Inspection on 05/09/05 for Sycamore Cottage Private Residential Home

This inspection was carried out on 5th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sycamore Cottage Private... 31/10/08

Sycamore Cottage Private... 01/05/08

Sycamore Cottage Private... 10/01/08

Sycamore Cottage Private... 20/04/07

Sycamore Cottage Private... 20/04/06

Sycamore Cottage Private... 04/05/05

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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 Helen Abel Unannounced 5 September 2005 10:00am th 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 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 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sycamore Cottage Private Residential Home Address 14 Harborough Road Oadby Leicestershire LE2 4LA 0116 2711720 0116 2711880 None Sycamore Cottage Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 14 Category(ies) of Old age (14) registration, with number of places Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To be able to admit the named person of category DE(E) named in variation application number V2342 dated 29th January 2004. Date of last inspection 4th May 2005 Brief Description of the Service: The home is set on Harborough Road in Oadby. Sycamore Cottage offers care for 14 older people. The home is set on two levels and is generally spacious. Rooms have en-suite with central heating throughout. Some rooms look south over the garden. There is a stair lift to the first floor. A choice of menu is offered daily and special diets are catered for. A smoking room is available for service users. The home is maintained to a good standard and is very clean and tidy. Within short walking distance there is Oadby shops, two churches and transport routes, there are many local amenities available. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during a weekday morning over a 4-hour period. A full tour of the building took place with care records, policies and procedures inspected. There was the opportunity to talk with three residents. The Registered Provider was present throughout the inspection and assisted with the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Seek professional advice about the promotion of continence for identified residents. To undertake safety checks, repairs and maintenance to individual accommodation, bathrooms, and communal areas. This will ensure a safe, clean, fresh and comfortable environment for people living in the home. To develop staff recruitment systems, provide essential training and effective deployment of staff to meet the assessed needs of the residents. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 6 Develop systems for recording small financial transactions of residents money. This ensures residents financial interests are properly safe guarded. Devise a quality monitoring system with an annual development plan to ensure the home is run in the best interests of residents. Draw up a 4 to 6 week menu plan to further promote choice and variety at mealtimes. Develop safe working practices: Undertake regular hot water testing with records held; set up accident reporting systems to managers, and update the Control of Substances Hazardous to Health Regulations (COSHH) policy and procedures. These practices will ensure the health, safety and welfare of residents and staff are promoted and protected. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5, Residents benefit from an admission process, which works well and ensures that the placement is right for the individual. EVIDENCE: The Acting Manager undertakes a needs assessment prior to the new resident entering the home. Trail visits are then flexibly arranged and are usually taken for a half- day around a mealtime. Written information is given to the resident with a brief description of the accommodation and services provided. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11, Residents health, personal and social care needs are generally satisfactory and set out in an individual plan of care. Generally residents’ health care needs are met, however not all fully met. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans were well documented and comprehensive with photographs held of each resident. Two residents require support around the promotion of continence care; to ensure their health care needs are fully met. Staff are currently on accredited medication training and due to complete in November 2005. Medication records were examined and found to be of a good standard, demonstrating that the policies and procedures were being effectively enforced. Staff were observed being polite, friendly and chatting with residents in the lounge area. Staff were respectful of residents choice to spend periods of time in their bedrooms. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Residents are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Meals on offer are varied with residents offered a choice each day. Diabetic food alternatives are always provided. All meals are served in the dining room that overlook the garden area, which is light and comfortable. Some residents request their meals are served in their bedrooms and commented: “ I like the rice pudding today” “ Good cooking here” “ I like one of the staff’s baked cakes” The Registered Provider confirmed new menus will be being drawn up and will incorporate residents’ favourite meals. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17,18 Residents are protected from abuse in accordance with written policies and procedures. EVIDENCE: The Registered Provider confirmed at the recent May elections she arranged for all residents to have access to voting papers with a number of residents going onto register their vote. Adult protection policies and procedures are in place with some staff taking part in this training as part of their National Vocational Qualifications. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 to 26 The premises are not consistently well maintained and comfortable. EVIDENCE: The Registered Provider confirmed maintenance is seen as a priority and ongoing. The large lounge is to be upgraded and is due for completion December 2005. The smoking room is in the process of being updated. An upstairs bathroom needs redecorating and will be completed in March 2006. A resident’s wash hand basin is not working in the bedroom and requires maintenance. An odour of urine was noted in the reception area and requires attention. In consultation with the identified resident rearrange the bedroom furniture to ensure a more comfortable living arrangement. Recommendations were made around improved cleaning and tidying routines of the communal bathroom and identified bedrooms. Three wheel chairs were left in the lounge and should be appropriately stored so as they do not present a safety hazard to residents and staff. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 13 The garden area is attractively presented and residents may enjoy the garden of fruit trees, lawn and border plants. Garden furniture is available. Residents commented how nice to the pears tasted from the tree. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents’ needs are not met by the skill mix of staff. Recruitment policy and practices are unsatisfactory with new staff members not receiving the relevant training, which would enable them to be competent to do their jobs. EVIDENCE: Warm interactions between residents and staff were observed. Some residents commented, “ I am happier here, than I have been happier for a long time” “ The Acting Manager is very kind and helpful” “ The staff are very polite”. The written staffing rota did not reflect people working at the home on the day of inspection. The staffing rota format must be revised to ensure staff and their position held can be clearly identified. Upon examining the staffing rota’s over a two-week period, it was noted there were not enough care staff on duty to fully meet the needs of the residents. For a temporary period care staff with food hygiene training are undertaking a day of kitchen duties. This situation is impacting on care staff and sufficient domestic staff must now be recruited. It was noted two staff had not received staff inductions and all the required information and documents as part of the recruitment process, had not been obtained. The Registered Provider has just received a staff induction from The National Training Organisation for Social Care, which will now be used as the new staff induction. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36,38 New leadership and guidance is taking time for changes to become effective which has resulted in practices that do not promote the health, safety and welfare of residents. EVIDENCE: The Registered Provider is looking to develop quality-monitoring systems and agreed to carry out an internal audit involving residents their families, and staff in early 2006. Managers hold records of small transactions for resident’s money but the record keeping system could be improved upon. Advice was given around this. Staff benefit from regular formal staff supervision with the Acting Manager making sure they are properly supervised. Some staff had not received training in first aid, food hygiene and moving and handling. It was agreed all safe working practice training would now be obtained as a priority. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 16 Portable appliance testing took place in 2003 and must now be undertaken. It was noted that a large number of light bulbs were not working throughout the home and staff reported light bulbs were constantly being replaced. Fixed electrical systems must be checked in the home by a competent person to ensure a safe environment. Systems are in place to regulate the hot water accessible to residents. It is recommended testing hot water outlets at intervals with written records held will further supports this. Discussion took place with the Registered Provider around risk assessing all parts of the home to ensure safe working practice. This includes identifying , assess and manage any asbestos containing material, in line with new legislation. The accident report contained brief information and should be developed. For good practice systems should be set up for reporting onto the Registered Provider all accidents and incidents, and any action to be taken is followed up and recorded. This ensures residents and staff’s welfare is promoted and protected. Cleaning materials were found left out in a communal bathroom; and the cleaning cupboard was found to have no locking mechanism and presents a hazard to residents. This area must be kept secure. Discussions took place with the Registered Provider around the use of bleach, and a recommendation made to update the Control of Substances Hazardous to Health Regulations (COSHH) policy Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 2 3 3 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 3 3 3 x 1 Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 18 No 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 8 Regulation 13 Requirement The Registered Person shall make arrangements to receive where necessary treatment, advice and other services from any health care proffessional: The promotion of continence is sought and acted upon for the identified residents. 2. 19 23 The Registered Person shall ensure that there are sufficient wash hand basins with hot and cold supply: To repair the identified wash hand basin. 3. 19 23 The Registered Person shall ensure all parts of the home are kept clean and free of odours: To clean and eliminate odours from the identified areas. The Registered Person shall ensure the layout of rooms is suitable for their needs: In consultation with the identified resident to re-arrange the bedroom furniture. 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Timescale for action Immediate 11th September 2005 Immediate and ongoing 4. 23 23 11th September 2005 Sycamore Cottage Private Residential Home Version 1.40 Page 19 5. 27 17 A copy of the duty rota of persons working at the home and a record of whether the rota was actually worked: The written staffing rota must be revised to ensure staff and their position held, can be identified during the day and night. Information and doucuments in respect of persons working at the care home must be obtained: 1. Satisfactory police checks. 2. Two written references. 3. Proof of the Persons identity, including a recent photograph. 4. The persons current passport (if any). 5. Documentary evidence of any relevant qualification. Immediate 6. 29 7 Immediate and ongoing 7. 30 18 Ensure that persons employed Immediate by the Registered Person to work and at the care home receiveongoing Training appropriate to the work they are to perform; a staff induction. The Registered Person shall establish and maintain a system for reviewing at appropiate intervals, and improving the quality of care at the home: As part of the quality monitering systems, an audit should take place annually and review, reflect aims and outcomes for residents. The results are published and made available to current and new residents. The Registered Person must ensure staff at the home receive training appropiate to the work they are to perform. March 2006 8. 33 24 9. 38 13 31st October 2005 Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 20 10. 38 13 11. 27 18 12. 38 12 13. 38 13 The Registered Person must ensure all parts of the home to which to which residents have access are so far as possible eliminated: 1. The fixed electrical installation must be tested. 2.The portable appliances must be tested and checked. This must be carried out by a competent person who should advise of any defects, repair them and produce a report indicating what needs to be done to remedy them. The Registered Person shall ensure that at all times suitably qualified competent and experienced persons are working at the home: 1. A cook is employed to ensure that standards relating to food, meals and nutrition are fully met. 2. Adequate staffing numbers and skill mix of staff must be working at the home, to meet the assessed needs of residents. The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of residents: To provide a written statement /risk assessment for all safe working practice topics in the home, including asbestos. The Registered Person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety: The dedicated area holding cleaning materials must be kept secure. 30th September 2005 16th September 2005 31st October 2005 Immediate and ongoing 14. Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 21 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. 2. 3. 4. 5. 6. Refer to Standard 15 21 22 35 38 38 Good Practice Recommendations Ensure 4-6 week menu plans are drawn up that can be rotated and provide fresh home baking/cooking. Provide a clean and tidy environment in the communal bathroom areas and identified bedrooms; and make arrangements for residents to hold their own toiletries. Ensure wheel chairs are stored appropiately. Develop better record keeping systems for small transactions of residents monies. It is recommended the regulation of hot water is supported by testing of the hot water outlets at intervals, with written records held. Obtain a current accident reporting record; and set up systems for reporting onto the Registered Provider all accidents and incidents and any action to be taken is followed up and recorded. Update the Control of Substances Hazardous to Health Regulations (COSHH) policy. 7. 38 Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 22 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Cottage Private Residential Home 20050905 Sycamore Cottage X00015 UN Stage 4 S62462 V242571 C51.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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