Inspection on 10/01/08 for Sycamore Cottage Private Residential Home

This inspection was carried out on 10th January 2008.

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

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 Private... 31/10/08

Sycamore Cottage Private... 01/05/08

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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Hunter`s Lodge

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Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Sycamore Cottage Private Residential Home 14 Harborough Road Oadby Leicestershire LE2 4LA Lead Inspector Keith Charlton Unannounced Inspection 10th January 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.V355617.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.V355617.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 *** Vacant *** 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.V355617.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 15th August 2007 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 bedrooms 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 £320 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.V355617.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 No 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 three 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 and one of the Proprietors were on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection, the last Inspection Report, correspondence between the Commission for Social Care Inspection and the Registered Provider dealing with the progress of how Requirements from the last inspection have been put into place, and the Annual Quality Assurance Assessment, which describes how care is delivered to National Minimum Standards. The Inspection took place between 09.30 and 16.45. The inspection included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with six residents, though this was limited due to the mental frailty of residents with dementia or confusion, two members of staff, the Acting Manager and a Proprietor. What the service does well: There were a number of issues, which covered residents needs – residents spoken to were satisfied with the care they received from staff, they thought that the food was generally satisfactory, and they liked their bedrooms. The inspector also observed that staff generally helpful in their dealings with residents. Residents said visitors are made welcome, and residents feel that the management would quickly act on any issue they raise. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 6 Staff showed awareness of how to promote residents independence and this was reflected in Care Plans. Residents said that there were no rules so they could choose how they live their lives. 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 residents stating they could bring in their 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? What they could do better: Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 7 Residents needs would be more effectively covered by ensuring that: Assessments are more thorough and contain evidence of the last appointments with Medical Services – dentist, optician etc, that Care Plans contain more specific detail as to residents continence needs so that staff can offer toileting before residents need to go, that Plans have full details of the care requirements of residents regarding Risk Assessments so that the proper care is always given and any risks minimised, that the approach to residents is always based on respect, that residents are provided with an Activities Programme that is frequent and reflects their choices, that food is fresh and more varied, that the refurbishment of the home continues to give residents a more attractive environment, that staffing levels are increased to ensure that there are sufficient staff to cover residents needs especially at weekend periods to provide essential supervision for residents with dependency needs, for example, dementia, and so have the ability to meet all residents needs. To extend the training programme to include some more relevant issues regarding residents care so that staff to have knowledge of residents conditions, e.g. stroke management, diabetes, epilepsy, hearing and sight impairment etc. Stringent control of the records of residents finances are needed so as to properly account for these monies. It is recommended that residents are encouraged to have a say in the running of the home in that a representative from the resident group can sit on staff recruitment interviews and in staff meetings. The Annual Quality Assurance Assessment needs to be returned within the timescale stipulated to ensure information can be used for inspection purposes. There had been no recent recorded fire drill, which meant residents were at risk if staff failed to follow the proper procedure. There were further health and safety concerns noted by the inspector in regard to access to harmful chemicals because of an unlocked cupboard and potential trip hazards in an unlocked storeroom and a wedged fire door. The Commission for Social Care Inspection issued another Immediate Requirements Notice for the Registered Provider to rectify these situations. To further focus on the needs of residents with dementia, for example by providing signs and colour coded doors to facilities would assist residents so that they can identify facilities clearly. There has not been a Registered Manager in place for over a year, which is needed to ensure there is an identified experienced and competent person in charge who can deal with all aspects of the running of a home that meets and promotes the needs of residents. The Commission for Social Care Inspection have directed the Registered Provider to send in detailed Regulation 26 monthly Reports as to the running of the home. A review of how they do these Reports is needed so that they properly follow up Requirements from the Commission for Social Care Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 8 Inspection and to ensure that the home is meeting standards that protect residents welfare. If this had been the case then the Requirements outlined in this Inspection Report should not have been present, as they would have already been dealt with. 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.V355617.R01.S.doc Version 5.2 Page 9 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.V355617.R01.S.doc Version 5.2 Page 10 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: The usual assessment form was inspected and which contained relevant information as to residents needs. The Acting Manager said there were also assessments on file 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.V355617.R01.S.doc Version 5.2 Page 11 The Acting Manager was asked to ensure that the form includes medical checks – 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 Standard are included. The Registered Provider does not provide intermediate care. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 12 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. Respect is not always present in the staff approach to residents. Residents health needs are monitored and acted upon. Effective medication systems are generally in place. EVIDENCE: No residents said that they were aware of Care Plans. It is recommended that residents or relatives (with residents permission) be reminded that they can see Plans and ask for changes if they do not feel they are accurate. Care plans inspected were found to contain relevant information regarding residents needs. There are also some Risk Assessments so as to manage any area of risk to residents. The Acting Manager stated that she was in the process of fully updating Care Plans. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 13 Some areas of need are not specific enough – e.g. there was no evidence of when appointments are needed regarding when checks are needed for the optician and dentist, the need for a hearing test etc though there was good information regarding residents appointments with medical services – the GP, District Nurse etc. There was a discussion with the Acting Manager regarding Care Plans being more specific as to the frequency residents with continence difficulties needing to be taken to the toilet based on their assessed needs. The Acting Manager said she was in the process of obtaining support from Medical Services to put this in place. Care records were kept on a daily basis and were detailed as to residents care needs. There needs to be a more detailed personal history section to ensure residents are seen as individuals with a valued past. Staff said they had been asked to read Care Plans, which helps to ensure that all relevant information is available for staff to meet residents needs. Monthly reviews of plans had not always been carried out to ensure they were still relevant to residents needs. Records show that medical services are contacted following illness to a resident. Accident records were viewed and it was found that incidents had been properly followed up with medical services where necessary, though there were a small number of instances where records had not been completed. The Acting Manager said this would be followed up with staff. Medication records were found to be generally up to date. There were only a small number of gaps on records, which the Acting Manager said would be followed up. Staff members said they only staff who have received training administer medication. Information regarding this was on training records. Medication is kept in a locked and properly secured trolley. There is a register for the recording of controlled drugs. Staff were generally observed to be talking to the residents with respect though there were some instances where staff were assertive rather than encouraging and friendly. The Acting Manager agreed with this observation and said she had been trying to get staff to change their approach and she would be raising this in staff supervision and monitoring by observation. The Acting Manager herself was found to relate to residents in a friendly and caring manner. The residents who could express a view said that staff were good to them. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 and evidenced. EVIDENCE: Residents were seen to be in the lounge though there were no activities on offer at the time on inspection, apart from the TV, which they did not appear to be watching. The Acting Manager said that she was setting up an Activities Programme, which was to concentrate on having short one to one sessions with residents with dementia. There is also some information on residents Care Plans as to the activities residents like to participate in. Staff said that residents also have memory boxes where their personal photos are kept and shown to them and there are games available if they wish to join in. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 15 There were comments on the Quality Assurance forms completed by relatives that the variety and choices of activities were ‘average’. The Acting Manager agreed to send the proposed Activities Programme to the inspector so that this could be checked. Residents spoken to said that visitors were made welcome by staff. Residents and staff said that there were no rules and residents could please themselves about things – getting up and going to bed times, when to have a bath, have alcohol and that staff encouraged them to retain their independence. A resident was seen to be going out for a meeting with her advisor – another indication that residents choice was respected. Staff said that it was important that residents were able to do things for themselves, and confirmed this aim of the service. There have been no Residents/Relatives Meeting held where all residents are invited to attend and share their views about the home. The Acting Manager said these are to be arranged, though she said she has spoken to residents and relatives on a one to one basis to ascertain their views. It is recommended that these communications be recorded to form part of the Quality Assurance system of the home. The Acting Manager is recommended to see if any residents are able to influence the running of the home by a representative being on staff recruitment panels and attending non-confidential discussions in staff meetings. Residents said they thought the food was generally good. There was a comment received that there are too many pastry based main meals and that a lot of tinned food was used. Fresh vegetables were seen to be in the kitchen though this supply was limited There were no fresh fruit available, though there was tinned fruit. It was found that peas were served four days out of five on menu one therefore demonstrating limited choices. There were comments on the Quality Assurance forms completed by relatives that the variety of food and choices were ‘average’. There is no choice of dishes, which is needed to meet the National Minimum Standard. Food records were generally full and recorded the variety of vegetables offered. Food preferences were found in Care Plans inspected. The food tasted was found to be of a satisfactory standard with two courses with two vegetables plus potatoes served. The Acting Manager and Proprietor were asked to review the food supply so as to increase the quality, nutrition and choice available to residents, and they agreed to do so. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 good. This judgement has been made using available evidence including a visit to this service. The current system generally protects residents from the possibility of abuse as staff awareness of the abuse procedure is in place, though the Complaints Procedure does not indicate the current procedures. EVIDENCE: Residents said that they did not need to complain but if they did they thought the management would look into it properly if they ever needed to. The Complaints file could not be viewed, as there was not one in place. It was recommended that a book be obtained to clearly show how the service handles complaints. The Acting Manager said there had been no complaints since the last inspection. There have not been any complaints made to the Commission for Social Care Inspection since the last inspection. The Complaints Procedure in the Statement of Purpose needs to be altered to give the complainant the choice to go to the investigating body – the local Social Service Department - now the lead agency for investigating complaints. The Proprietor said this would be changed. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 17 Staff members were asked about their understanding of the adult protection procedures, and demonstrated a generally good understanding of these. They said that they had attended Protection of Vulnerable Adults training held by the home. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 adequate. This judgement has been made using available evidence including a visit to this service. A homely, generally clean environment is provided to residents. EVIDENCE: Residents all said that they liked their bedrooms and the home’s facilities were satisfactory in general. They said they could have their bedrooms in the way they wanted and could bring in their own furniture and other personal possessions. Bedrooms were observed to be personalised and homely by the inspector. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 19 The Acting Manager outlined how a new quiet area was being created in the old dining section to assist residents with activities, have an n area for visits etc. This looked to be a good development. Facilities were found to be generally clean and odour free except for one bedroom where there was a urine infection and a toilet where there had been an accident. To further focus on the needs of residents with dementia, for example by providing signs and colour coded doors to facilities would assist residents so that they can identify facilities clearly. Having a board displaying the daily menu, date, weather etc would also help to orientate residents. The Acting Manager is recommended to check with care experts (e.g. Alzheimers Disease Society) as to creating a clearer environment for residents with dementia. There has been a new carpet fitted to the lounge. The Proprietor said that further new carpets will be fitted, furniture is to be replaced, more bedrooms will be decorated and there was to be a new bathroom fitted out on the ground floor for the week following the inspection and the first floor bathroom to be refitted with three months of the inspection. The painting to the front of the home has been marked by soil and exhaust fumes and looked grubby. This needs to be repainted or cleaned so as to give a smarter appearance and a better impression of the home. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 at all times. Recruitment processes are generally thorough 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: There were some comments received that there were sometimes not enough staff on duty to met residents needs, especially at weekend periods when there were only two staff on all day and they also had to do domestic and catering duties. The current staff ratio is for two care staff (and this includes the Acting Manager) on all daytime/evening shifts with a cook and domestic worker on until after lunchtime, for five days a week, plus one awake staff at night with a staff member on call nearby. There was a discussion that staffing levels need to increase at the weekend especially, and that there needs to be the on call member written on the rota Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 21 when the Registered Provider is indicated to be on call, as she lives approximately forty miles away. Staff records were inspected and generally met expected standards with two references and Criminal Records Bureau checks obtained, copies of passport or similar ID. One staff only had one reference. The Acting Manager said that this would be followed up. Staff said that training is provided and that there is encouragement to complete National Vocational Qualification level 2 training. There were training certificates on file to validate training. The Company has a core training programme for staff – e.g. for Food Hygiene, Health and Safety, Protection of Vulnerable Adults, First Aid, Dementia, Infection Control, Moving and Handling, Medication etc. As discussed with the Acting Manager and Proprietor there is a need to extend core training topics to add other essential topics and adding knowledge of residents conditions, e.g. stroke management, diabetes, epilepsy, hearing and sight impairment etc, to the list of training issues. The Acting Manager said this would be followed up. The Acting Manager said there is an induction programme for new staff, which covers relevant topics and it will follow the induction information used from ‘Skills for Care’ organisation, which is the recommended method. The Acting Manager said she kept a training matrix for staff to quickly identify training needs of individual staff, which she agreed to send to the inspector so that it can be checked. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 poor. This judgement has been made using available evidence including a visit to this service. Systems are not in place to fully protect the health and safety of residents. EVIDENCE: From information received from residents and staff there was a consistent message that the Acting Manager always tried to uphold residents welfare. The Registered Provider needs to ensure that there is a Registered Manager in place in the short term to ensure the continuity of care for residents and be able to take forward and put in place improvements that are needed to ensure residents welfare. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 23 Residents monies records were checked but were not found to be up to date in that they did not tally for two residents. The Acting Manager then brought it up to date for one resident and said she would send the inspector a receipt where she had spent money on behalf of a residents so the other account would then tally. Two staff, or one staff plus a resident/ representative, need to sign each transaction, as was not always found to be the case. There was evidence that staff are given formal supervision. There was evidence that the Quality Assurance system has been carried out for relatives views on the care provided. The Acting Manager said this would also be carried out for residents and other interested parties - District Nurses, GPs, Social Workers etc, that an Action Plan will be drawn up to meet any issues that come up, and this information included in the Statement of Purpose. The Acting Manager said staff meetings are to be held frequently in the future. The minutes of the last meeting were available and were well set out and detailed. Fire Precautions: a fire drill had not been carried out since April 2007. The Inspector has previously informed the Registered Provider that drills need to be carried out on a three monthly basis, so an Immediate Requirements Notice was served for this to be carried out within a day of the inspection. Fire bell testing was carried out though not always on the required weekly basis and emergency lighting testing was not being carried out on the required monthly basis. The Acting Manager said these issues would be followed up and put in place. Staff were aware of the proper fire procedure. There is a format for Risk Assessments for safe working practices to be carried out for issues that present risk for any issues that may present a danger to residents and staff, and the Acting Manager said this was to be done in the next few weeks following this inspection as the Environmental Health Officer was due to visit the day after the inspection. This was needed as the inspector observed that there was a cupboard door open near to the office where Control of Substances Hazardous to Health were stored. There was also a storeroom that was open, which was a tripping hazard and a fire door seen to be wedged open to the kitchen on two separate occasions during the inspection, thereby potentially compromising residents safety. An Immediate Requirements Notice was served for such health and safety systems to be in place at all times. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 24 There was also a discussion that there is an assessment regarding the need for proper window restrictors to ensure they are sufficient to meet the needs of current and future residents. The Registered Provider said that he was currently ensuring that there were proper service contracts in place, e.g. hoist and wheelchair servicing, etc and that radiator covers are to be fitted to prevent a burning risk to residents. A hot water outlet in a first floor bathroom was found to be 40c, which met the National Minimum Standard of 43c, to prevent a scalding risk to residents. Sycamore Cottage Private Residential Home DS0000062462.V355617.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 1 X X 1 Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 26 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 Requirement Care plans should contain comprehensive information regarding resident’s needs including how to properly deal with incontinence needs, with all necessary Risk Assessments and medical checks in place and they be reviewed on a monthly basis. The Registered Provider must provide an Activities Programme based on residents needs and preferences and submit it to the Commission for Social Care Inspection. Timescale for action 10/03/08 2. OP12 16 10/04/08 3. OP27 18 The Registered Provider should 10/02/08 review the dependency needs of each resident and ensure that staff are provided in sufficient numbers to meet residents needs and maintain their health and safety at all times, especially at weekends. A staff rota with increased staffing hours needs to be sent to the Commission for Social Care Inspection. Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 27 4. OP30 18 The Registered Provider must ensure that staff are fully trained to meet residents needs. The Registered Provider must ensure that there is an Application to the Commission for Social Care Inspection for a Registered Manager to be in place to run the service. The Registered Provider must ensure that the records of residents monies are in place to demonstrate that they are always in order. The Registered Provider must ensure that all health and safety systems are in place to protect residents - e.g. that fire systems are in place, that residents are protected from Substances Hazardous to Health, there is no access to areas where there are tripping hazards and that Risk Assessment for safe working practices are in place and followed. 10/04/08 5. OP31 8 10/03/08 6. OP35 17 10/02/08 7. OP38 13 10/01/08 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. 1. Refer to Standard OP10 OP12 Good Practice Recommendations The Registered Provider needs to ensure that residents are always treated with respect. It is recommended that a staff member attend specialist training to provide appropriate Activities to residents with DS0000062462.V355617.R01.S.doc Version 5.2 Page 28 Sycamore Cottage Private Residential Home dementia. 2. OP19 The Registered Provider should seriously consider methods of signing facilities to provide orientation for service users with dementia, and to provide bedroom locks so that residents are protected from service users who wander. The Registered Provider needs to provide a varied, wholesome and nutritious diet with an emphasis on fresh ingredients, with fresh fruit available. 3. OP15 Sycamore Cottage Private Residential Home DS0000062462.V355617.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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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