Inspection on 20/04/07 for Sycamore Cottage Private Residential Home

This inspection was carried out on 20th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report 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... 10/01/08

Sycamore Cottage Private... 20/04/06

Sycamore Cottage Private... 05/09/05

Sycamore Cottage Private... 04/05/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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 Key Unannounced Inspection 20 April 2007 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.V336615.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.V336615.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 Sycamore Cottage Limited *** Vacant *** Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To be able to admit a person under the category of DE(E) named in variation application number V29043 dated 2nd January 2006. To admit the named person in the category DE/E who is the subject of variation application V29359. 20th April 2006 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 is 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 £350 and £420 per week. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, etc. Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three service users 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. This was conducted with the Acting Manager in charge with the Registered Providers also coming in to assist. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. There have been no complaints made to the Commission for Social Care Inspection since the last inspection of the service. The Inspection took place between 14.00 and 16.00 with its completion on 24/4/07 between 09.30 and 16.00 on 24/4/07 and included a selected tour of the home, inspection of records and direct and indirect observation of care practices. The Inspector spoke with six service users (though this was limited for some owing to the difficulty with communicating with some service users with a high level of mental frailty) two staff members, and three visitors. Five Comment Cards were received from service users, a relative and a friend of a service user which detailed their views regarding the quality of care received by service users. What the service does well: Service users and visitors said that staff were very friendly and helpful towards them, reported that staff welcome visitors and they thought some of the food provided to them was good. Staff were observed to be friendly towards service users. Service user needs were well covered regarding medical authorities being involved where necessary following illness or injury. Care Plans contain the past life history of service users if service users/their representatives agree to supply this information. This helps staff see service users as people with a valued past and assists in talking with them. Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 6 Service users generally spoke positively about some of the activities arranged by staff, which provided interest and stimulation for them. The Acting Manager has a positive attitude in seeking to improve the care standards in the service and was receptive to ideas as how to improve the service for service users. Staff thought they were valued in their performance of their jobs by the Acting Manager. All the Comment Cards received praised the care that service users received. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of service users is protected at all times, as there were staff without written references from their last employer, which meant service users were exposed to staff who may have posed a risk to them if they had a poor work record in their past jobs. The service was without a hoist for service users who needed this and a service user was observed to be lifted by staff, therefore increasing the risk of injury to service users and staff. There had been no recent recorded fire drill, which meant service users were at risk if staff failed to follow the proper procedure. The Commission for Social Care Inspection issued an Immediate Requirements Notice for the Registered Provider to rectify these situations. There were further health and safety concerns noted by the inspector in regard to access to harmful chemicals because of an unlocked cupboard, potential trip hazards and hot water temperatures. Staffing levels need to be reviewed and increased as there are only two care staff available, one of which is often the Acting Manager, for service users care from 8am to 8pm, which does not provide essential supervision needed for some highly dependant service users with, for example, dementia, and the ability to meet all service users’ needs. Staff must always be aware of service users care needs; this would include ensuring that the needs of service users with dementia are met, for example providing signs to facilities would assist service users who have dementia in that they can identify facilities clearly, and providing relevant activities provided by properly trained staff, that staff need to read all Care Plans to ensure they meet individual needs, that Plans have full details of the care Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 7 requirements of service users regarding Risk Assessments so that the proper care is always given and any risks minimised, and staff being aware of all the Policies and Procedures of the service to ensure proper and consistent practice. Some comments were made that there should be outings for service users as there were none last year. Staff always need to carry out medication procedures properly, have full training on all essential care issues, and have a full understanding of the Vulnerable Adults procedure to protect service users from abuse. 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 service users. The Registered Provider must ensure that service users are not admitted to the home that are outside the registration categories, to ensure that the service can fully meet the needs of these people and of current service users. 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.V336615.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.V336615.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 managed so that most service uses receive a satisfactory assessment, thereby ensuring that their main health and welfare needs are being met. EVIDENCE: No service users could remember anyone from the home coming to see them prior to admission to discuss their care needs, saying they could not remember that far back. There was very little information on the needs of a service user recently admitted from another home. At the time of inspection the Registered Providers had applied for a major variation to admit service users with dementia. In the meantime three service Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 10 users with dementia had been admitted before the variation had been approved. The Registered Provider said this was due to a misunderstanding and no more service users with dementia would be admitted until, the Commission for Social Care Inspection had approved this. An Immediate Requirements Notice was issued to direct that this was the case. The Registered Providers must ensure that the conditions of registration are adhered to or they could face legal action by the Commission. The usual assessment form was inspected and which contained relevant information as to service users needs, as per most of the issues in the National Minimum Standard. The Acting Manager said were also assessments on file from Social Service Departments available, which outlined service users needs. The home does not offer intermediate treatment facilities. Sycamore Cottage Private Residential Home DS0000062462.V336615.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. Service users are not always well looked after regarding their personal care with regard to Moving and Handling practices. They are treated with respect, and generally looked after in respect of their health needs. EVIDENCE: Service users said that staff would call the doctor if they were not well and they made medical appointments for their regular health checks. Service users care plans were inspected and included records of the service users care needs. There was no written evidence that service users/their representatives were given the choice to be involved in the setting up and reviewing of the Care Plan, though the Acting Manager said this was the case in practice. Care Plans contain some past life history of service users if service users/their representatives agree to supply this information, though the Acting Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 12 Manager was asked to expand this to provide more detail. This helps staff see service users as people with a valued past and assists in talking with them. Risk assessments were kept and set out within a risk assessment framework though these were not detailed and need to be reviewed so that they state the specific risk and how it needs to be managed. More risk assessments were needed, e.g. for Moving and Handling, risk of falls etc. Care Plans did not clearly set out medical checks, e.g. dental and optical needs as regards routine checks, or whether the service user needed a chiropodist, and there was no information regarding daily living wishes. The inspector observed Moving and Handling practices whereby the service user was being inappropriately lifted. The Registered Provider said that a hoist would be purchased to meet the needs of service users with Moving and Handling needs. Accident records were viewed which showed that medical services were called if there had been injuries to service users. Service users and visitors said staff were friendly and caring. The inspector observed that staff were very friendly and the inspector also observed good practice where staff were explaining and encouraging in a friendly manner at the service user’s pace. A Care Assistant confirmed that only that staff that issue medication have undertaken medication training. Staff training records confirmed this. There were no gaps in medication record sheets though some staff only signed with one initial. The inspector observed a practice whereby a service user was supplied with medication and the record signed without checking that the medication had been taken, and the medication trolley left open and unattended for a short period of time. The Acting Manager agreed to take this matter further to ensure safe practice at all times. Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users do not always have the opportunity to lead an active lifestyle and can exercise choice in their daily living arrangements. Service users see the food supply as satisfactory. EVIDENCE: Service users said that there were usually enough activities and they enjoyed them, though they would like more outings and walks out with staff. The Acting Manager said this would be followed up. Staff said service users sit out and use the garden in good weather. The inspector recommended that parasols are bought and sun lotion used to protect service users from sunburn. The Registered Provider said that the home had received a grant and the garden was to be upgraded. Activities were observed to be offered to service users during the inspection. The Registered Provider is recommended to look into providing specialist training to provide relevant activities for service users with dementia. Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 14 It is also recommended that service users with dementia would benefit from having memory boxes filled with important items of interest to them and used to discuss events from the past, so as to provide more stimulation. There was evidence of some Residents and Relatives Meetings, with minutes of meetings evidenced these as taking place, though not on a regular basis. The Registered Provider said this would be followed up, so that views of care provision can be regularly put forward to improve care provision. Both service users and a relative stated that visitors are always welcomed to the home by staff and no one reported any restrictions. Service users said that there were no rules – they said they could rise and retire when they wanted, and a number of service users liked to stay in their rooms and this choice was respected. The inspector also observed that a resident was able to have a drink of beer for lunch, which showed that service users choice was respected. Service users said that they were satisfied with the food and thought it was generally good. Menus were inspected and found to have choices for the main meal. The inspector observed this at lunchtime where three different main meals were provided. Food records did not always detail what vegetables were served so this variety can be properly monitored. There were a large number of occasions where mixed vegetables were provided so this needs to be reviewed to provide more variety. The inspector tasted the food. It was broadly satisfactory though the potato in the shepherds pie was lumpy and lacked flavour. The Registered Provider said these issues would be followed up. Sycamore Cottage Private Residential Home DS0000062462.V336615.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are in place though refresher staff training on the Adult Protection procedure is needed to result in the full protection of service users rights. EVIDENCE: Service users generally said that they thought that if there was a problem then the Manager or other staff would sort it out. A Complaints Book is kept. The last recorded complaint was two years ago. The Registered Provider confirmed this was the case. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the local Social Service Department/ Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. The Registered Provider said this issue would be followed up with altering the procedure. Care staff spoken with were unaware of the full procedure regarding of which Agencies to contact if the in house arrangement failed. The Registered Provider said this issue would be followed up, refresher training provided to staff and a Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 16 short procedural statement drawn up to help staff to follow the correct procedure. Sycamore Cottage Private Residential Home DS0000062462.V336615.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. 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. Facilities are seen to be comfortable by service users and are to undergo improvement. Odour control is generally satisfactory though there needs to be greater monitoring of this to ensure all facilities are odour free. EVIDENCE: Service users said they were satisfied with their rooms, which the inspector observed to be personalised with, for example, items of resident’s furniture, pictures and photographs in them. The Registered Provider said that he had recently had a grant application accepted and the home facilities were to be refurbished, in that there would be Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 18 new décor, carpets and furniture throughout. There is need for this – for example the carpet does not fully fit in the lounge, a bathroom needed a bath panel and a toilet frame repainting as they were chipped. There was an old chair in the back garden that needed removing, as it could have become a health and safety issue. A service user said that someone had gone into her room during the night and disturbed her. There are no locks on bedroom doors to prevent this happening. It was recommended that the Registered Provider fit locks to provide security for service users, especially with a high number of service users with dementia now accommodated in the home. It is recommended that the Registered Provider look into providing signing to the environment to assist service users with dementia, e.g. same colour doors for bathrooms, recognisable pictures on bedroom doors etc. Odour control was of a generally satisfactory standard. There was one bedroom where the carpet was odouress, and an easy chair also had an odour. The Registered Provider said this would be followed up. This needs monitoring on a regular basis and action taken as necessary. Sycamore Cottage Private Residential Home DS0000062462.V336615.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are not maintained to a level to meet service users needs. Recruitment procedures need to be in place to meet service users needs and properly protect them. Staff training systems are in place but need to be more comprehensive. EVIDENCE: There were comments that there was not enough staff at times, especially with three service users with dementia being recently admitted. There is a need to ensure there is sufficient staff available to protect the Health and Safety of service users and staff. The staffing rota demonstrated insufficient staff on duty from 8am to 8pm in that there are a high number of occasions where there is only one care assistant and one senior staff on duty. (The Commission for Social Care Inspection would also expect that the Registered Manager is not fully included into the necessary staffing compliment as she has Management duties to perform, and not only care tasks). Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 20 There is one care staff awake on night duty with an on call staff member available in case of emergency. The Registered Provider was asked to review the on call rota, as the Acting Manager was the only staff available, seven days a week. This could cause fatigue and impaired job performance as she has important management duties to carry out during the day. There also needs to be monitoring as to whether there will be a need to have two staff on night duty if service users needs for care and supervision increase with having more dependant service users in the home. There is domestic cover five days a week. The Registered Provider was asked to review this so that this cover is in place every day to ensure facilities are fresh and clean at all times, which it is not at present. Staffing needs to be reviewed to ensure that service users are properly protected and their needs are met. This is especially important, as there are currently a high number of service users with dementia, which demonstrates the need for ongoing supervision. This revised rota needs to be sent to the Commission for Social Care Inspection. The Registered Provider said that staffing levels would be increased to meet need. Staff said there had been training in the last twelve months and records were seen by the inspector that demonstrated this, for example for dementia training, coupled with information seen arranging more training on sensory impairment. There was also some evidence of proper induction training for new staff, with a relevant ‘Skills for Care’ booklet in the office, though no evidence that this had been gone through with staff. The Registered Manager was recommended to devise a Training Matrix to identify key issues that staff need training in (to quickly access who needs training in any relevant issues) – e.g. first aid, challenging behaviour, moving and handling, health and safety, medication, dementia, training on service users conditions – stroke care, diabetes, parkinsons disease etc. A staff member said she had been encouraged to undertake National Vocational Qualification level 2 training. The Registered Provider needs to ensure that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 is achieved. Recruitment records were inspected and found in some areas to be poor with written references from previous employers not in place at the commencement of employment. An Immediate Requirements Notice was served for this to be quickly rectified by the Registered Provider. The Acting Manager said she now fully understood the proper procedure and would be immediately implementing this. Sycamore Cottage Private Residential Home DS0000062462.V336615.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of service users. EVIDENCE: Service users and visitors said that they thought the Acting Manager ran the home well and that she was approachable, very caring and thoughtful. However the service has been without a Registered Manager for approximately a year and this needs to be rectified now. The Registered Provider said that Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 22 steps are being taken to ensure that a suitable candidate is put forward to apply for registration. A Quality Assurance system was in place for 2007. The questionnaire had been supplied to service users and three had been returned. The inspector recommended that relatives and other stakeholders, e.g. GPs, District Nurses, the hairdresser, be also asked their views and a summary of the outcome to be comprehensively presented. It is recommended the results are included in the Statement of Purpose. There was evidence on staff records that staff are supervised and supported. Staff Meetings have been recently held and were recorded but there had only been one meeting from April 2005 to January 2007. The Manager is recommended to have frequent meetings to support staff and ensure practice issues were regularly discussed. There is a Health and Safety folder with Risk Assessments for safe working practices though this appears basic with only a small number of issues covered, e.g. no Control of Substances Hazardous to Health Risk Assessments seen. This is needed as it was observed by the inspector and Registered Provider that a cleaning cupboard in the ground floor corridor had been left unlocked therefore posing a health and safety risk to service users. There were also no Risk Assessments to important issues such as window restrictors, use of the lift, bed rails, hot water temperatures, hot radiators etc. The Registered Provider was advised to contact the Environmental Health Officers for advice on fully covering this issue. There are a number of radiators without covers. The Registered Provider said that thermostats had been fitted to control the risk but he would be fitting radiator covers and arrange for a Risk Assessment to be carried out, as a number of service users have unpredictable behaviour and could be at risk from burning. Fire Precautions: The Registered Provider has a fire risk assessment. Fire extinguishers had been regularly serviced. Staff members were asked the fire procedure but were not fully aware of the whole procedure. System testing was not to the required schedules for monthly emergency lighting testing, weekly fire bell testing, and there had been no recorded fire drill for ten months. An Immediate Requirements Notice was issued to direct that this be carried out within twenty four hours. The hot water temperature was checked in a bathroom and found to be 47.8c; the National Minimum Standard is 43c. There was evidence on file of hot water temperature checks carried out, the last one some six weeks previously. It was recommended that testing be carried out more frequently to ensure proper safety was ensured for service users. The inspector observed that there were two unlocked rooms, one a storage area and the other where the bedroom was Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 23 being redecorated, where there were items, furniture, wheelchairs etc that service users could have tripped on. The Registered Provider was asked to deal with this quickly to ensure service users safety. There was no Risk Assessment to cover this risk. The Registered Provider said action would be taken. Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 1 Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Residents must only be admitted to the home after a full assessment of their needs is undertaken. Care plans should contain comprehensive information regarding service user’s needs, with all necessary Risk Assessments and medical checks in place. Residents health needs must be promoted by way of staff using proper Moving and Handling techniques. The Registered Provider must ensure that all staff can operate the Vulnerable Adults procedure to alert the relevant Agencies if abuse is suspected. The home must be kept free from offensive odours. The strong odour identified in the resident’s private accommodation and a lounge chair must be eradicated. DS0000062462.V336615.R01.S.doc Timescale for action 24/04/07 2. OP7 15 24/06/07 3. OP8 13 24/04/07 4. OP18 13 24/05/07 5. OP26 16 25/04/07 Sycamore Cottage Private Residential Home Version 5.2 Page 26 6. OP27 18 The registered providers should 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. A staff rota with increased staffing hours needs to be sent to the Commission for Social Care Inspection. Relevant staff references must be received prior to commencing work. The Registered Provider must ensure that staff are fully trained to meet residents needs. The Registered Provider must appoint a Registered Manager to run the service. The Registered Provider must ensure that all health and safety systems are in place to protect residents – e.g. that fire systems are regularly serviced and tested, all staff fully understand the fire procedure, that service users are protected from Substances Hazardous to Health and there is no access to areas where there are tripping hazards. 24/05/07 7. OP29 19 24/04/07 8. OP30 18 24/07/07 9. OP31 8 24/06/07 10. OP38 23 30/05/07 Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 27 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 OP12 Good Practice Recommendations It is recommended that a staff member attends specialist training to provide appropriate Activities to service users with dementia. 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 service users are protected from service users who wander. The Registered Provider needs to ensure that there is 50 of care staff with National Vocational Qualification level 2 training or equivalent, to ensure there is a workforce with the skills to respond to the needs of service users. 2. OP19 3. OP28 Sycamore Cottage Private Residential Home DS0000062462.V336615.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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