Inspection on 28/06/07 for Sycamore Court

This inspection was carried out on 28th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sycamore Court 17/08/09

Sycamore Court 23/02/09

Sycamore Court 15/09/08

Sycamore Court 17/03/08

Sycamore Court 31/01/07

Sycamore Court 15/05/06

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 Unannounced Inspection 28th June 2007 08:00 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.V342142.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.V342142.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 (West) Limited Vacant Post Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2007 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 £700.00 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 and within individual bedrooms. A Annual Quality Assurance Assessment was forwarded to the Commission prior to the unannounced inspection. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced `key site` visit was carried out by Michelle Love and Bernadette Little, inspectors over a total period of approximately 25 hours. At this site visit both inspectors conducted the inspection with the acting manager and with the assistance of other senior members of staff. As part of the inspection process a number of records relating to individual residents and care staff were examined, for example care plans/risk assessments/healthcare records, staff employment files, training records, accident records, complaint records etc. Additionally the homes medication systems were observed and records inspected. On the day of the site visit, 36 residents were observed to be residing at Sycamore Court. During the site visit several residents and members of staff were spoken with. Following the site visit 10 surveys were randomly forwarded to residents relatives and/or representatives to seek their views as to the service provided at Sycamore Court. Of 10 surveys sent out the Commission for Social Care Inspection received 7 completed documents. Issues and direct quotes where appropriate have been recorded and highlighted within the main text of the report. Inspectors spoke with a visiting healthcare professional, comments were positive and improvements noted. Prior to this inspection, the Commission received an anonymous complaint pertaining to the homes medication practices and procedures. As a result of this, an unannounced random inspection was conducted on 13th April 2007 to Sycamore Court by Michelle Love and Bernadette Little. Although 3 statutory requirements and 4 recommendations were highlighted, it was positive to note that no serious areas of concern were found. What the service does well: In general terms residents appear happy and content with living at Sycamore Court. The majority of the staff team have worked at Sycamore Court for some considerable time. The home does not use high numbers of agency staff to fill staffing gaps. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 6 The home is situated within lovely grounds and provides the majority of residents with a lovely view. All residents within the home have their own bedroom and en-suite toilet and wash hand basin facilities. What has improved since the last inspection? What they could do better: The homes care planning and risk assessing systems and documentation require further development to ensure that all areas of individual care needs, assessed risk and staff interventions detailing how care is to be provided are recorded. Although an activities programme is readily available, the registered provider must consider how to enhance resident’s participation/access within the local community. Some staff interaction and actual delivery of care to those people who have complex needs and/or poor communication/cognitive development remains poor. Attention must be given to the existing staffing levels, as these do not meet the needs of residents residing at the care home on occasions. As detailed within the report the deployment of staff within the home is not always appropriate and in some instances the needs of residents appear secondary and routines within the home are rigid. Gaps were noted in relation to staff recruitment records and must be addressed. Training for staff is poor and needs to be addressed as a matter of priority. The cleanliness of the home environment and the recruitment of sufficient numbers of domestic staff must be improved to ensure that the home is clean. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 7 The Commission for Social Care Inspection recognises improvements undertaken since the last inspection, however there is still more work to be done to reduce the number of Statutory Requirements and Recommendations, some of which have been repeated on several occasions. Additional random inspections to the care home will be undertaken to check compliance. 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 Court DS0000018123.V342142.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 Court DS0000018123.V342142.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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good system for formally assessing the needs of prospective residents prior to admission. EVIDENCE: On inspection of three care files for the newest people admitted to the care home, it was positive to note that a pre admission assessment had been completed. Information recorded was observed to be informative and detailed and as part of the assessment process, formal assessments relating to dependency, moving and handling, pressure area care, nutrition and continence were completed. In addition to the assessments undertaken by the home, information had been sought from hospitals and/or placing authorities. The acting manager was advised that of three care files examined for those people newly admitted, written confirmation from the registered provider was Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 10 available within one file detailing that it could meet the needs of the person assessed. A copy of the homes Service Users Guide was located within individual resident’s bedrooms. A copy of the Statement of Purpose and Service Users Guide was also placed within the main reception area of the home. The home does not provide intermediate care. Sycamore Court DS0000018123.V342142.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive system/format for recording individual’s health, personal and social care needs, however individual plans of care were seen to be adequate. The homes medication procedures and records were in general terms seen to be satisfactory. EVIDENCE: At this inspection a random sample of eight individual care plans were inspected. It was positive to note that evidence suggested that since the last inspection, the homes care planning procedures and documentation have improved, care plans were seen to be a working document and some elements of the care plan were person centred. Some elements of individual care plans inspected were observed to be detailed, comprehensive and informative. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 12 Formal assessments relating to dependency, manual handling, pressure area care, continence, falls, nutrition and malnutrition were completed within each care file examined. The acting manager was advised that some elements of individual people’s care plans still require additional information which provides a full overview of the persons needs. For example one care plan made reference to the resident requiring assistance from one carer when getting in and out of the wheelchair. No information was recorded detailing what assistance was required for them to have a bath/shower or if they sustained a fall/fell out of the wheelchair, the nature of the specific assistance required. Daily care records evidenced on 17.6.07 that the person was found on the floor having slipped out of their wheelchair. The person refused assistance from paramedics. The acting manager was advised to ensure that all necessary information as recorded within the pre admission assessment and as highlighted from individual’s Placing Authorities/NHS Trusts must be transferred to the individual’s plan of care. For example one care plan made reference to the resident being allergic to penicillin, however this was not recorded within the care plan and no risk assessment was devised. On inspection of daily care records for one resident, this suggested on several occasions that the resident had displayed aggression/inappropriate behaviours. This was not detailed within the care plan and no risk assessment had been devised setting out the specific nature of the risk, steps to minimise the risk or clear guidelines and management strategies for staff to follow. There was some evidence that individual resident’s are involved in some decision making, for example times they get up/go to bed, where they choose to eat their meals, participation within the homes activities etc. Risk assessments were also much improved, however not devised for all areas of assessed risk. Some examples have already been highlighted in the text above. The acting manager was advised that staff who devise documentation must record accurately, factually and not to make assumptions. For example the risk assessment for one person made reference to the person suffering with depression and being able to hear themselves. It was not clear as to how staff knew this or whether or not this was their opinion. The care plan for one resident detailed that they had contracted MRSA, no risk assessment was devised. The care plan although good did not include details of the frequency of district nurse visits or include actual care provided by healthcare professionals. Daily care records were noted to be much more informative and detailed. The acting manager was advised to ensure that staff interventions are recorded detailing care provided to individual people. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 13 In general terms care plans were observed to be reviewed monthly, however gaps were noted in some cases. It was positive to note that in some cases there was evidence to suggest that where possible the care plan had been devised with the resident and/or their representative. Accident records for individual residents were inspected. It was positive to note that there is not a high incidence of accidents/incidents within the care home. Although accident records were completed, limited information was recorded pertaining to staff’s interventions. One relative survey forwarded to the Commission recorded “It would be nice if they had a male carer to see that male resident’s are shaved and kept better groomed”. Another survey recorded “we are delighted with the care and support provided by Sycamore Court” and “mother has first class personal hygiene and cleanliness”. Storage facilities on the ground floor were inspected in relation to the homes medication. Storage facilities were observed to be satisfactory and secure. The acting manager was advised that the temperature within the storage room was relatively high and needs to be closely monitored, as some medication above a certain temperature is known to deteriorate. The acting manager advised the inspector that she was aware that the air conditioning unit was not operational and a new one was required to be purchased. Medication profiles for all residents had been reviewed and updated. PRN (as and when required medication) protocols were devised, however some were noted to be basic and did not provide sufficient detail pertaining to the specific circumstances when medication should be administered, how the person expresses that they are in pain and the dose/times to be given medication before medical advice is sought. On inspection of the homes Medication Administration Records (MAR) for all residents residing at Sycamore Court, only two omissions of signatures/initials were observed, whereby staff had not signed the MAR record to indicate that medication had been administered to and received by residents. Where `F` is recorded on the MAR record, staff had not always recorded additional information on the reverse of the MAR. The inspector was advised that at the time of the inspection one resident within the care home required controlled drug medication. Storage facilities were seen to comply with regulations and the records of medication and actual medication available tallied. One relative survey forwarded to the Commission stated “sometimes we are not totally sure that required and prescribed ointments have been applied Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 14 regularly”. If this is correct, appropriate measures must be undertaken to ensure that all prescribed medication, including ointments is administered in line with the prescribers instructions. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who reside at the care home are given the opportunity to participate within an activity programme. EVIDENCE: Since the last inspection an activities co-ordinator has been newly appointed and is contracted to work 30 hours per week Monday to Friday. A weekly programme of activities is devised and displayed both within the homes main reception area and within the hallway by the dining room (ground floor). The programme of activities included bingo, discussion groups, gardening group (hanging baskets), community access, cooking (jam tarts/peppermint creams/coconut ice/fairy cakes/Victoria sandwich), knitting, coffee and cake morning, hairdresser, pat dog and variety of board games. On the day of the site visit 5 people were observed to play dominoes. The activities co-ordinator advised inspectors that she also undertakes a 1-1 session of dominoes with one resident during the week. The activity co-ordinator advised that she has received no formal training pertaining to activities, but has access to a book Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 16 and suggestions from NAPPA. A summer fete is planned for mid July 07. Residents spoken with advised “nothing to do, nothing on television so I just go to bed”, “would like to go out more” and “activities are OK”. Relatives surveys returned to the Commission stated, “It would be nice for residents to have stimulating outside events e.g. local theatre, look round shops” and “I would like them to take them out on trips and excursions”. On inspection of care plans there was evidence detailing specific activities undertaken by individual residents. The acting manager was advised that more detail is required within each care plan depicting their personal preferences, likes and dislikes and to record their strengths and weaknesses as to how they are able to participate/not able to participate. On the morning of the inspection the activities co-ordinator was noted to attend a training course. For the majority of the morning residents were observed to sit in lounge areas with very little to occupy them. Staff interaction was observed to be poor and residents were left to their own devices. The home continues to have an open visiting policy, whereby visitors to the home can meet with their family member or friend at any reasonable time during the day and evening. The relationship between visitors to the home and care staff was seen to be positive. The home continues to operate a rolling four-week menu. Menus were noted to offer two choices of meals at both lunchtime and teatime, for example cottage pie/vegetables or sausages/vegetables at lunchtime and for tea, fish fingers or assorted sandwiches. Inspectors observed both breakfast and the lunchtime meal within the two dining areas on the ground and first floor. It was positive to note that the eating experience for those people on the ground floor was much better than at previous inspections to the home. However this was in contrast to that observed on the first floor. For example the dining area was observed to be cramped/tight for space, no scoop was available to dispense cereal from a plastic container into cereal bowls and one staff member was observed to use their fingers to flick off excess cereal from the bowl. Additionally there was no sugar or milk on the tables and resident’s were reliant on staff doing this for them, yet some residents could have completed this task without assistance. At the lunchtime meal, extras are not offered to residents and one resident was not verbally/physically encouraged to eat more of their meal before the plate was withdrawn. During the inspection, several residents were spoken with and comments were noted in relation to food, “food is OK, but not enough”, “breakfast is small” and “food is good”. Relatives surveys returned to the Commission made reference to “sometimes when the normal cook is not there the food is not up to it’s usual standard”, “mother is well fed”, “it would be nice if they could arrange for a salad main meal which is served in an appetizing way, to make residents want to eat it” and “the food is very good”. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure, which meets regulatory requirements, however complaints are not always fully recorded. EVIDENCE: Since the last inspection to the care home the homes complaints procedure has been amended to reflect that the Commission for Social Care Inspection no longer has any statutory responsibility to investigate complaints. The procedure was displayed within the homes reception area and within the Statement of Purpose/Service Users Guide. One relative survey returned to the Commission indicated that they did not know that the home had a complaints procedure. On inspection of the complaints folder it was positive to note the home had received a number of complimentary cards and letters, thanking care staff for the care provided to their friend/member of family. Comments such as “she was happy here” and “thanks for the care and kindness” were recorded. Since the last inspection (31.1.07) the care home had received two complaints. Records for one complaint did not include details of the specific nature of the complaint or the investigation undertaken. Information was recorded pertaining to the action taken and the outcome. On inspection of one resident’s Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 18 care file (review records), where issues had been raised by the individual’s family this had not been addressed. Inspectors were advised by the acting manager that she had not been made aware of the issue and had she been it would have been dealt with in line with the homes policy and procedures. The home has a adult protection policy and procedure. The homes training matrix evidences that at the time of the inspection only 22 of staff working within the care home had received training relating to protection of vulnerable adults (10 senior care staff/care staff did not have this training). No staff had received training relating to challenging behaviour. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a homely and comfortable for people who live there. EVIDENCE: The home environment is comfortable and generally meets the specific needs of people who live there. The main reception area to the premises is welcoming and pleasant. Consideration should be given to ensure that there is better signage within the home for residents so as to assist orientation. Both inspectors conducted a tour of the premises throughout the day of the inspection. On observation many carpets within the home were observed to be heavily stained and some areas of the home were observed to be dirty and to have a strong odour of stale urine. One resident survey was noted to state “It would appear that due to a lack of staff resources, cleanliness of rooms and Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 20 communal areas is not always up to standard”. Other comments noted were “curtains in my mums room could do with replacing as they are torn”. The kitchenette on the first floor was observed to be very dirty (walls/sink and floor) Prior to the inspection the Commission for Social Care Inspection received notification of the homes air conditioning system having not worked within the care home for some considerable time. This was clearly evident on the day of inspection and when discussed with the acting manager, she confirmed that she was waiting for estimates from Southern Cross Healthcare Estates Department. The registered provider must act promptly to rectify the issue, as the air quality within the home is poor and stale. A written response as to when this will be dealt with must be forwarded to the Commission within 7 days of receiving this report. Of those people’s bedrooms inspect, all were seen to be personalised and individualised with people’s personal effects. Some residents were observed to have their own television, radio, DVD/Video player and to have smaller items of furniture from home. Some bedrooms on both the ground and first floors require redecorating as walls were marked and/or scuffed. Two health and safety issues were highlighted on the day of inspection and this related to the homes two sluice rooms on the ground and first floor and a mop and bucket/dust pan and brush being left out (tripping hazard). The acting manager was advised that although the ground floor sluice room was locked (bolt), possible easy access to the room by residents was observed. The first floor sluice room was observed to be unlocked with several COSHH (Control of Substances Hazardous to Health) items being easily accessible. The homes laundry area was observed to be clean, tidy and well organised. However the laundry area was easily accessible to those residents who wander. Inspectors were advised that as a result of the homes passenger lift not working recently, laundry had to be brought down to the laundry area via the stairwell. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 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 are inadequate to meet the needs of people who live there. The service has a poor recruitment procedure with shortfalls. Training for staff is inadequate. EVIDENCE: The staffing levels at the care home are 1 senior carer and 2 members of care staff on the ground and first floor between 08.00 a.m. and 20.00 p.m., and at night there is 1 senior carer and 1 member of care staff on the ground and first floor between 20.00 p.m. and 08.00 a.m. The staff rosters do not allow for a handover period between each shift. On inspection of four weeks staff rosters from 3.6.07 to 28.6.07 inclusive, evidence suggested on three occasions that there were insufficient staff on duty on 8.6.07 (a.m.), 19.6.07 (a.m. and p.m.) and 20.6.07 (p.m.) during the day. The Commission had not been notified as part of Regulation 37 and it was unclear as to what measures had been undertaken by the acting manager/senior staff to ensure that the care home was fully staffed. The staff rosters indicate that the majority of staff, continue to work long days (12 hours shifts) and some staff are working between 54-60 hours per week. Week commencing 3.6.07 one member of night staff was observed to complete 6, twelve hour shifts totalling 72 hours. The staff rosters evidence three members Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 22 of staff regularly undertake both day and waking night duties totalling in excess of 60 hours per week. Staff rosters were clear to follow, however on some occasions the full names of staff were not recorded. At the time of the inspection there was insufficient domestic cover available at the care home. This has had a detrimental effect on the cleanliness of the home. The acting manager advised inspectors that current vacant hours are for a deputy manager (42 hours per week) and kitchen/domestic (53 hours per week). On inspection of three staff employment files, some gaps were noted whereby not all records as required by regulation had been sought in line with regulatory requirements. Gaps were noted in relation to a full employment history not being explored for one person, evidence of the original criminal record bureau check not available for all three newly recruited members of staff, health questionnaires completed but not a declaration confirming that employees are mentally and physically fit to undertake their role, the curriculum vitae for one person detailed that they worked at a care home but was not detailed within the application form, no evidence of qualifications and experience for one member of staff and no evidence of an induction. Inspectors were advised that two members of staff have temporarily transferred from another Southern Cross Healthcare home to Sycamore Court. No staff file when requested by the inspector was available for one member of staff and the other file had to be brought over to the care home. No employment file was available for the acting manager. This has been previously requested but remains unavailable. The acting manager was advised that this remains unacceptable and not in line with regulatory requirements. The Commission is aware that Southern Cross Healthcare have a centralised HR Department and that the files for managers are located within. However in order to comply with Regulation 19 and Schedule 4 of the Care Homes Regulations a proforma must be completed detailing the persons name, address, qualifications/experience, date commenced at the home/date ceased, job title, contracted hours, other personnel issues held centrally (grievance/disciplinary action/medical issues) and verification and dates pertaining to references, criminal record bureau checks/POVA 1st checks, proof of identity, details of registration within a professional body, full employment history, reasons for leaving previous employment and a record of training including induction. The record of training statistics recorded 32 people as being employed at the care home (11 care assistants, 10 senior care assistants, 1 nurse, 3 kitchen staff, 4 domestic/laundry staff, 1 maintenance person, 1 activity co-ordinator Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 23 and 1 administrator). Evidence suggested that no staff have up to date fire awareness training, 8 members of staff have participated in fire drills within the last 6 months, 72 of staff have undertaken food hygiene, 63 of staff had undertaken moving and handling training, 13 had received COSHH training, 44 of staff had undertaken health and safety training, 22 of staff have training relating to protection of vulnerable adults, 28 of staff had received training relating to infection control, 100 of staff who administer medication to residents had up to date training, 91 of staff had received training pertaining to care planning and 6 of staff had received dementia awareness training. The training matrix submitted to inspectors detailed 23 staff have attained basic first aid training and 3 staff received training in 2004 relating to optical awareness. No staff had received training relating to nutrition, pressure area care, sensory impairment, challenging behaviour and those conditions associated with the needs of older people, for example Parkinson’s Disease, diabetes, continence, communication etc. Within individual staff employment/training files completed ` assessment of learning` documentation were available for courses undertaken. It was also noted that the acting manager has provided some of the training to staff, yet has not undertaken a `train the trainer` course. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 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 manager has the necessary experience to run the care home. EVIDENCE: The acting manager advised inspectors that as yet no application has been forwarded to formally register with the Commission. This has been outstanding for some considerable time and the home has been without a registered manager since 2005. The registered provider must make a decision as to whether or not the current acting manager is to be proposed as the registered manager. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 25 It is positive to note that since the last inspection, progress has been made in a number of areas and it is clear that the acting manager and staff team have made attempts to address previous identified shortfalls. This is detailed within throughout the main text of the report. Since the last inspection the acting manager has implemented a `surgery` once weekly for residents/relatives to discuss any issues. Since the last inspection the acting manager has attained the Registered Manager’s Award. The Annual Quality Assurance Assessment forwarded to the Commission, details that resident surveys have been devised and implemented. The acting manager advised that the results of the surveys will be made public to all interested parties once information has been collated. The acting manager was advised to ensure that staff, visiting professionals and other interested parties are also consulted and their views sought. Records were available to indicate that staff meetings are generally held 6 weekly and that resident meetings are undertaken. On inspection of staff employment files, evidence suggested that supervision is being conducted but not in line with regulatory requirements and recommendations. A random sample of resident’s monies and records were inspected. Records, receipts and actual monetary totals were seen to tally. Money for residents was observed to be held securely. A random sample of records as required by regulation were inspected. The homes registration certificate needs to be amended as this still refers to the previous registered manager. The acting manager was advised that the certificate needs to be forwarded to the Commission for reviewing and updating. A number of records relating to emergency lighting, alarms, fire system checks and other maintenance records have not been kept up to date as a result of the home being without a maintenance person. The acting manager advised inspectors that a person has been newly recruited to the post of maintenance person and that in the meantime the maintenance person from another Southern Cross Healthcare home has been providing some support. Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A 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 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Ensure that all residents have a detailed and comprehensive plan of care specifying their individual care needs and how these are to be met by care staff. Previous timescale of 15.8.03, 1.12.05, 1.8.06 and 14.4.07 not met. Ensure that risk assessments are devised for all areas of assessed risk. Previous timescale of 15.8.03, 1.12.05, 1.8.06 and 14.4.07 not met. Ensure that all residents residing at the care home receive a programme of activities. This refers specifically to, community based activities. Timescale for action 01/09/07 2. OP7 13(4) 01/09/07 3. OP12 16(2)(m) &(n) 01/09/07 4. 5. OP15 OP16 16(2)(i) 22 Previous timescale of 1.7.06 and 14.4.07 not met. Ensure that all residents who live 01/08/07 at the care home receive adequate quantities of food. Ensure that the homes records of 01/08/07 complaint contain information DS0000018123.V342142.R01.S.doc Version 5.2 Page 28 Sycamore Court relating to the details of the investigation, action taken and outcomes. Previous timescale of 7.6.06 and 14.4.07 not met. Ensure that all staff receive training relating to protection of vulnerable adults and all care staff receive training relating to challenging behaviour. 6. OP18 13(6) 01/10/07 7. 8. OP19 23(2)(d) 13(4) OP19 9. OP27 18(1)(a) Previous timescale of 1.7.05, 1.12.05, 1.9.06 and 1.7.07 not met. Ensure that all areas of the home 01/09/07 are kept clean and reasonably decorated. Ensure that the sluice rooms 01/08/07 within the home are locked and that all COSHH items are stored securely. Ensure that staffing levels are 01/08/07 appropriate to meet the needs of residents. Previous timescale of 13.9.04, 7.5.05, 1.11.05, 14.6.06 and 21.4.07 not met. Ensure that all records as required by regulation are sought and available for inspection. Ensure that a staff file is available for all staff working in the care home. This refers specifically to staff who have transferred from another home and to the acting manager’s file. Previous timescale of 14.4.07 not met. Ensure that all staff working at the care home receive appropriate training to the work they perform. Previous timescale of 1.10.06 10. OP29 19 01/08/07 11. OP30 18(1)(c)& (i) 01/11/07 Sycamore Court DS0000018123.V342142.R01.S.doc Version 5.2 Page 29 12. OP31 13. OP36 11(1), Part II of the Care Standards Act 2000 18(2) not met. Ensure that the home is managed by a person who is registered with the Commission for Social Care Inspection. Ensure that all staff are regularly supervised. Previous timescale of 1.6.05, 1.7.06 and 1.5.07 not met. Ensure that appropriate arrangements are made to maintain records relating to fire drills, emergency lighting/alarms etc. 14/08/07 01/08/07 14. OP38 23(4) 01/08/07 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. 7. Refer to Standard OP7 OP7 OP9 OP9 OP12 OP14 OP26 Good Practice Recommendations Ensure that daily care records record staff interventions/care provided to individual residents. Ensure that accident records record staff interventions and outcomes of treatment for individual residents. PRN (as and when required medication) protocols should clearly identify when the medication should be administered, for what specific purpose and its frequency. Where `F` is recorded on the MAR record, additional information should be recorded on the back to clarify the coding. Ensure that individual care plans record people’s preferences/likes and dislikes relating to activities and hobbies. Ensure that staff interaction between residents and staff is improved. Ensure that the homes laundry area is not accessible to residents residing at the care home. Sycamore Court DS0000018123.V342142.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: 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 Court DS0000018123.V342142.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. 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