Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 31/10/08 for Sycamore Cottage Private Residential Home

Also see our care home review for Sycamore Cottage Private Residential Home for more information

This inspection was carried out on 31st October 2008.

CSCI found this care home to be providing an Adequate 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Sycamore Cottage provides a homely environment for older members of the local community, and culturally appropriate activities and meals. Residents said they liked living at the home and a relative told us: `I like the home because it is very welcoming and homely. My relative gets likes to be on her own and this is respected and she is not forced to do anything`. We looked at care records and they showed staff making every effort to respect residents wishes. For example, one resident said she was able to go out when she wanted and she could get up when she wanted.Residents have the opportunity to take part in an activities programme including games, bingo and music. Two relatives were visiting during the inspection and said they were able to talk to staff about their relatives progress. One said, `Staff are welcoming and friendly. We have never had any problems and I think the new Manager knows what she is doing`. We saw that the Manager and staff treated residents in a friendly and reassuring manner. The home`s cooked food is a feature of the home. Individual food preferences can be catered for and staff are aware of residents preferences through information displayed in the kitchen. The residents we spoke to praised the food. The front of the home has been painted so that it looks more attractive and homely to visitors and residents.

What has improved since the last inspection?

Care Plans contain more specific detail as to resident`s continence needs so that staff can offer toileting before residents need to go. Residents/relatives are encouraged to have a say in the running of the home in that there is now an informal meeting held every two months to gather views of the service.

What the care home could do better:

Residents needs would be more effectively covered by ensuring that: Residents are always treated in a respectful and dignified manner aNd that Moving and Handling practices do not endanger residents or staff. Care Plans contain more specific detail as to resident` needs so that staff can always supply the care requirements of residents. Medication is always handled in a safe way to prevent the possibility of cross infection. The Complaints Procedure is made more user friendly so that complainants can have an independent investigation into their concerns.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. hearing impairment etc. The service needs to further focus on the needs of residents with dementia, for example providing memory boards and colour coded doors to facilities would assist residents so that they can identify facilities and services more clearly. Obtaining an expert assessment of facilities would identify which improvements would assist residents. Health and safety systems are fully in place to protect residents fully from identified risks.

CARE HOMES FOR OLDER PEOPLE Sycamore Cottage Private Residential Home 14 Harborough Road Oadby Leicestershire LE2 4LA Lead Inspector Keith Charlton Unannounced Inspection 31st October 2008 09:15 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.V372980.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.V372980.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.V372980.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 1st May 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 £330 and £350 per week. The 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 or can be accessed via the CSCI website: www.csci.org.uk. Further information about the home can be obtained from the Manager. Sycamore Cottage Private Residential Home DS0000062462.V372980.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 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit we, throughout the report the use of‘ ‘we’ indicates the Commission for Social Care Inspection, spent half a day reviewing information relating to the home. During the course of the inspection, which lasted seven hours, we checked the key standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three residents living at the home by meeting them, talking with the staff who support their care checking records relating to their health and welfare, and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home including health and safety and management issues were examined. We also talked to three residents, two relatives, the Manager and two care workers. Because people with dementia are not always able to tell us about their experience of the service, we used a formal method of observation called the Short Observational Framework for Inspection (SOFI). This involved spending a period of one and a half hours within the lounge area of Sycamore Cottage observing the care of three people. The observation period gave an indication as to how the service supports the individuality of people living with dementia. What the service does well: Sycamore Cottage provides a homely environment for older members of the local community, and culturally appropriate activities and meals. Residents said they liked living at the home and a relative told us: ‘I like the home because it is very welcoming and homely. My relative gets likes to be on her own and this is respected and she is not forced to do anything’. We looked at care records and they showed staff making every effort to respect residents wishes. For example, one resident said she was able to go out when she wanted and she could get up when she wanted. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 6 Residents have the opportunity to take part in an activities programme including games, bingo and music. Two relatives were visiting during the inspection and said they were able to talk to staff about their relatives progress. One said, ‘Staff are welcoming and friendly. We have never had any problems and I think the new Manager knows what she is doing’. We saw that the Manager and staff treated residents in a friendly and reassuring manner. The home’s cooked food is a feature of the home. Individual food preferences can be catered for and staff are aware of residents preferences through information displayed in the kitchen. The residents we spoke to praised the food. The front of the home has been painted so that it looks more attractive and homely to visitors and residents. What has improved since the last inspection? What they could do better: Residents needs would be more effectively covered by ensuring that: Residents are always treated in a respectful and dignified manner aNd that Moving and Handling practices do not endanger residents or staff. Care Plans contain more specific detail as to resident’ needs so that staff can always supply the care requirements of residents. Medication is always handled in a safe way to prevent the possibility of cross infection. The Complaints Procedure is made more user friendly so that complainants can have an independent investigation into their concerns. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 7 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. hearing impairment etc. The service needs to further focus on the needs of residents with dementia, for example providing memory boards and colour coded doors to facilities would assist residents so that they can identify facilities and services more clearly. Obtaining an expert assessment of facilities would identify which improvements would assist residents. Health and safety systems are fully in place to protect residents fully from identified risks. 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.V372980.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.V372980.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. EVIDENCE: People who are considering coming to Sycamore Cottage are invited to visit prior to making a decision. The Manager carries out an assessment of their needs. This can happen in their own homes, in hospital, or during a visit to the home. Information is sought from health and social care professionals where appropriate. This process helps to ensure the home is suitable for those who are considering living there. We talked to one resident. She said when she arrived the staff were friendly and she was made to feel at home. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 10 ‘I was anxious but made to feel welcome by the staff so they made me as comfortable as possible,’ she said. Standard 6 was not inspected as this home does not provide intermediate care. Sycamore Cottage Private Residential Home DS0000062462.V372980.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. Staff in the home do not fully meet residents health and personal care needs. Medication needs to be improved in how it is given to residents. EVIDENCE: Care plans are well organised and give clear instructions to staff on how to meet residents’ needs. They are begun once a resident comes into the home and are regularly reviewed. Those we looked at showed that staff make efforts to respect residents’ wishes. For example, one resident said she was able to organise her room the way she wanted as she likes to keep a lot of personal possessions and there is an agreement in place that as long as she does not trip on her possessions then staff will respect the way she has her room. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 12 All residents receive appropriate healthcare services and that health problems are addressed and dealt with by GPs, District Nurses, and other healthcare professionals. More detail was needed in some Care Plans regarding resident’s needs including treatment of pressure sores, up to date information about Moving and Handling needs (one Care Plan stated a hoist was needed but this was not used by staff), referrals regarding constipation and hearing, detailed past history, past hobbies and interests etc. Accident records were viewed and it was seen that if residents had a potentially serious accident then staff involved Medical Services to see if treatment was needed. We looked at a resident being helped onto her frame. She was helped by staff lifting her. This is not an acceptable Moving and Handling practice as it can injure residents and staff. The Manager said this would be followed up with staff and amending the resident’s Care Plan so staff know how to properly assist residents. We saw a lot of positive contact between staff and residents during the SOFI observation in that staff were friendly and diverted residents from confused behaviour though there were some instances whereby a staff member was too directive in giving medication to a resident in that she did not explain to the resident what she was doing, only telling her to ‘open her mouth’, then trying to put the medication in. The resident then became angry and told her to go away. Residents said that staff were very friendly in general though there was comment that one staff member often curtly told a resident to sit down when she was wandering and it sometimes looked as though she tried to keep the resident in her chair by putting a table in front of her. The manager said these issues would be followed up and action taken if needed. We observed that medication was given to residents by hand without the use of gloves, which posed an infection control risk though after a while the staff member then put on plastic gloves. Medication records were generally well recorded though there were a small number of gaps, which the manager has tried to tackle with staff, as per staff meeting records. Staff and the manager said that staff cannot issue medication to residents without being trained and there were certificates in records to prove this. Medication was found to be properly secured. Sycamore Cottage Private Residential Home DS0000062462.V372980.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. Daily life and social activities at Sycamore Cottage satisfies residents’ social, and recreational interests and needs. EVIDENCE: Residents said that they had activities during the day and they were satisfied with them. A resident said, ‘I am ok. I can go out when I like’. The Manager told us that each resident is individually assessed to see what activities they would like and this was reflected in information on a notice board. Residents have the opportunity to take part in a varied activities programme including: • • • • Music sessions with organ or guitar. Bingo Reminiscence Games DS0000062462.V372980.R01.S.doc Version 5.2 Page 14 Sycamore Cottage Private Residential Home The Manager said that there are a lot of one to one activities with residents and staff, as a number of residents have dementia and they cope with this better. We observed that this was the case with staff showing residents photos and playing with bean bags. A resident also was given the opportunity to have a walk with staff though this was declined. The Manager said she is to select a staff member to lead on activities and to have training on providing activities to residents with dementia. We noticed on one Care Plan that a resident was religious but it did not go on to say how the home has taken this forward, e.g. arranging to take the resident to church etc. The Manager said this would be followed up to ensure residents religious needs are met. Visitors and residents confirmed that visitors are welcome at the home at any time. Two relatives were visiting during the inspection and were chatting to staffing a friendly fashion. Neither staff or residents said that there were any rules that residents had to follow though if a resident needs personal care this has to be done before 8.00pm and so have to go to bed before this time, as there is only one staff member after this time. One Care Plan stated that the resident wanted ‘to stay up as long as possible’, but in reality she needed staff assistance and went to bed before 8.00pm – the Manager said she was satisfied with this arrangement. The Manager needs to keep this under review and extend staffing cover if needed in the future. We witnessed that staff put the TV on when no resident had requested this and no resident then watched it. The Manager agreed to follow this up with staff, as residents choice may have been music or silence. Residents said that the food was good and menus indicated that there was a vegetarian option. A resident said: ’The food has definitely improved as there is not so much processed food now’. Lunch was served during the inspection and residents had a choice of dishes including fish, vegetable burger and scrambled egg, with peas. There is not always a choice of main dish though residents can request another dish and staff are aware of residents preferences as this information is displayed in the kitchen. Food records are complete except for stating what the vegetarian option is each day. Food ordering shows that fresh vegetables and fruit are ordered to give residents the opportunity of having a healthy diet. Sycamore Cottage Private Residential Home DS0000062462.V372980.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel able to talk to staff about any concerns they might have and staff are trained to safeguard adults. EVIDENCE: All the residents we talked to said they would speak out if they had a complaint. One resident said: ‘There is nothing to complain about but if I did I am sure the Manager would put it right’. There have been no formal complaints since the last inspection. The Manager said that minor complaints would be logged and action taken to resolve them recorded. This means residents and relatives can be confident that any complaints they make, however minor, are taken seriously and addressed. We looked at the home’s procedure for staff to follow if a safeguarding issue arises. This is in place emphasising the role of social services as lead agency in any safeguarding investigation. 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), rather than the home, first, as per the National Minimum Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 16 Standard. The Commission for Social Care Inspection office address needs to be changed as well as the Leicester Office has now closed. All staff spoken with were aware of the procedure regarding of which Agencies to contact if the in house arrangement failed. The Manager has followed up the issue of providing a short procedural statement and displayed to help staff to follow the correct procedure. Staff had statutory essential legal Criminal Records Bureau / Protection of Vulnerable Adults first checks in place so that the Requirements made in previous Inspection Reports that statutory checks need to be in place prior to employment commencing, as detailed in Schedule 2 of the Care Homes Regulations 2001, have been carried out. Sycamore Cottage Private Residential Home DS0000062462.V372980.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is spacious, safe and cleaned to a high standard. EVIDENCE: Sycamore Cottage is a large detached house situated in an suburban area of Leicester close to many local shops and businesses. The home is on two floors with a stair lift for access. On the ground floor there is a large lounge/dining room, which overlooks a back garden. Bedrooms are mostly medium size, and the majority have ensuite facilities. The premises are homely, comfortable and spacious and all areas are accessible to residents with limited mobility, though residents using wheelchairs may find problems using the stair lift to get to the first floor. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 18 The Manager said much of the interior of the home has been decorated recently and this is continuing for some remaining bedrooms. This was an unannounced inspection and all the areas we inspected were clean and fresh. The front of the home now looks attractive with it being newly painted. Signing still 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, notice board for the lounge with essential information etc. Sycamore Cottage Private Residential Home DS0000062462.V372980.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet residents needs. Recruitment processes are 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: Residents and relatives spoken to during the inspection praised the staff team. One resident told us, ‘The staff are friendly and mostly very patient with the residents.’ During the inspection relationships between staff and residents were seen to be largely warm and professional. Comments were again received that there were enough staff to cover residents needs at present though when there are more residents there will be a need to increase staffing to ensure residents needs are met as the home, if the home continues to have a high number of residents with high dependency needs. The staffing rota again demonstrated that there are two care staff on duty throughout the day with the Manager in addition five days a week and one night care worker on duty at night with an on call arrangement if needed. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 20 The Acting Manager stated that there was domestic help for weekends but this person left and there is to be another attempt to have this post in place, which will help with care staff not being called upon to carry out domestic duties so they can concentrate on residents needs. Training Records seen by the inspector showed that staff receive relevant training and there was evidence that some staff are to have mandatory training soon. There was also evidence of induction training for new staff. The Manager was asked to follow up using the recognised Skills for Care induction pack. 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 etc. More training on residents conditions – e.g. hearing and sight impairments etc is needed. Staff said they were encouraged to undertake National Vocational Qualification level training and the Training Matrix showed that the National Minimum Standard regarding of 50 of care staff with National Vocational Qualification level 2 has been met. Records showed that all staff have two references and a satisfactory CRB disclosure before beginning work in the home. This helps to safeguard residents and ensure staff know how to meet their needs. One member of staff told us, ‘I am very happy here; it’s a nice place to work. I have been encouraged to do my NVQ 2 in Care to help me do my job well’. Sycamore Cottage Private Residential Home DS0000062462.V372980.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure that residents live in a home that is fully safe. EVIDENCE: The Manager is a capable member of staff with substantial experience of working with older people. She is responsible for the day-to-day running of the home and is line managed by the Responsible Individual / Director who visit the home regularly to talk to the Manager. During the inspection the Manager was seen to have excellent relationships with both residents and the staff team. She is knowledgeable about the home Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 22 and in discussions demonstrated a good understanding of how it should be run in the best interests of the residents accommodated there. One resident said: ‘I really need to tell you how good Ann is. She always offers to help me and I appreciate it’. Staff also said how supportive the Manager was to them. Visitors said that she was friendly and efficient. Annual quaity assurance questionnaires are sent out to residents and their relatives. The results were availabe and have been used to improve the home and increase residents’ involvement in how the home is run. The Manager looks after residents money and appropriate records are kept, though two signatures are needed to witness each transaction to have proper verification. Records showed that appropriate policies and procedures are in place to protect the health, safety and welfare of residents and staff, though where a health and safety issue had been assessed as ‘medium risk’ there was not always enough information recorded as to how the risk has been reduced, only a reference to speaking to the owners regarding this. Risk Assessments have now been done for window restrictors and radiator covers to aim to ensure that residents are always safe. The hot water temperature was measured and found to be within safe limits to ensure residents are protected from scalding. 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 have been sent to us so that we can gauge the quality of the service. 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 always supply proper care to residents. Staff are currently informally supervised. The Manager said she would plan to have one to one supervision with staff, as per the National Minimum Standard. This will enable issues to be discussed in depth to assist in residents welfare. Fire Precautions: Weekly fire bell testing records was largely being carried out though there were some gaps in achieving this frequency. Fire drills have been carried out on the required six monthly basis. Staff members were asked the fire procedure. One was not fully aware of the whole procedure – the Manager said this would be followed up to ensure that residents are kept as safe as possible if there is a fire. System testing was on the required monthly schedules for emergency lighting. Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 OP38 Regulation 13 Requirement 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. weekly fire bell testing and staff knowing the full fire procedure), and that all Risk Assessments for safe working practices are fully followed up. This will ensure residents health and safety is fully promoted. Timescale for action 01/12/08 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 treatment of pressure sores, referrals regarding constipation and hearing DS0000062462.V372980.R01.S.doc Version 5.2 Page 25 Sycamore Cottage Private Residential Home hearing, detailed past history, past hobbies and interests etc. 2. OP8 Resident’s health needs in respect of in respect of proper Moving and Handling practices being in place, needs to be met at all times. Medication needs to be given safely, without the risk of cross infection. Staff needs to always explain how they are to assist residents before they supply personal care. A Complaints Procedure needs to be in place giving the complainant the choice to go to the Lead Agency first if they do not want to go to the Manager or Registered Provider, and the details of the Lead Agency - Social Service Department(s). The Registered Provider needs to consider methods of signing facilities to provide orientation for residents with dementia. Staff training needs to include training on residents conditions – e.g. sight and hearing impairment etc. 3. 4. 5. OP9 OP10 OP16 6. OP19 7. OP30 Sycamore Cottage Private Residential Home DS0000062462.V372980.R01.S.doc Version 5.2 Page 26 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.V372980.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!