Inspection on 15/05/06 for Sycamore Court

This inspection was carried out on 15th May 2006.

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 Court 17/08/09

Sycamore Court 23/02/09

Sycamore Court 15/09/08

Sycamore Court 17/03/08

Sycamore Court 28/06/07

Sycamore Court 31/01/07

Sycamore Court 14/10/05

Sycamore Court 07/05/05

Sycamore Court 13/09/04

Sycamore Court 22/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Sycamore Court Magpie Lane Little Warley Brentwood Essex CM13 3DT Lead Inspector Michelle Love Key Inspection 15th May 2006 08:30 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 Court DS0000018123.V297160.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 Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Court Address Magpie Lane Little Warley Brentwood Essex CM13 3DT 01277 261680 01277 202028 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) Southern Cross Healthcare Service Limited Mr Peter Edward Watchorn Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 2005 Brief Description of the Service: Sycamore Court is a purpose built, elegant two storey building situated in a rural location outside Brentwood/Warley and within easy access of A127 and M25. The home provides accommodation for 39 older people on two floors, in 39 single ensuite rooms. Other facilities include 4 lounges, 1 of which is a smoking lounge, and separate dining areas. In addition the home benefits from a specially equipped hairdressing salon. A passenger lift provides access to all levels within the home. There are large open grounds with excellent views across the local countryside and a patio area with seating. Car parking facilities are available to the side of the property. The home is not serviced by any public transport. Brentwood station is approximately 3 miles away and the nearest bus stop is advised as approximately 40 minutes walk. The homes weekly fees range from £413.28 for a `block contract` bed, £426.09 for an Essex County Council Locality bed and £560.00 for a private room. Additional charges are provided to residents relating to hairdressing, personal toiletries, newspapers and magazines, chiropody and sweets. Inspection reports are contained within the homes Statement of Purpose/Service Users Guide. A copy of these documents was located within the main entrance of the care home. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced `key` site visit was conducted by Michelle Love and Bernadette Little, inspectors and lasted approximately nine hours and forty five minutes. As part of the process a number of records relating to individual residents and care staff were examined i.e. care plans, staff employment files, nutritional records, accident records, training matrix etc. Additionally the homes medication systems were observed and records inspected. Also as part of the process, inspectors talked with the acting manager, operations manager, several residents and care staff. Following the site visit a number of letters were forwarded to resident’s next of kin, requesting their views as to their member of families experience in the care home. The information gathered will be highlighted within the final inspection report and will maintain individuals anonymity. What the service does well: What has improved since the last inspection? What they could do better: It remains disappointing and of concern that at the last inspection there were 18 Statutory Requirements and 4 Recommendations highlighted and there appears to have been little improvement noted at this site visit, as 22 Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 6 Statutory Requirements and 5 Recommendations have been identified. It is evident that the previous management of the home and operations manager did very little to address previous identified shortfalls, despite providing the Commission with an action plan/timescale for action. The registered provider must be prepared for the fact that continued poor performance and non compliance for the National Minimum Standards and Care Homes Regulations for Older People will result in `Enforcement` action being taken against Southern Cross Healthcare (Sycamore Court). A number of the Statutory Requirements have been repeated and detailed within past inspection reports. Main areas of concern relate to the homes care planning/risk assessment processes, general recording and poor care practices and delivery of care to residents by some care staff. It is evident that some issues relate to the lack of strong management within the home and the fact that staff have been left to their own devices. Additionally the registered provider must ensure that at all times sufficient numbers of staff are on duty to meet residents needs and that staff receive appropriate training and supervision. Two Immediate Requirement forms were issued at the site visit relating to care planning/risk assessments/healthcare records and for staffing levels. Evidence relating to both issues can be found within the main text of the report. 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 Court DS0000018123.V297160.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 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 the following standard(s): 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are formally assessed prior to admission. It is unclear as to whether or not prospective residents and/or their representatives have the opportunity to visit the care home prior to admission. EVIDENCE: On the day of the site visit, three pre admission assessments were requested for two newly admitted residents and for one resident admitted in August 2005. It was positive to note that pre admission assessments had been conducted for the newest residents, however no assessment was available for the person admitted in August 2005. Pre admission assessments inspected were observed to be adequate but basic in detail. Not all elements as detailed within the document were completed i.e. no Medication Plan depicting a list of medications prescribed were recorded for one person. Pre admission assessments had been completed prior to the persons’ admission and were signed and dated by the person completing the Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 9 documentation. No evidence was available to indicate that either the resident and/or their representative had been offered a trial visit and that they had received information relating to the home so as to make an informed choice as to whether or not this was the right home for them. From inspection of the homes training matrix and from staff files sampled at random, no training has been provided to staff relating to those conditions associated with older people i.e. Diabetes, Parkinsons Disease, Sensory Impairment etc. It was of concern that the home had admitted one resident on respite care, who had a formal diagnosis of mental disorder. The acting manager and operations manager were advised that this is unacceptable and that Sycamore Court is not registered to take people who have this condition. The home does not provide intermediate care. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes care planning processes are not detailed and comprehensive. There is no evidence to indicate that these have been devised with the individual resident and/or representative. The homes medication procedures are in general appropriate, however some minor issues were highlighted. EVIDENCE: On inspection of seven individual plans of care, these were noted to vary in detail. Formal assessments pertaining to Manual Handling, Waterlow Pressure Sores, Nutrition, Continence, Falls and Dependency Profiles were available, but not completed in all cases i.e. one care plan made reference to the resident being at risk of falls, however no formal assessment had been completed. It was of concern that records relating to healthcare, personal hygiene and activities for individual residents were poorly documented and did not include the specific nature of need, how care was to be delivered by care staff and staff interventions i.e. the care plan for one resident detailed that they “occasionally get depressed”. No information was recorded as to how this is Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 11 managed and what staff’s intervention will be in the event of the resident having a relapse. In the majority of cases the care plans did not include information identifying resident’s personal preferences, likes/dislikes and/or details of what tasks individual residents could manage and what tasks they required assistance from care staff i.e. one care plan relating to personal hygiene stated that the resident required assistance with some aspects of their personal hygiene. No specific information was recorded identifying those tasks of which the resident needed help and those tasks whereby they were independent. Risk assessments were not devised for all areas of identified risk i.e. one care plan made reference to the resident needing to be assisted with eating/requiring supplements/at risk of losing weight. The nutritional assessment highlighted that as of 30.4.06 the risk to the resident was `very high`, however no risk assessment had been devised detailing how this was to be managed and minimised. Additionally it was of concern that `nutritional intake` records were not recorded daily i.e. week commencing 4.5.06, nothing was recorded on 7.5.06, 8.5.06 and 10.5.06. No evidence was available to indicate what fluids, had been received by the resident between 6.5.06 and 12.5.06 inclusive. Daily care records were noted to not be written after every shift and did not always include staff’s interventions or detail how the resident was supported by care staff e.g. records for one resident indicated that they had been aggressive whilst care staff were providing personal care. No further information was recorded. Prior to the site visit the Commission for Social Care Inspection received an anonymous complaint. One element of concern expressed by the complainant was that residents were not receiving baths/showers on a regular basis. This was confirmed from inspection of care records and from discussion with several residents. In addition records indicated that they were in contradiction to the individuals care plan i.e. the care plan for one resident detailed that they should have a bath once weekly, however records indicated that the resident had two baths between March and May 2006. Professional Visitors Records indicated that residents receive a variety of support from healthcare professionals i.e. District Nurse Services, Dietician, GP, Community Psychiatric Nurse etc. Records did not always include evidence of outcomes following visits by these professionals. Observation of medication administration on both the ground and first floors for residents was seen to be appropriate and satisfactory. Medication was seen to be securely stored and the home utilises the Monitored Dosage System. A list of staff names, initials and signatories were available of those staff deemed competent to administer medication to residents. On inspection of medication administration records it was noted on several occasions that prescribed Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 12 medication was not administered to individual residents as `they were sleeping`. The deputy manager was advised that this is unacceptable and satisfactory measures must be undertaken to ensure that all residents residing at Sycamore Court receive their prescribed medication at the appointed time. No PRN (as and when required medication) protocols had been devised. The acting manager and deputy manager were advised that these must be formulated and implemented for the future. Sycamore Court DS0000018123.V297160.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There appears to be little opportunity for residents to engage within a stimulating programme of activities, either `in house` or within the community. Residents are provided with a variety of meals. EVIDENCE: The acting manager advised the inspector that the activities co-ordinator has recently left the employment of Sycamore Court and that a vacancy for this post now exists (36 hours per week). This is seen as inadequate for the numbers and needs of current residents and the registered provider must look at ways of ensuring that all residents within the home receive opportunities to participate within a range of stimulating activities. Records pertaining to activities undertaken by individual residents were observed to be poorly completed and incomplete in some instances. Residents spoken with confirmed that activities are a bit sparse and that there is little opportunity to engage in community activities. Residents’ comments relating to the meals provided at the care home were generally positive with few negative remarks. The menu evidences that Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 14 residents are offered choice at all meals (breakfast, lunch and teatime). It was positive to note that residents are offered a cooked breakfast. The home is able to provide for those residents who require a pureed/diabetic diet. The pureed diet for one resident was seen to be well presented with each type of food separately portioned. Tables were attractively set with nice tablecloths, flowers and condiments. It was suggested to the acting manager that jugs of drink could be placed on the table so that residents could help themselves rather than wait until a staff member was free. Those residents requiring assistance from care staff at meal times were given help. The acting manager was advised that care staff as part of good practice procedures should be seated when providing 1-1 support for residents at mealtimes instead of standing. Additionally care staff must consider interacting more positively with residents at this time. Inspectors observed that dining space within both dining areas is limited and this can impact on residents safety i.e. one resident was observed to require the toilet quite urgently, however they had to leave their walking frame as a result of there being no room to manoeuvre. Some residents were noted to have their meals in their own room. Clearly there is insufficient dining space should all residents choose to eat in the respective dining areas. Sycamore Court DS0000018123.V297160.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure, but not all complaints have the action taken and outcomes documented. It is unclear as to whether or not senior members of staff have a good understanding of Protection of Vulnerable Adults procedures. EVIDENCE: The homes complaints procedure was observed to be displayed within the main reception area. Since the last inspection to the home, the home has received three complaints (two informal according to the homes records). From inspection of documentation one issue remains unresolved as Social Services are reported to be meeting with the residents family to discuss the home’s investigation, action plan and outcome. Records pertaining to the two recorded informal complaints, do not include information relating to any investigation, action taken and outcome. Prior to this site visit the Commission for Social Care Inspection received an anonymous complaint/concerns relating to insufficient staff on duty and a variety of poor care practices. It was concerning to note that some elements of the complainants concerns were substantiated e.g. insufficient staff on duty, no chef on one occasion and the kitchen stores were locked, residents not bathed on a regular basis and poor environmental hygiene issues within the home. Also prior to this site visit the acting manager advised the Commission of an incident whereby a resident sustained injuries whilst being restrained by night staff. It was of concern that following discussions between the acting manager Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 16 and inspectors, the acting manager appeared unsure of local protection of vulnerable adults procedures and no initial action to notify Social Services or complete a Protection of Vulnerable Adults `Alert Form` was undertaken. On the day of the site visit no Protection of Vulnerable Adults policy and procedures (local guidelines) could be located. Since the site visit it has been confirmed by Social Services that the aforementioned resident is to receive an urgent review. The acting manager has been advised by the Commission to undertake an investigation to the incident within 14 days and to forward all paperwork as evidence of action taken and outcomes. The Commission for Social Care Inspection would also recommend that the acting manager receive additional training relating to protection of vulnerable adults and that a simple but effective `bullet point` guide detailing what to do in the event of an incident be devised and readily displayed. Despite some residents displaying aggressive/inappropriate behaviours on occasions, no staff have received training on how to deal with challenging behaviours. This has been highlighted at previous inspections to the home and it remains of concern that the registered provider has failed to act. With regards to the above incident both members of night staff had not received training to deal with challenging behaviour or Protection of Vulnerable Adults (POVA). The homes staff training matrix evidences that nine people have not received POVA training. It is of concern that training for staff is through watching a video and completing a work-book on their own initiative. The latter was confirmed by care staff. Sycamore Court DS0000018123.V297160.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home are not clean and hygienic and there is insufficient domestic cover on occasions. EVIDENCE: Carpets were observed to be heavily stained in several areas and some toilets within the home were in need of de-scaling. Other areas of the home are in need of a good clean. It is evident that on some occasions the home has had insufficient domestic cover. A random sample of individual resident’s bedrooms were inspected and all were seen to be personalised and individualised. One resident advised the inspector that despite her daughter writing to the home and the resident speaking directly to staff requesting her net curtains to be taken down and washed, no action had been taken. Both the acting manager and operations manager were advised at the time of the site visit, and assurances were given to the inspectors that the issue would be resolved satisfactorily. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 18 Residents advised the inspectors that difficulties had been experienced in relation to hot water in their bedrooms and within the homes communal bathrooms. The acting manager confirmed that problems had been encountered and inspectors were advised that engineers were due at the home to try and rectify the issue shortly. The acting manager must confirm in writing to the Commission within 7 days of receiving this report that all works have been completed and the hot water system is fully functional. Sycamore Court DS0000018123.V297160.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home have been inadequate on occasions to meet the needs/numbers of current residents. Staff recruitment procedures need to be more robust so as to protect residents. Further training for staff must be provided for all staff. EVIDENCE: The acting manager confirmed that the homes minimum staffing levels are 1x senior carer and 2x members of care staff on each floor between 08.00 a.m. and 20.00 p.m. and 1x senior carer and 1x carer on each floor at night. The acting mangers hours are full-time and supernumerary to the roster. Four weeks rosters were examined, however initially those provided were not accurately dated and did not run in sequence. Advice was provided on ensuring that these are accurately maintained for the future. The staff rosters showed on some occasions that minimum staffing levels had not been met e.g. 17.4.06 (14.00-20.00), 21.4.06 (14.00-20.00), 27.4.06 (14.00-20.00), 30.4.06 (08.00-20.00), 3.5.06 (14.00-20.00) etc. Staff records indicate that one member of staff walked off shift on 25.4.06 leaving the shift short, however the staff roster was not amended to reflect the shortfall. The acting manager was advised that the Commission should have been informed when minimum staffing levels were not met and to maintain details of efforts made to obtain cover. The homes operations manager stated that he was under the impression that Sycamore Court were exceeding the staffing hours Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 20 allocated by the registered provider in accordance with the residential forum guidance. Both the operations manager and acting manager were advised to undertake a detailed review of individual resident’s dependency needs, as there was clear evidence from inspection of records that dependency levels undertaken were not accurate and they need to be monitored and audited appropriately. The acting manager advised that where minimum staffing levels have run short, she covers `the floor` and has undertaken the cleaning tasks to help to cover the domestic vacancies. In feedback to both the acting manager and operations manager, the inspector advised that previous inspections to the home clearly identified that Sycamore Court is in need of strong clear management and that the acting manager needs to give herself an opportunity to do that role, which she is unlikely to have enough time for if she continues to do all the other tasks in the home as well. Current vacancies include 1x activity co-ordinator (36 hours) and 1x domestic post (30 hours). On inspection of a random sample of two staff files indicated that the Home Office had given permission for the individual employees to work no more than 20 hours per week during term time. Staff rosters indicated that both employees were working a minimum of 24 hours in any one week. This issue was raised at the last inspection, though not necessarily for these members of staff. Since the last inspection two new staff had been appointed, one of which is the acting manager. No file was evident for the acting manager even though she had worked at the home for at least two months. The file for the other new member of staff was inspected. It was evident that the majority of records as required by regulation had been sought, however the employees work history had not been explored prior to 2002. References were observed to come from two separate care home’s, of which neither was detailed on the application form. No evidence of the employees Criminal Record Bureau check was available. In discussion with the operations manager the inspector was advised that it was the registered providers understanding that the original document would be available for inspection. A training matrix was provided for the inspectors, identifying training courses undertaken by individual members of staff. Records indicate that the majority of senior and care staff have achieved mandatory training relating to manual handling, fire awareness and basic food hygiene. Records indicate that only 1x member of staff has attained health and safety, 5x staff have cross infection training and 7 staff have infection control. It is of concern that the number of specialist courses provided to staff pertaining to those conditions associated with older people appears to be very limited. In relation to NVQ training, 4x staff have attained NVQ Level 2, 5x staff have commenced NVQ Level 2 and the homes deputy manager has NVQ Level 4. Records of induction for staff were not available in all files inspected. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 21 Information on the role of the key worker was displayed on a noticeboard on the ground floor. The acting manager stated that much work is required on improving the key worker system and some changes will need to be introduced and implemented. Following discussions with some staff, it was evident that some staff demonstrated a better approach and understanding of the role than others. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has appointed a new acting manager to run the home. Staff supervision has yet to be implemented. EVIDENCE: The acting manager confirmed on the day of the site visit that she had been formally appointed as the home’s manager. Past experience includes working as a deputy manager in a home in Hemel Hempstead and she is a qualified nurse (level 2-enrolled nurse). It was evident from this site visit that the manager has a lot of work ahead of her to ensure that previous identified shortfalls are addressed and care practices are improved upon. Through discussions with the manager the Commission feel assured that the acting manager is keen and committed to improve the homes current poor performance. Staff spoken with said that they find the manager approachable Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 23 and supportive, that staff morale is much improved and that issues at the home are already getting better. The registered provider must demonstrate clearly their commitment to offering adequate support to the manager for her to achieve the necessary improvement in the Home’s performance. From inspection of a random sample of staff employee files, it was evident that staff supervision has been not undertaken on a regular basis. The acting manager advised that she has the necessary forms downloaded from the intranet and will be introducing regular supervision sessions for all staff. A limited number of records as required by regulation were inspected. All records were seen to be satisfactory. It was disappointing to note that there was no record of recent staff meetings/senior meetings undertaken. Sycamore Court DS0000018123.V297160.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 2 1 1 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X X 1 X 3 Sycamore Court DS0000018123.V297160.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 The registered person must ensure that all residents are assessed prior to admission and that there is clear evidence to indicate that the care home is suitable to meet individual residents needs. Timescale for action 07/06/06 2. OP3 3. OP7 (Previous timescale of 1.12.05 not met) Care The registered person must 07/06/06 Standards ensure that no person is Act 2000, admitted to the care home out of Part II, the homes category of Section 24 registration. 15(1) A written service user plan must 01/08/06 be prepared, based on the assessment, to identify how each service user needs, in all aspects of their health and welfare, are to be met. (Previous timescales dating back from 15.8.03 to 1.12.05 not met) The person registered must evidence that the service user is involved and consulted regarding their care plan. (Previous DS0000018123.V297160.R01.S.doc 4. OP7 15 07/06/06 Sycamore Court Version 5.2 Page 26 5. OP7 13(4) timescales dating back from 13.9.04 to 1.12.05 not met) The registered person must ensure that all risks to residents are identified and minimised wherever possible. (Previous timescale of 15.8.03 to 1.12.05 not met). The registered person must ensure that the health and welfare needs of residents is recorded, identifying action taken and outcomes. The registered person must ensure that nutritional records are completed in sufficient detail so as to determine if the diet is satisfactory. The registered person must make suitable arrangements for the recording, handling and safe administration of medicines received into the care home. The registered person must ensure that all residents residing at the care home receive a programme of activities which meet their individual needs. The registered person must ensure that adequate staffing hours are provided so that residents receive a varied programme of activities both `in house` and within the community. The registered person must ensure that the premises meets the needs of residents. This refers specifically to meal times/dining areas. The registered person must ensure that a record of all complaints, investigation, action taken and outcomes is recorded and available for inspection. The registered person shall ensure that residents are DS0000018123.V297160.R01.S.doc 01/07/06 6. OP8 12(1)(a) and 12(4)(a) 17(2), Sch 4, 13 07/06/06 7. OP7 07/06/06 8. OP9 13(2) 07/06/06 9. OP12 16(2)(m) and (n) 01/07/06 10. OP12 18(1)(a) 01/08/06 11. OP15 23(2)(a) 01/07/06 12. OP16 22 07/06/06 13. OP18 13(6) 01/09/06 Page 27 Sycamore Court Version 5.2 protected and that all staff receive POVA and challenging behaviour training. (Previous timescale of 1.7.05 to 1.12.05 not met). The registered person must ensure that where restraint is used, a record of any physical restraint used by care staff is recorded in detail. The registered person must ensure that all parts of the home are kept clean. This refers to the cleaning of the carpets to remove stains and to de-scale toilets and to ensure adequate domestic staff hours. (Previous timescale of 1.6.05 to 1.12.05 not met) The registered person must ensure that there is a sufficient hot water supply at the care home for residents (wash hand basins/communal baths/showers). The person registered must maintain adequate minimum staffing levels at all times. (Previous timescale of 13.9.04, 7.5.05 and 1.11.05 not met) The person registered must ensure that staff do not exceed the hours there are legally allowed to work. 14. OP18 17(1)(a), Sch 3(p) 07/06/06 15. OP19 23(2)(d) 01/07/06 16. OP19 23(2)(j) 07/06/06 17. OP27 18(1)(a) 14/06/06 18. OP27 17(2), Sch 4(6) 07/06/06 19. OP27 37(1)(e) (Previous timescale of 1.11.05 not met). 07/06/06 The person registered must notify the Commission for Social Care Inspection of any event that adversely affects the well being of service users, this refers to minimum staffing levels not being met at Sycamore Court. DS0000018123.V297160.R01.S.doc Version 5.2 Page 28 Sycamore Court 20. OP29 19 & Schedule 2 21. OP30 18(1)(c) and (i) 22. OP36 18(2) (Previous timescale of 13.9.04, 7.5.05 and 1.11.05 not met) The person registered must ensure all records relating to staff required by regulation are available. This refers to employment histories being explored, CRB’s being readily available and employment files for all staff available for inspection. The registered person must ensure that all staff working at the care home receive appropriate training to the work they perform. The person registered must ensure that staff are provided with appropriate supervision (Previous timescale of 1.6.05 not met) 07/06/06 01/10/06 01/07/06 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. Refer to Standard OP5 OP7 OP9 Good Practice Recommendations Written evidence should be available detailing whether or not prospective residents and/or their representatives visited the care home prior to admission. Daily care records should be written after every shift as part of good practice procedures. PRN (as and when required medication) protocols should be devised for those residents who receive this type of medication. The protocol should clearly identify when the medication should be administered, for what purpose and its frequency. Records depicting leisure/social activities for residents should be maintained and detailed. The acting manager should obtain a copy of local DS0000018123.V297160.R01.S.doc Version 5.2 Page 29 4. 5. OP12 OP18 Sycamore Court 6. OP28 Protection of Vulnerable Adults Procedures and Policies. 50 of all care staff should attain/achieve NVQ Level 2. Sycamore Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Court DS0000018123.V297160.R01.S.doc Version 5.2 Page 31 - 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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