out an annual review for all service users so that they have a chance at least once a year to discuss their life at Sycamore Lodge and the plan of care in place, with the support of family and other important people in their lives. The manager and proprietor were both in agreement with this. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff work hard to support service users to live appropriate and fulfilling lifestyles both in the home and the local community. However without the employment of an Activities Coordinator solely to work with this task, activities can be compromised when support with personal care is needed. So that service users do not become socially isolated they are encouraged to maintain contact with families and to maintain friendships of their choice. As a result of staff promoting service users’ independence, service users’ are actively encouraged to exercise choice and control over their lives. Meals are healthy, nutritious and attractive, and are prepared to meet the individual dietary needs of each service user. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 14 EVIDENCE: A senior member of the care staff team has responsibility for organising and coordinating activities in the home. Two service users were supported to go out for a walk and others played bingo and ball games at different times throughout the day. The extensive grounds to the home allows for safe and interesting walks. Daily activity programmes are on view in the entrance hall so that service users and staff can refer to what is planned for the day. Staff talked about how service users enjoy making chocolate crispies and preparing things to cook, singing along to music and playing bingo. One family member said: “The girls are really good they are always talking to the residents and try and get them involved in doing things.” Ideas are beginning to take shape regarding making the environment on the first floor more stimulating for people with dementia care needs. The provider discussed plans in place to access sensory lighting for the unit. Further discussions took place in relation to how ideas regarding stimulating activities if set up, could be accessed for short periods of time, particularly by people with short attention spans. Such activities might divert attention when individuals feel agitated and upset. The Life Histories currently being developed could help staff to develop this part of their work. Although activities take place throughout the home they might be more effective if one person was employed to solely plan and coordinate them. Although the staff team are enthusiastic to make activities happen, the carers’ primary task is to address the care needs of the service users, therefore the senior and carers can be called away from the activity task to address personal needs. The senior member of staff that organises the activities advised that she requests the assistance of another carer if needed in such an situation. A midday meal was taken and enjoyed with the service users. The dining room is in the conservatory part of the building therefore is light airy and has a pleasant outlook onto the garden. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 15 Attention is taken to set the tables in a coordinated and attractive way and vegetables are served in serving dishes so service users can serve themselves. Service users said that, “The food is excellent.” “The food is always good, the cook is new and he talks to us to see what we like.” Service users were assisted with their food when needed in a sensitive and respectful way. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure of which service users and their representatives are aware. Service users were confident that their concerns or complaints would be addressed appropriately. Service users and their representatives are encouraged to discuss their concerns on a daily basis and these are addressed directly. The Complaints File includes several concerns from service users and their families that have been taken seriously and addressed in a way that has given comfort to the service user knowing that their concern had been listened to. Staff recieve training regarding the local authority’s Safeguarding Adults procedures and they are aware of the action they would take if an abusive incident was observed or reported to them. The manager was advised that this training should be updated regularly. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 17 Service users are encouraged to look after their own finances when appropriate. For those who need support with this comprehensive procedures are in place for staff to follow and these help safeguard service users possible from possible financial abuse. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is clean, warm and well maintained offering service users a homely and safe environment in which to live. EVIDENCE: This home is situated in an attractive setting away from the main road and within well-maintained grounds that includes extensive green areas with trees. Currently the provider of the home is building accommodation for a new service within the grounds and this has meant that many of the trees have been felled, however there are plans to re-landscape the area with plants and new trees on completion of the new build. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 19 All service users and their families have been informed about this development with timescales for the completion of the building. A site plan is situated within the entrance of the home where everyone can see. The well-kept, safe and comfortable environment reflects a comprehensive maintenance programme. New furnishings are regularly purchased, the necessary equipment is bought and rooms are regularly decorated. The home is decorated and furnished to a very high standard and the cleanliness throughout reflects effective cleaning routines that are discreetly and safely carried out by the domestic staff team. All staff have completed a comprehensive infection control course and the home aims to monitor the effectiveness of their infection control management by following the Department of Health’s guide “Essential Steps.” The home is also currently working towards the “Healthy Homes Award” that is monitored and awarded by the Environmental Health department. The home is divided into different units one of which caters for people with dementia. The units are small and easily negotiated making it easy for service users to find their way around. Discussions took place with the provider and manager regarding how stimulating pictures and reminiscent articles placed around the units could engage service users’, especially those with dementia, attention and interests and as a result stimulate conservation and activity. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a competent and qualified staff complement that effectively meets the care needs of the service users. The robust recruitment procedures ensure that the welfare and interests of the service users are protected. EVIDENCE: The home employs a team of staff with diverse experiences and qualifications. The manager confirmed that the number of staff needed was regularly reviewed and that the numbers needed reflect the current needs of the service users. 2 senior members of staff and 4 carers were on duty. In addition to this there were 3 domestics 2 full time and 1 part time, 2 kitchen staff and the manager also on duty. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 21 All of the domestic staff have achieved NVQ awards and almost all of the care staff have achieved an NVQ level 2 award. Some staff are also completing level 3 awards and 3 staff have successfully gained the level 4 award in care. 3 care staff members have completed the Assessor’s Award and can now assess NVQ work. The owners also provide access to training not only around mandatory training but courses to improve staff knowledge about specific care needs such as nutrition. Care practices observed in the home reflect the skill and dedication of a well trained and motivated staff team. Staff were observed sensitively interacting with service users and working as a team. One new member of staff commented on how well she had been supported and trained through her induction period. Appropriate recruitment records of staff recently employed demonstrate that the home’s robust recruitment procedures are generally followed. Application forms identifying a clear up to date record of employment, 2 written references and a satisfactory CRB (Criminal Records Bureau) checks were in place for 2 newly employed staff. However a third person, although a POVA First check had been received, a full clear CRB clearance had not. Although this person does not carry out any personal care as part of their role, the manager was advised that when there is a critical situation regarding staffing and needing to employ a member of staff quickly after receiving a POVA First check but prior to the CRB clearance being received, she must discuss this with CSCI who will confirm what action should be taken. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. External management support and oversight arrangements ensure that the registered manager is supported to effectively address her role. Effective quality assurance systems are in place and these include seeking the views of service users, relatives and others. These systems operate well and ensure that the service is run in the best interests of service users. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has worked in this role for several years at this home. She is registered with CSCI (Commission with Social Care Inspection) and is qualified in the Registered Managers Award (RMA) and NVQ 4 in Care. The manager is supported well by her senior staff team and the administrator for the home. The provider who visits the home daily also gives good support as her line manager. The manager feels that the responsibilities of managing the home are shared by this support system. This allows her enough time to work directly with the staff team for a proportion of her time, while still having designated hours to address her managerial responsibilities. The manager was advised that this must be monitored. The manager is up to date with mandatory training and attends training to support her role. She has completed a 12 week distant learning course in dementia care and other recent training includes supervision and appraisal, Safeguarding Adults and The Mental Capacity Act. There is a good quality assurance system in place the outcomes of which are recorded. This ensures that the home’s policies and procedures are put into practice and that the service is led in the best interests of the service users. The home has also been awarded the Investors in People Award and this is to be reassessed in March 2008. Good arrangements are in place to safeguard service users monies held in the home. Comprehensive procedures are followed and recorded appropriately. Risks identified throughout the home are monitored and addressed well. Fire safety is practiced appropriately and accidents to both service users and staff are recorded and addressed satisfactorily. Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 30/09/07 2 OP2 5(1)(b) 2. OP7 15 The registered manager must ensure that: • A copy of the Terms and Conditions of the home including the range of fees charged must be included in the Service User Guide. The registered manager must 30/09/07 ensure that: • The full costs of the fees are included in individual contracts that state the terms and conditions of the home. Care plans must continue to be 30/09/07 developed as advised during the inspection. Timescale of 03/05/07 not fully met. The registered manager must receive agreement from CSCI prior to employing a member of staff without full CRB clearance but after receiving a clear POVA First check. CSCI will only confirm this action in extreme circumstances. 3 OP29 12(1) 30/09/07 Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations Risk management plans could be more effectively used if they are integral to the care plan and recorded directly next to the plan of care to which they refer. It is advised that individual care plans are reviewed annually when the service user, their representatives and any other person involved in the individual’s care, is invited to discuss and review the placement and the plan of care in place. Serious consideration should be given to employing someone solely to organise and support activities in the home. It is advised that training regarding Safeguarding Adults is regularly updated. The Residential Forum Guidance should be reviewed as residents’ needs changed and calculations should include activities, one-to-one support and difficulties caused by the building. The registered manager should monitor the effectiveness of how she divides her hours in relation to working directly with service users, with the responsibilities of her managerial role and address accordingly if needed. 3 4 5 OP13 OP18 OP27 6 OP31 Sycamore Lodge Residential Home DS0000015741.V347613.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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