Inspection on 04/10/06 for Sycamore Cottage

This inspection was carried out on 4th 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 but made no statutory requirements on the home.

Other inspections for this house

Sycamore Cottage 09/12/08

Sycamore Cottage 16/06/08

Sycamore Cottage 17/12/07

Sycamore Cottage 05/06/07

Sycamore Cottage 25/10/05

Sycamore Cottage 05/05/05

Sycamore Cottage 07/10/04

Sycamore Cottage 15/04/04

Sycamore Cottage 30/09/03

Sycamore Cottage 23/01/03

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

CARE HOMES FOR OLDER PEOPLE Sycamore Cottage Skippets Lane West Basingstoke Hampshire RG21 3HP Lead Inspector Anita Tengnah Unannounced Inspection 4th October 2006 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 Cottage DS0000011821.V312194.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 Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Cottage Address Skippets Lane West Basingstoke Hampshire RG21 3HP 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) 01256 478952 Mr A Vanderslott Mrs K Vanderslott Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (6) of places Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/10/05 Brief Description of the Service: Sycamore cottage is registered to provide accommodation and personal support to twenty residents over the age of sixty-five years with dementia type care needs. The home is situated within a private residential lane close to an industrial estate on the outskirts of Basingstoke. The home is privately owned by Mr and Mrs Vanderslott, Mrs Vanderslott is the homes registered manager. The current fees charged ranged between £387- £420 per week. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A fieldwork visit was undertaken on the 4th of October 2006. The process included a tour of the service when a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. Staff practices were observed; service users and staff records were examined. As part of the case tracking a number of the service users, relatives, healthcare professionals and staff views were sought. What the service does well: What has improved since the last inspection? What they could do better: Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 6 There was a lack of care plans and risk assessments for some service users, that could be to the detriment of the service users. There is continued offensive odours in some parts of the home that need to be eliminated. This was also indicated in the last report and continues to be a problem. The duty roster did not demonstrate which staff were on duty at any time during day and night and in what capacity. Care hours were eroded by noncare duties due to a lack of domestic/ kitchen staff. The number of waking staff on night duty did not take into account the needs and layout of the service and is to the detriment of the service users. The home infection control practices were poor and put the service users at risks. There were a number of creams/ ointments found in different parts of the home that were not labelled. This would be a cross infection issue. Staff who undertake food preparation had not completed basic food hygiene training in order to safeguard the welfare of the service users. A clear management structure would benefit the staff and service users in the absence of the manager. 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 Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 7 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 Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The pre admission process ensures that the home can meet the service users’ needs. The home continues not to provide intermediate care. EVIDENCE: A sample of a recently admitted service user’s records was seen as part of case tracking. There was a detailed assessment record in place including assessment from a local primary care trust from where the service user was transferred. The manager undertakes assessments of the service users and the provider reported that these assessments are used as part of the care planning. Staff reported that the service users are offered the opportunity to visit the home prior to admission. However not many service users actually do due to their poor health, the family visited instead. Information pertaining to the Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 9 statement of purpose and the service users’ guide are made available on admission. The provider confirmed that the service does not provide intermediate care. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Some of the care plans were detailed and contained good information. However the lack of care planning and risk assessments for some service users put them at risk. The health care needs of the service users are well managed and support is available from external agencies and the home accessed these as needed. The medication management relating to topical creams/ointments is poor and pose risks to the welfare of the service users. The service users feel that they are treated with respect and their right to privacy upheld. EVIDENCE: Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 11 The provider reported that this would be rectified A sample of 4 service users’ records was seen as part of the case tracking. Two of the care plans were detailed and included personal care, sleep and special diet such as diabetic. There was evidence that the care plans are discussed with the service users family as appropriate as all the service users cannot participate in their care planning due to their mental frailty. Some service users care plans contained details of family tree, which the staff said was very useful and helped the service users in reminiscing. The home also maintains record of personal care given on a separate sheet as the provider said that was easier for the carers. However these records were found to be incomplete, in one service user’s record there was no record of bath or hair wash since August 06. The provider stated that he would have been bathed and that record keeping needed to be addressed. Three of the care plans had good daily records available. One of them however had no entry since the 26th of September 06. Some reviews of care plans were undertaken, however this was not undertaken for all the service users in care plans seen. It was discussed that monthly reviews should be in place due to the changing needs of the service users. It was also noted that two of the service users did not have any care plans. The provider stated that the manager had taken them home to review. It was discussed that care plans must be available at all times for all the service users, as these would be used by staff to deliver care. There is a danger that the lack of care plans would lead to inconsistency of care and to the detriment of the service users. The provider reported that this would be rectified and care plans would be put in place. Care records identified one service user as aggressive towards staff and another as risk of wandering and leaving the home. There were no risk assessments available to demonstrate how the staff would be dealing with these matters. The provider said that some risk assessments had been completed but none could be located at the time of the visit. It was discussed with the provider that risk assessments are fundamental in the formation of care plans and inform staff on how to manage the risks identified. This would help to ensure the safety of the service users. The service users access to healthcare was maintained. Two health professionals were visiting the home on the day of the visit. Staff reported that they are well supported by the local surgery. The wound care plan for a service user seen indicated that the district nurses attended to the wound/ ulcer for Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 12 the service user and detailed treatment plan was kept at the home. Staff commented that this provided with useful information. Another service users needed daily insulin injection and the district nurse attends the home daily. Staff said that they felt confident in approaching the district nurses who were always ”very helpful”. The community psychiatric nurse was also visiting another service user as part of his regular visit. During the tour of the premises there were a number of ointments and topical creams found in service users’ rooms, communal bathrooms and cleaning cupboard. Some were prescribed to service users and others did not have any labels on and one belonged to a service user who was no longer there. This was brought to the attention of the provider and removed, as it has the potential of being used as communal in particular in the shared areas and putting the service users at risks. The provider reported that this would be rectified and would be taking these up with the staff. A sample of the Medication Administration Record (MAR) sheet was seen and it was evident that staff adhered to the procedures for the administration and disposal of medication. Record of medication received was available and staff were aware of the safe keeping of the service users’ medication. There was no service user self- medicating at the time. Discussed the development of pain risk assessments as staff stated that some of the service users are not able to communicate if in pain due to their mental incapacity. The inspector observed the staff interacted well with the service users and found them friendly and respectful when dealing with them. It was evident from interaction observed and comments from the service that the staff have developed good relationships with the service users. Some of the service users comments included “this is a nice home”. One service user said that she enjoyed staying in her room and reading and that staff respected her wishes. Another service user said that “staff are good” and she likes living at the home. Sycamore Cottage DS0000011821.V312194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. There were some activities provided for the service users, however further development in the provision of activities would meet the expectations of the service users. The meals at the home are good, but there is a lack of consultation with the service users regarding meals choices. EVIDENCE: There were some activities available on the day of the visit. One carer was observed playing game with a group of three service users that they seemed to enjoy. Comments from relative were that there were limited activities provided. Carers provided some of the activities as able and this was dependent on time available to them. One service user talked about how she enjoyed her books and went to the library with her daughter on a regular basis. She commented that she enjoyed reading and kept her entertained. Another service user talked about making small crotchet square in wool she enjoyed. Two service users said that they all spent a lot of time sitting in the lounge “with nothing to do”. There is a separate lounge where a television is Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 14 available. Comments from a relative indicated that his mother enjoyed watching television when she visited them but did not watch television at the home as she usually sat in the main lounge where there was no television. The home has a separate lounge where a television is available, discussed that staff may need to facilitate access to the lounge and make the service users aware of this. The home has an open visiting policy and a record of all visitors to the home was maintained that showed that there was no restriction on visiting times. Service users said that they could see their visitors in private and in the large lounge or the dining room. One relative spoken with said that he visited at various times and there was no restriction on visiting. He was taking his mother shopping on the day of the visit. The home has a planned menu that indicated that there is a choice of meals at lunchtime. Staff reported that the menu was rotated on a four weekly basis. The home does not have a cook and one of the carers cooks the lunchtime meal and the other carers prepared teatime meals. Five of the service users spoken with said that the meals were “very nice”. The lunchtime meal appeared balanced and well presented. Staff were observed to be available to offer support with meals as required. Comments from some service users were that they would like cooked breakfast such as bacon sandwich, sausages and eggs sometimes, as this was not available. This was discussed with the provider who stated that this had never been available. Other comments from the service users were that “you never know what’s for dinner until it’s put in front of you”. Staff stated that they did not complete a menu with the service users but offered them choices if they did not like a particular meal at the time. A record of meals taken or any deviation from the set menu was not available. Staff reported that they often changed the menu and were aware that a record of the service users’ meals should be maintained. It was noted that a number of spices in the kitchen cupboard had expired. Cooked meat and sauces seen in the fridge were not labelled appropriately such as the date of opening/ expiry dates. Food and freezer temperatures were not recorded regularly. All these issues were brought to the attention of the provider and staff and the provider stated that this would be rectified. The provider reported that a form to record all meals taken by the service users has been developed and will be put in place following this visit. The provider must ensure that there is a menu that offers a choice of meals and the service users are consulted with regards to meals. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. There is a satisfactory complaint process in place. The lack of training in the prevention of abuse for staff can be to the detriment of the service users. EVIDENCE: The home has a complaint procedure in place and service users spoken with were not aware of the procedure but said that they would speak to the staff if they were unhappy. The service users spoken with stated that they had “ no grumbles” and were happy living at the home. Some service users said that they would speak to their family if “anything is wrong” and “if I have any worries”. The registered person should ensure that the complaint procedure is displayed and available to the service users. There was one compliant recorded in the log that related to a complaint that had been referred by CSCI to the provider to investigate. Log did not contain copy of letter to complainant or CSCI, only notes to say responded to both parties. This was brought to the attention of the provider, as the registered person must maintain a full record of all complaints and the action taken in respect of any such complaint. The commission had received concerns that were raised in August 2006 about the home. The concerns raised were about the offensive odours around the Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 16 home, lack of security and poor lighting. This was discussed with the provider and looked at as part of this visit. There were offensive odours in some parts of the home and two visitors spoken with on the day commented that this is an ongoing problem. One of them commented that some days the offensive odour is worse than others. The provider said that carpets are cleaned often. The lack of security could not be substantiated as the front door was checked at different times and was always locked and staff were observed answering the doorbells on two occasions. One relative spoken and a visitor confirmed that that they usually ring the bell in order to gain access to the home. The lighting to the stairs was satisfactory when the inspector toured the building, however this visit was undertaken during day light hours. The provider said that he was not aware that this had been a problem. Policies and procedures for the protection of vulnerable adults were available and included the Hampshire adult protection procedures. Discussion with staff indicated that they have some knowledge of what constituted abuse. Staff reported that they would approach the manager or provider if any allegation of abuse were made to them. Basingstoke social services department undertook an investigation under adult protection procedures following concerns relating to the care of two service users at the home in September 2006. The outcome of the investigation by Social Services indicated that this due to poor practice and they were planning to undertake a review of all the service users at the home and discuss the concerns with the registered persons. The provider confirmed that none of the staff had attended any training in adult protection. He stated that he would be looking into accessing this training, as this would be beneficial for the staff. This would help to ensure that all staff have up to date knowledge about the prevention of abuse and the reporting and recording of all allegation of abuse. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. The majority of the home was clean but offensive odours persist in some parts of the home. The infection control procedures are poor and detrimental to the service users. EVIDENCE: A tour of the building was undertaken as part of the visit. Adaptation and equipment were available to maintain and support the service users in maintaining their independence. Most of the bedrooms were personalised and comments from some of the service users were that they liked their rooms. Other comments included” my room is very nice and I have everything I need in here” and “I like it in here and I have all my family photos around”. One lady said that she liked to spend most of her time in her room as she stated it was “very comfortable”. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 18 There are two communal lounges and most furnishing was in satisfactory condition. The décor within the home was in need of attention with uneven flooring and paint peeling in some areas and offensive odours in the communal areas and one bedroom. There was a leak from the first floor and water was leaking from the ceiling in the corridor by the stairs. The provider said that a plumber was expected that day to deal with this. The ceiling was water damaged and the water had also affected the lights by the stairs on the day of the visit. The areas needing refurbishment was discussed with the provider and a response will be needed. The home has large well- maintained and mature gardens that are accessible to service users with limited mobility where seating was provided. The patio area had been refurbished with decking and the service users said that this was nice and staff said that the service users had enjoyed this facility during the good weather. The home has a laundry and staff stated that all the service users laundry is undertaken internally. The laundry area was clean and the flooring was impermeable. It was noted that the laundry did not contain a sink. This was discussed with the provider who said that alcohol gel was available. The communal bathroom and shower room on the ground floor was poorly maintained. The shower tray was heavily stained and commode pans were found soaking in the baths and shower room. This was discussed with the provider, as this is poor infection control practice that poses risks to the service users. The provider agreed that this needed to be rectified. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality outcome in this area is adequate. The judgement has been made using available evidence including visits to the service. The staffing level is poor as care hours are eroded by non-care duties to the detriment of the service users. The recruitment process is good and ensures that the welfare of the service users is safeguarded. There is a satisfactory training programme in place, however the lack of training in food hygiene and prevention of abuse is detrimental to the welfare of the service users. EVIDENCE: A sample of three staff records seen showed that there is a good recruitment process in place. Records indicated that staff completed an application form and references were sought, Criminal Record Bureau (CRB) checks were carried out prior to employment to ensure the safety of the service users. The home has a training programme in place. Some staff have achieved National Vocational Training at level 2 and 3 and the provider reported that Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 20 this is ongoing. Staff spoken with were enthusiastic about the dementia care training that six staff were undertaking. Comments from staff were that “this was very good” and “enjoyable”. Another staff member told the inspector that she had learnt quite a lot from the course. It was reported that most of the carers are involved in the preparation of meals for the service users. However there was no evidence that any of them had completed food hygiene training. There was no evidence of staff training in the prevention of abuse. These were brought to the attention of the provider who reported that staff had done this training but the certificates could not be located. The provider confirmed that training in food hygiene and abuse would be put in place for all staff. The home has a duty roster in place. Records of the roster for the month of September 06 and the first two weeks in October showed that there had been 1 sleeping and 1 waking staff for 16 nights. The provider reported that the home had been experiencing a staff shortage and had relied on the home staff to provide cover and had not used agency cover. Staff reported that some service users do wander at night and needed support. The provider confirmed that this situation would be rectified as from week beginning the 9th of October 06 where two waking staff would be on night duty in order to meet the care needs of the service users. Staff reported that they undertook the cooking; some cleaning and laundry duty however the roster did not reflect the hours that the staff were working or in what capacity they were employed. Staffing hours appeared to be eroded by non- care duties. The provider must ensure that a review of the staffing levels including domestic hours is undertaken and the service users are provided with adequately trained staff and in sufficient numbers to meet their needs at all times. It was evident from interaction observed and comments from the service users that the staff had developed good relationship with the service users. Comments from the service users were that “They are all very good” when referring to the staff. Staff were observed to be attentive and two staff commented that they loved their jobs and have got to know the service users well. The home has a training programme that included National Vocational Training (NVQ) at level 2, manual handling, fire safety and six carers were undertaking training in dementia care. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36.38 Quality outcome in this area is adequate. The judgement has been made using available evidence including visits to the service. There is a lack of guidance for staff in the absence of the manager. There is a lack of structured supervision for staff and their practices are not monitored as part of their work. There is a programme in place for the servicing of equipment in order to ensure the safety of the service users. EVIDENCE: The home has a registered manager who is not currently available. Staff reported that they seek support from the provider as required. Comments from two service users indicated that there was a lack of direction for staff as the Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 22 manager has not been around for weeks and they did not know who was in charge of the service. Comments from a healthcare professional included that it was often difficult to find any staff around when he visited the home. This was discussed with the provider and will look the management structure and a dedicated member of staff should be in place to be responsible for the day- to day management of the service in the absence of the manager. The access to some records was difficult as the records had not been maintained in orderly manner and others could not be found. The provider is aware that records management could be improved and records filed appropriately and said that this would be rectified. A sample of the supervision programme for staff was seen it showed that in the three records seen staff had not received supervision since September 05. The provider is aware that staff must have a minimum of six supervisions during a twelve months period and that their practices should be monitored as part of their work. A sample of the servicing of equipment was seen and fire equipments, emergency lightings had all been serviced and records of these were available. It was noted that the emergency lighting was last serviced in September 05 and the provider said that he would be talking to the contractor to find out about the frequency of checks needed for emergency lighting. The bedroom door of one service user identified as a fire door was found wedged. This was brought to the attention of the provider who would be seeking advice about automatic door guard in order to safeguard the welfare of all the service users. Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X 2 Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) 13(4) (b) (c ) 17(1) (a) Schedule 3 3. OP12 12(4) Requirement The registered person must ensure that care plans are in place for all the service users and include risk assessments as appropriate. The registered person must ensure that the handling, safekeeping and disposal of medication are managed safely for the welfare of the service users. The provider must ensure that the activity programme meets with the expectations and needs of the service users. The registered person must ensure that staff training in the prevention of abuse is put in place for all staff to ensure that the service users are protected. The care home is kept free from offensive odours. This is a repeated requirement, as timescale of November 2005 has not been met. The provider must ensure that there is a programme of routine maintenance and the home is DS0000011821.V312194.R01.S.doc Timescale for action 30/11/06 2. OP9 30/11/06 30/11/06 4 OP18 13(6) 30/11/06 5. OP19 16(2) (k) 12(1) 30/11/06 6. OP19 23(2) (b) 30/11/06 Sycamore Cottage Version 5.2 Page 25 7. OP26 13(3) 8. OP27 18(1)(a) kept in good state of repair. The registered person must ensure that staff adhere to infection control procedures for the safety of the service users. The registered person must ensure that there are adequately trained staff and in sufficient numbers at all times in order to meet the assessed needs of the service users. These must include domestic staff as appropriate. A review of staffing level must be undertaken and adequate staffing implemented. The registered person must ensure that the duty roster reflect the hours worked by staff and in what capacity. The registered person must ensure that all staff involved in food preparation have the appropriate training to protect the service users and records of these are kept. The registered person must ensure that all staff have formal supervision as part of their work on a continuous basis. 30/11/06 30/11/06 9. OP27 17(2) Schedule 4 18(1) 30/11/06 10. OP30 30/11/06 11. OP36 18(2) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sycamore Cottage DS0000011821.V312194.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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