Inspection on 01/05/08 for Sycamore Cottage Private Residential Home

This inspection was carried out on 1st May 2008.

CSCI found this care home to be providing an Poor service.

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 Cottage Private... 31/10/08

Sycamore Cottage Private... 10/01/08

Sycamore Cottage Private... 20/04/07

Sycamore Cottage Private... 20/04/06

Sycamore Cottage Private... 05/09/05

Sycamore Cottage Private... 04/05/05

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St Marys Nursing Home

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Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sycamore Cottage Private Residential Home 14 Harborough Road Oadby Leicestershire LE2 4LA Lead Inspector Keith Charlton Unannounced Inspection 1st May 2008 09:30 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 Private Residential Home DS0000062462.V363637.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 Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Cottage Private Residential Home Address 14 Harborough Road Oadby Leicestershire LE2 4LA 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) 0116 2711720 0116 2711880 harwinderjagpal@yahoo.co.uk Sycamore Cottage Limited Care Home 14 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (14) of places Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - code OP Dementia, over 65 years of age - Code DE(E) (5) The maximum number of service users who can be accommodated is 14 10th January 2008 2. Date of last inspection Brief Description of the Service: Sycamore Cottage is a residential care home for a maximum of 14 older people. The home is situated off the Harborough Road in Oadby, and is close to local shops and supermarkets. The home is a converted detached house with a ground floor extension. There are 10 single and two shared bedrooms. The first floor comprises of five bedrooms and a bathroom that are accessed by a stair lift. The communal areas include a lounge and dining room. There is a courtyard and garden to the rear of the property. The range of fees for the service is between £344 and £350 per week. The Acting Manager provided this information on the day of the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, etc. There is a displayed copy of the last Inspection Report in the hallway and the Statement of Purpose describing the home’s services is available on request. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Acting Manager was on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection, the Annual Quality Assurance Assessment which the service sent in and which contains information as to how the home is run, and the last Inspection Report. The Inspection took place between 9.30am and 4.15pm and included a tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with one resident - communication with other residents was very limited owing to the difficulty with communicating with residents with a high level of mental frailty, two staff members, and one relative. Surveys have been sent to relevant people and have been received back from five staff members. Please refer to the staffing section of the Report. What the service does well: The resident spoken with thought the Acting Manager was friendly and efficient, was satisfied with the care received from staff, thought that the food was generally satisfactory, and liked her bedroom. The inspector also observed that staff generally helpful in their dealings with residents. The relative said visitors are made welcome, and felt that the management would quickly act on any issue raised. Staff showed awareness of how to promote residents independence. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 6 The resident said that there were no rules so she could choose how she lives her life. One resident was provided with an alcoholic drink at lunchtime, which was an indication of how residents’ choices are respected. Bedrooms were found to be homely and personalised with a resident stating she could bring in her personal possessions. Staff training is now encouraged so that staff are given most essential training and they are encouraged to undertake National Vocational Qualification training to add to their care skills. Staff are asked to read residents Care Plans and the Policies and Procedures of the home so that they know what to do and are consistent in their work. What has improved since the last inspection? Residents are provided with an activities programme that reflects their choices, there appears to be more staff contact with residents, which is based on respect. The food provided is fresh and more varied. The refurbishment of the home continues to give residents a more attractive and homely environment. The training programme has been extended to some more relevant issues regarding residents care so that staff have more knowledge of residents conditions, e.g. diabetes, sight impairment etc. More stringent control of the records of residents’ finances is in place so as to properly account for these monies. There had been a number of recorded fire drills, which meant residents were safer as staff are more able to follow the proper procedure. Access to harmful chemicals has stopped due to better security and potential trip hazards have been eliminated with a locked storeroom. There were no wedged fire doors therefore protecting from the risk of fire spreading. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 7 What they could do better: 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 Cottage Private Residential Home DS0000062462.V363637.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 Cottage Private Residential Home DS0000062462.V363637.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): 3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is satisfactory but needs to be better managed to meet the needs of residents. EVIDENCE: This is the same picture as the inspection report of four months previously in that there have not been any new admissions and the usual assessment form was inspected, which contained relevant information as to residents needs. There were also assessments from Social Service Departments available, which outlined residents needs. The Inspector looked at residents files, which contained relevant information in terms of medical, physical and social needs of residents. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 10 The Acting Manager was asked to ensure that the form includes medical checks e.g. last optical and dental checks, whether there is a need to refer to medical services regarding hearing tests etc and that all the aspects stated in the National Minimum Standards are included. The Registered Provider does not provide intermediate care. Sycamore Cottage Private Residential Home DS0000062462.V363637.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify most care needs and outline action to ensure their needs are met but need more detail of residents needs. Resident’s health needs are not always acted upon. Effective medication systems are in place. EVIDENCE: Residents care plans were inspected and included information of their care needs. There was no written evidence that residents / their representatives were given the choice to be involved in the setting up and reviewing of the Care Plan, which needs to be included. The Acting Manager said that the two residents case tracked did not have relatives to be able to be involved in this. The visitor was unaware of the Care Plan for her relative, though the Acting Manager stated that the resident had signed her Care Plan. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 12 Care Plans contain little information of the past life history of residents, which would help staff see residents as people with a valued past and assists in talking with them to provide ongoing stimulation for residents. Staff said they had read all the Care Plans so were aware of the care needs of residents. However when the inspector asked a staff member as to details of these needs this did not completely tally with the written Care Plan. The Acting Manager said it was her intention to rewrite the plans and that all information was correct. The Acting Manager stated that this information has been corrected. Risk assessments were found to be a part of the plans so that staff know how to keep residents safe from identified risks. Care Plans did not clearly set out medical checks as they did not include all aspects of medical checks e.g. dental, optical (though there was a separate record that they had been offered optical checks), hearing etc or whether the residents needed a chiropodist, and there was no information regarding daily living wishes. Daily care recording was in place though there were gaps of four to five days in records. The Acting Manager stated that this was a new system and staff were getting used to it. Accident records were viewed which showed that generally accidents were properly dealt with but there was one incident where medical services were not contacted with a head injury to a resident in March 2008. The inspector observed that in general staff were friendly and gave residents choices and explained what they were going to do before doing it so as not to alarm the resident, and were explaining and encouraging in a friendly manner at the residents pace. The Acting Manager’s approach to residents was warm and friendly, which helped to divert residents from confused behaviour. Another staff member quickly reacted to a resident wanting to play bingo and set up a game. There were also instances where a staff member did not respond to a resident when the resident said she wanted a cup of tea – the Acting Manager said this resident drank a lot though she agreed there was nothing in the Care Plan to indicate how to deal with this or whether it was a problem in practice – and where a resident said she had lost her handbag but the staff member did not offer to try to find it. The Acting Manager said she would take this up further to ensure there was always a proper response to residents though later stated that this was a valid response to the resident who said similar things all the time. However the Commission would not agree that ignoring a resident showed sufficient respect to a resident. Such an approach must be agreed with relevant professionals, e.g. Social Worker, and contained in the resident’s Care Plan. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 13 The visitor the inspector spoke with said she thought the staff were very caring and friendly and did a good job. The Acting Manager confirmed that only staff who had received training issue medication and medication training records on file which showed that this had happened. Medication was found to be locked away securely. Medication records were generally well completed with a small number of gaps on record sheets. There was one instance where medication was signed for before being issued to a resident, which should not be done as if may have been refused by the resident etc and then there would have been an incorrect recording. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to have a stimulating lifestyle though this needs to be extended. EVIDENCE: A resident said that there are things to do though not many residents were interested. As stated above staff played bingo with residents. There was also evidence of staff taking a resident out to the garden to have a walk and enjoy the sunshine. Staff said that they tried to do activities when they had time. Currently there is an Activities Programme so that staff know what activities are to be carried out. It is still recommended that a staff member receive specific training so as to be able to plan to provide relevant activities for residents with dementia. The Annual Quality Assurance Assessment stated that individual memory boxes have been set up to help residents with reminiscence – this will offer a good, stimulating activity to residents. The Acting Manager said that this has Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 15 been actioned though it has been adapted so that there is a general memory box for all residents as individual information was difficult to obtain. The Acting Manager said there currently no residents / relatives meetings though she would look into this and the Manager was recommended to increase the frequency of these to increase relevant input to look at how to improve the quality of life for residents. The Acting Manager thought that the current system of having an open door policy meant that relevant information was obtained to improve services. A relative stated that visitors are always welcomed to the home by staff and there were no restrictions. Staff said that there were no rules for residents – e.g. they said they could rise and retire when they wanted and if they did not want a shower then this would be worked round so they did not have to have one at that time. The resident and visitor thought that the standard of food was good. The inspector noted an improvement in the food supply in that there was fresh fruit available and this was offered, cut up to suit residents preferences, throughout the week. There are also two vegetables on offer each day for the main meal. Menus were inspected and found to have choice for the main meal though the ‘vegetarian option’ on the menu needs to be specific as to what is on offer. The menus could be improved further to offer a choice of cooked breakfast. Records need to be more detailed and to include the detail of vegetables and sandwiches served on records so this variety can be monitored. It is recommended that residents food preferences be available to staff to act as a reminder as to what foods individual residents like. The inspector tasted the food. It was broadly satisfactory though the mashed potato again had lumps in it and needed flavour, e.g. some milk/butter, and the lamb was a little tough and needed more cooking time to tenderise it. Sycamore Cottage Private Residential Home DS0000062462.V363637.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): 16,18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The current system generally does not protect residents from the possibility of abuse as staff recruitment procedures are not in place and staff knowledge of what to do if abuse is suspected is not fully in place. EVIDENCE: The relative spoken with thought that if there were a problem then the Management would sort it out. A Complaints Book is kept; there have been no complaints in the past year. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the Social Service Department(s) – as relevant, as per the National Minimum Standard. It also states that all complaints need to be made to the home first – the National Minimum Standard states complainants can choose to go to the lead agency first. The Commission for Social Care Inspection office address needs to be changed as well as the Leicester Office has now closed. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 17 All staff spoken with were not fully aware of the procedure regarding of which Agencies to contact if the in house arrangement failed. The acting Manager said these issues would be followed up and a short procedural statement drawn up and displayed to help staff to follow the correct procedure. It was found that a staff member recommencing employment this year had not had statutory essential legal Criminal Records Bureau / Protection of Vulnerable Adults first checks in place. This is a serious issue and a legal Notice will be served on the Registered Providers to ensure residents are fully protected from unsuitable staff. This is especially serious as in the 2007 inspection it was stated in the Inspection Report that statutory checks need to be in place prior to employment commencing, as detailed in Schedule 2 of the Care Homes Regulations 2001. The Commission for Social Care Inspection will seriously consider taking further legal action with regard to this breach. Sycamore Cottage Private Residential Home DS0000062462.V363637.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 good. This judgement has been made using available evidence including a visit to this service. A homely, generally clean environment is provided to residents. EVIDENCE: The residents said she liked her bedroom and visitor said she was satisfied with the refurbishment work. Bedrooms looked generally homely and clean. The Acting Manager said that residents some bedrooms were to be decorated to complete the programme. The garden area looked attractive and user friendly with a resident using it with staff supervision. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 19 However the front of the home still looks grubby and unattractive with cracked paint on windowsills and marks on the painted front of the home. The Acting Manager said that this is to be dealt with by the agreed timescale at the end of this summer. There is signing to bedrooms to assist with residents with dementia and this needs to be extended through out the home as assessed by an expert, e.g. same colour doors for bathrooms etc to make them more recognisable to residents so they do not make a mistake when using facilities. The Acting Manager did not think this was currently relevant for residents. However if done it will be relevant for future residents who are admitted. All bathrooms have functioning locks to ensure privacy for residents. There were some radiators without the protection of having covers on them to ensure the health and safety of residents. The Acting Manager said that they were to be fitted with radiator covers before the cold weather period started later in the year. Odour control was of a good standard apart from one bedroom. The Acting Manager said that the carpet was cleaned but odour was now ingrained and agreed to talk to the Registered Providers about getting this flooring changed to a more suitable flooring that can be easily cleaned and eliminate the odour. Sycamore Cottage Private Residential Home DS0000062462.V363637.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels may not meet residents needs. Recruitment processes are not thorough enough to ensure the protection of residents from unsuitable staff. A staff training system is in place to ensure staff are aware of residents needs though this needs to be extended. EVIDENCE: Staff surveys were received back from five staff, which were generally positive about the way that staff were trained and supported by the manager. However there were some comments regarding the lack of staff: ‘…at least two staff a night because I feel that one carer is not enough and a cook to do the cooking because its hard to do both the care work and the kitchen work’. Comments were also received that there were enough staff to cover residents needs at present but when there are more residents there will be a need to Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 21 increase staffing to ensure residents needs are met as the home has a high number of residents with high dependency needs. The staffing rota demonstrated that usually there are two care staff on duty throughout the day with the Acting Manager in addition five days a week and one night care worker on duty at night. There were instances where the inspector noted that in the lounge where residents there were did not have any staff with them at times, as they were busy with other duties, which could effect residents health and safety if they were to get up and fall. The Acting Manager and the Annual Quality Assurance Assessment stated that there is to be domestic help for weekends, who is due to start shortly. This will help with care staff not being called upon to carry out domestic duties so they can concentrate on residents needs. Staffing needs to be reviewed and increased as needed to ensure that residents are properly protected and their needs are met, especially when residents number increase in the future. The Annual Quality Assurance Assessment and staff members said there had been training in the last twelve months. Records seen by the inspector showed this. There was also evidence of induction training for new staff. The Acting Manager is asked to follow up whether the recognised Skills for Care induction pack is being used. The Acting Manager has devised a Training Matrix to identify key issues that staff need training which quickly shows who needs training in relevant issues. Training in important areas – e.g. first aid, Moving and Handling, Fire, Food Hygiene, Vulnerable Adults training, infection control, health and safety, dementia. Staff said they were encouraged to undertake National Vocational Qualification level training and the Annual Quality Assurance Assessment stated that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 has been met. Recruitment records were inspected. There was no Criminal Records Bureau / Protection of Vulnerable Adults check in place for one staff member and no current written references in place. Sycamore Cottage Private Residential Home DS0000062462.V363637.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): 31,33,35,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to fully protect the health and safety of residents though need to be strengthened. EVIDENCE: The Acting Manager stated that she is ready to apply to be the Registered Manager for the home. The Annual Quality Assurance Assessment states that she is undertaking the Registered Managers Award to provide relevant training to deliver high quality care for residents. The visitor spoken with thought the home was well run. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 23 Staff said that they were listened to and valued by the management of the home and that they received one to one supervision to discuss issues of care practice etc. The Commission for Social Care Inspection have directed the Registered Provider to send into the Commission detailed Regulation 26 Monthly Reports as to the running of the home and all the National Minimum Standards and legal duties that need to be followed. They were not in the home and have not been sent in since January 2008, so were four months behind schedule. These need to be sent every month. A review of how they do these Reports is needed so that they properly follow up requirements from the Commission for Social Care Inspection and to ensure that the home is meeting standards that protect residents’ welfare. Staff Meetings have been held and were well recorded. They provide support for staff and ensure care practice issues are regularly discussed so that staff can get the care right for residents. Although the Annual Quality Assurance Assessment stated that a Quality Assurance system manual was in place, completed forms were not available so there was no evidence to prove this had happened. The Acting Manager said this would be followed up and completed in 2008 though pointed out that they were available for the last inspection. They need to be available for all inspection visits to provide evidence that they have been carried out. Resident’s monies records were found to be properly kept with running balances, and though two signatures had not often been recorded to show that transactions are witnessed. The Acting Manager said that would be followed up. There is a Health and Safety folder with Risk Assessments for safe working practices so residents are properly protected from any potential dangers in the home. The Acting Manager said she would do a Risk Assessment as to whether there is a need to install window restrictors to make sure no resident could fall from any first floor bedroom window. Fire Precautions: Weekly fire bell testing records was being carried out and fire drills carried out on the required three monthly basis. The Acting Manager thought that twice yearly drills were the Requirement and is to check this with the Fire Officer. Staff members were asked the fire procedure. One was not fully aware of the whole procedure – the Acting Manager said staff would be checked on their knowledge to ensure that residents are kept as safe as possible if there is a fire. System testing was on not on the required monthly schedules for emergency lighting as records showed it had been done every two months – the Acting Manager agreed to follow this up. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 24 There was a fire risk assessment on file but this had minimal information and needs to be reviewed. The Acting Manager said that she would check with the Fire Officer as to how to compile a detailed fire risk assessment. The hot water temperature was checked in a bathroom and found to be 44.4c, which nearly met the National Minimum Standard of 43c. The Acting Manager said she would get this adjusted to ensure no residents were at risk from scalding. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 25 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 1 2 Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 12 Requirement Resident’s health needs in respect of contacting medical services in respect of potentially serious injuries must be met at all times. This will ensure residents’ health, safety and wellbeing is promoted. 2. OP29 19.4 01/05/08 Staff recruitment systems must ensure that the necessary checks including Protection of Vulnerable Adults First check, a CRB and two references are put in place before any staff member commences employment. This will ensure that residents are protected from potential abuse. 3. OP27 18 Staffing needs to be reviewed to ensure that residents can be supervised and cared for as their needs dictate. This will ensure residents’ health, safety and wellbeing is promoted. Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 27 Timescale for action 01/06/08 01/06/08 4. OP37 26 The Registered Provider must inspect the home on an unannounced, monthly basis, inspect all relevant issues and send a Report on these findings to the Commission for Social Care Inspection. This will ensure that the provider is aware of their responsibilities and takes action to meet them. 01/06/08 5. OP18 13.6 All staff must be fully aware of Safeguarding Adults reporting procedures. This will ensure that residents are protected from abuse and are able to alert the relevant people if abuse is suspected. 01/06/08 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 OP7 Good Practice Recommendations Care plans should contain comprehensive information regarding resident’s needs including how to properly deal with incontinence needs (i.e. what is the assessed need that an individual resident needs to go to the toilet so they do not have accidents and sit in wet clothes), with all necessary medical checks in place, and they be reviewed on a monthly basis. It is recommended that a staff member attend specialist training to provide appropriate activities to residents with dementia. All meals need to be of good quality, choice needs to be extended and records more detailed to prove that choice is DS0000062462.V363637.R01.S.doc Version 5.2 Page 28 2. OP12 3. OP15 Sycamore Cottage Private Residential Home offered to residents. 4. OP19 The Registered Provider should seriously consider methods of signing facilities to provide orientation for residents with dementia. Odours need to be completely eliminated. To this end more appropriate flooring needs to be installed in one bedroom that has ingrained odour problems. The Registered Provider should review the dependency needs of each resident and ensure that staff are provided in sufficient numbers to meet residents needs to maintain their welfare and health and safety at all times. The Registered Provider must ensure that all health and safety systems are in place to protect residents - e.g. that all fire systems are fully in place (e.g. the fire risk assessment is fully detailed, emergency lighting testing is carried out at the required frequency), and that all Risk Assessments for safe working practices are in place. 5. OP26 6. OP27 7. OP38 Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Cottage Private Residential Home DS0000062462.V363637.R01.S.doc Version 5.2 Page 30 - 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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