Inspection on 31/01/07 for Sycamore Court

This inspection was carried out on 31st January 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 28/06/07

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 Key Unannounced Inspection 31st January 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.V324723.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.V324723.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 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.V324723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2006 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. A pre inspection questionnaire was forwarded to the Commission and arrived prior to the inspection. Sycamore Court DS0000018123.V324723.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, Regulation Inspectors, and lasted a total of approximately 22.5 hours. At this visit the acting manager was not available and throughout the inspection the deputy manager and administrator assisted both inspectors. 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, staff rosters etc. Additionally the homes medication systems/records were inspected and a tour of the premises undertaken. Also as part of the process, both inspectors talked with the deputy manager, senior and care staff. Relatives who visited the care home were asked to complete a questionnaire depicting their view of the service provided at Sycamore Court. Information gathered from these surveys have been incorporated into the main text of the report. 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 22 Statutory Requirements and 5 Recommendations highlighted, and there appears to have been little improvement noted at this site visit, as 17 Statutory Requirements and 5 Recommendations have been identified. The Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 6 registered provider must be prepared for the fact that continued poor performance and non-compliance of the Care Homes Regulations and National Minimum Standards will result in Statutory Requirement Notices being issued. As stated previously several requirements have been repeated and recorded within past inspection reports. Areas of concern relate to the homes care planning/risk assessment processes, inadequate staffing levels, lack of staff training, lack of meaningful activities for residents and residents not being given the opportunity to make decisions and choices. 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.V324723.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.V324723.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered provider has developed a Statement of Purpose and Service Users Guide, however both documents need to be amended and reviewed so that prospective residents can make an informed choice as to whether or not they wish to live at Sycamore Court. The home have a pre admission assessment/process, however evidence suggests that practice is not always consistent or well applied. EVIDENCE: The Statement of Purpose and Service Users Guide are located within the main reception area of the home. Additionally each resident is issued with a copy of the Service Users Guide. The Statement of Purpose needs to include information detailing the responsible individual’s qualifications and experience. The Service Users Guide must also include specific information pertaining to the total fee/weekly charges payable for the cost of a placement at Sycamore Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 9 Court, the arrangements for charging and paying for any services additional to those described and whether or not charges are different for people who have all or part of their care funded by either the local authority or primary care trusts. The home has an assessment format and process for assessing prospective residents. On inspection of three pre admission assessments for the newest residents, assessments were seen to be incomplete and inconsistently completed. Formal assessments pertaining to moving and handling, continence, pressure area care, nutrition etc, were only partially completed within all three pre admission assessments inspected. For one resident some notes were scribbled on a piece of paper depicting their dietary needs i.e. “won’t eat meat unless its falling apart, cos she can’t chew”, “but will eat a shep pie”, “don’t eat eggs”, “no onions” and “must be encouraged to eat”. In addition to the pre admission assessment format, information had been sought from prospective resident’s placing authorities/hospitals. It was noted that some information provided by these external agencies was not gathered and included within the pre admission assessment. There was no evidence to indicate that the pre admission assessment had been completed with either the resident and/or their representative. There was documented evidence to indicate that only one resident and their representative out of three were given the opportunity to visit the care home prior to admission. The resident’s relative advised inspectors that no confirmation had been received from the home detailing that they were able to meet their relatives needs and a copy of the Service Users Guide was not provided until the day of admission. The Statement of Purpose under `admission criteria` states “Sycamore Court will formally write to the service user to confirm that we can meet their needs” and “Prior to admission the pre admission assessment and draft care plan sheet will be given to the person responsible for the service users care”. Inspectors noted that one resident was due to be admitted to the care home the following day. No pre admission assessment was evident. When questioned the deputy manager was unable to confirm the resident’s name. The home does not provide intermediate care. Sycamore Court DS0000018123.V324723.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 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 and some people who use the service do not have a care plan. 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: The care files for four residents were requested. It was of concern that no care plan was available for the newest resident to be admitted to the care home. Additionally no `draft care plan` had been completed for this person. Staff working within the care home had no supporting information to advise them of the resident’s current care needs and how these were to be met. During the early afternoon, the resident’s relative arrived and the deputy manager in conjunction with both people initiated the care plan. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 11 Other care plans inspected varied in detail and comprehensiveness. The care plans did not always include the specific nature of need and how care was to be delivered by care staff and staff interventions. None of the care plans inspected recorded information relating to communication or residents mental health/well being. The care plan for one resident detailed that they must not eat pork and are to be weighed monthly. No rationale was recorded as to why the resident must be weighed monthly i.e. at risk of poor nutrition/poor appetite. 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 independently 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. There is little evidence to indicate that staff involve individual residents and/or their representatives in decisions or give them a say in how they would like their care to be delivered. The Statement of Purpose under the heading of `arrangements for consultation with service users and relatives` states “service users (or their representative with permission of the service user) are encouraged to become involved in the care planning process and will be fully consulted at each stage of the care plan”. Formal assessments relating to manual handling, pressure area care, nutrition, continence and falls were completed for three out of four care files examined. None of the homes manual handling assessments made reference to the specific type of hoist required, number of staff required or the type of sling utilised. Risk assessments were devised, however in most cases these did not record the rationale for the risk or provide specific information i.e. the risk assessment for one resident detailed that they had pressure sores and made reference to pressure relieving equipment being in place. No information was recorded detailing the latter and there was no information to suggest that appropriate healthcare professionals had been requested to provide support. The assessment was dated 23.9.06 and was not reviewed until December 06. On inspection of three validation audits completed by the registered provider, these detail in August 06 a score of 84 was recorded for care documentation based on 1x care plan inspected, 89 was recorded on 25.10.06 based on 1x care plan inspected and on 8.12.06 93 was recorded for care documentation based on 1x care plan inspected. The acting manager’s monthly home audit details on 22.8.06 a score of 79.85 was recorded for care documentation based on 4x care plans inspected, 72 was recorded on 5.9.06 based on 4x care plans inspected and on 9.11.06 81.25 was recorded, again based on 4x Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 12 care plans inspected. It is evident that the information recorded within the audit does not concur with the inspector’s findings at the site visit. Some improvement was noted in relation to daily care records, however these varied in content and detail. At the previous inspection to the home, issues were raised in relation to some residents not receiving baths/showers on a regular basis or in line with their care plan. This was once again confirmed at this inspection i.e. the care plan for one resident indicated that they should receive a bath at least once weekly. Records indicated that from 1.1.07 they only received one bath until they were admitted to hospital on 17.1.07. Another care plan detailed that the resident should have a bath/shower at least once weekly. Again records indicated that from 1.1.07 to the day of the inspection, only two baths were recorded for 6.1.07 and 18.1.07 inclusive. Observation of medication administration on both the ground and first floors for residents was undertaken both during the morning and at lunchtime. The morning medication for residents was observed to be administered quite late. The deputy manager advised that this was as a result of a reduction in staffing levels. This is of concern and needs to be addressed to ensure that residents receive their prescribed medication at the correct time. Medication was seen to be securely stored. A list of staff names, initials and signatures were available for those staff deemed competent to administer medication to residents. The deputy manager was advised that this needs to be reviewed and updated to reflect accurately those staff members who administer medication. As part of good practice procedures the homes Homely Remedy Policy needs to specifically include details of the type of homely remedy that can be used. On inspection of medication administration records several omissions of staff signatures were noted, whereby they were not signed to indicate that medication had been administered and/or received by residents. PRN (as and when required medication) protocols had been devised since the last inspection. Although `signed off` by the GP, many protocols were observed to be basic. The homes pre inspection questionnaire details 6x staff are deemed responsible for administering medication to residents. On inspection of the homes training matrix, records indicate all received medication training in September/December 2005. It is unclear as to when staff received updated/refresher training. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is limited evidence within individual care plans to indicate that people who live at the care home are consulted or listened to regarding their choice of daily activity. Activities are not provided on a regular basis. Food provided to residents is good, however interaction between staff and residents is poor on occasions. EVIDENCE: At the time of the inspection, the homes activity co-ordinator was on annual leave. Despite knowing in advance that this person would be on holiday, no provision had been made by the registered provider/acting manger to ensure that an alternative arrangement/programme was in place for residents to have their social needs met. Care plan documentation did not record in sufficient detail resident’s choice of daily activity both within the home and in the community. Little information appeared to be available depicting information on community based events and trying to make individual arrangements for people to attend. An activity programme was displayed on the ground floor for week commencing 22.1.07 to 29.1.07 inclusive. Resident’s comments in Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 14 relation to the range of activities provided varied i.e. “I join in bingo when things are on”, “no activities”, “yes, there are activities and I do join in sometimes and “not a lot to pass time” were expressed. Sample activity programmes were forwarded to the Commission with the homes pre inspection questionnaire. These detail residents have the opportunity to participate within activities such as hairdressing, bingo, dominoes, ball games, knitting, board games, arts and crafts, tea and chat and music morning. There are limited opportunities for residents to maintain independence and there seems to be little consideration given to supporting people’s individuality or social preferences. Interaction between staff and residents remains poor and it is unclear as to whether this relates to staff being too busy with tasks or them not being interested. One resident expressed that they found staff very good, but could not always understand some staff’s verbal communication due to their `broken English`. Routines in the home are rigid and staff are not prepared to change their way of working. Residents seem over compliant with the routine of the home e.g. at the time of the inspector’s arrival two residents were observed to be in bed fully dressed. Staff confirmed that night staff get several residents up in the morning before going off duty (washed and dressed). Little consideration is given to consulting residents and enabling them to make choices and/or decisions e.g. rising and retiring to bed. This is contrary to the homes Service Users Guide which states “While we will always encourage you to be up and about during the day and to be in bed at a reasonable time at night, when you rise in the morning and when you go to bed is your own choice”. The food in the home is of a satisfactory quality and is well presented. Menu’s are displayed within the home and offer residents two choices of main course/dessert at lunchtime and a hot or cold supper at teatime. Alternatives to the menu are available. Observation of breakfast and the lunchtime meal was undertaken by both inspectors within the ground and first floor dining rooms. Dining tables were attractively laid with tablecloths, flowers, serviettes, jugs of juice and condiments. Inspectors were advised that in total currently 6 residents choose to have their meals in their room rather than come to the dining area. Although those residents who require assistance with feeding, were supported by care staff, little or no verbal interaction was noted throughout the entire meal. There was evidence to indicate that the cultural or specific dietary needs of individual residents had been taken into account and was being met. This refers specifically to those residents who are diabetic and one resident of Jewish faith. Residents comments in relation to food were generally seen to be positive i.e. “food is very good, can recommend”, “teabags not good” and “food is lovely”. The home has an open visiting policy whereby visitors to the care home can visit at any reasonable time. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has a complaints policy and procedure, but not all complaints include details of the investigation, action taken and outcomes. Protection of vulnerable adults training and how to deal with aggression/inappropriate behaviours is required for some staff. EVIDENCE: The home has a complaints policy and procedure. This needs to be updated to reflect that the Commission no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. Since the last inspection the home has received three complaints. Information relating to the actual investigation undertaken, action taken and outcomes, was only available for one of the complaints. A copy of the homes training matrix was photocopied and handed to inspectors. This details that out of a possible 27 members of staff (acting manager, deputy manager, senior staff and care staff), 20 people have not Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 16 undertaken training relating to challenging behaviour and 12 people have not received training pertaining to protection of vulnerable adults. Some staff spoken with could not demonstrate a good understanding of protection of vulnerable adults issues and/or procedures. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment is well maintained and provides residents with a safe and homely place in which to live. EVIDENCE: A random sample of individual resident’s bedrooms were inspected and all were seen to be personalised and individualised. The home is well lit, clean, tidy and odour free. Although no health and safety issues were raised, the external laundry door was noted to be left open on several occasions. This poses a possible security risk and potentially places both residents and staff in danger. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 18 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 residents. Staff recruitment procedures were seen to be appropriate. Training provided for staff is fairly limited. EVIDENCE: Since the last inspection, staffing levels at the care home have been reduced. Previous minimum staffing levels of 1x senior carer and 2x members of care staff on each floor between 08.00 a.m. and 20.00 p.m. have been reduced to 1x senior member of staff and 1x member of care staff on each floor during the day. The inspectors were advised that an additional member of care staff is to `float` between both floors to provide supplementary support. Staffing levels at night remain as 1x senior carer and 1x carer on each floor at night. It is clear that the reduction in staffing levels does not provide satisfactory and safe outcomes for those residents living at Sycamore Court. This is evident through the late administration of medication to residents on the day of the site visit, some residents being put back to bed by night staff after being washed and dressed in the morning, lounge areas left unsupervised for long periods of time throughout the day, not all residents assisted with their lunch promptly, resident call alarms not always answered speedily and where some residents require 2x staff for hoisting, areas within the home are left Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 19 unsupervised. No rationale was available to evidence, why the decision to reduce staffing levels has been undertaken by the registered provider and there was no evidence as to the dependency levels for all residents at the home. The reduction of staffing levels is not in the best interests of residents and the health and welfare of people is adversely affected. The level of staffing restricts the ability of the service to deliver person centred care and support. The staff rosters indicate that the majority of staff consistently work 12 hour shifts from 08.00 a.m. to 20.00 p.m. Some staff were noted to work up to 60 hours per week. The acting manager must monitor this to ensure that staff remain competent to do their job. Inspectors were advised by the deputy manager that since the last inspection one new member of staff has been newly employed. On inspection of their employment file it was evident that the majority of records as required by regulation had been sought. There were two areas of discrepancy and these related to the start date for the member of staff being 3.8.06 and their application form being signed and dated 11.11.06. Additionally a copy of the original criminal record bureau check was not available for inspection. The only information available was written confirmation from the registered provider detailing the date and criminal record bureau number for the above person. No record of induction was available for this person and is in conflict with the homes Statement of Purpose “we have robust induction programme which is completed by all new staff”. A training matrix was provided for inspectors, identifying required and specialist training for individual members of staff. Records indicate that there are gaps in relation to both aspects of training for staff i.e. 6x staff have no manual handling and 4x staff require updated/refresher training, 4x staff do not have fire awareness training and 8x staff require updated/refresher training, 4x staff do not have food hygiene training, 10x staff do not have basic first aid training, 20x staff do not have health and safety training, 20x staff do not have COSHH (Control of Substances Hazardous to Health) training and 25x staff (including the maintenance person and domestic/laundry staff) do not have training pertaining to infection/cross infection control. Records indicate that very few staff have training relating to the needs of older people i.e. parkinsons disease, sensory impairment, dementia, care planning, taking risks etc. There is no evidence to indicate that the activities co-ordinator has received appropriate training relating to social activities/activities for older people etc. Concerns relating to training provided for staff remain prevalent and have not been addressed satisfactorily by the registered provider so as to meet residents needs. The training matrix details 7x staff have achieved NVQ Level 2, 1x staff member has attained NVQ Level 3, 8x staff have enrolled on NVQ Level 2 and the deputy manager has commenced NVQ Level 4. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced person however they demonstrate an inability to raise the homes standards and to meet regulatory requirements and National Minimum Standards. EVIDENCE: The acting manager was not present during the site visit to Sycamore Court as on annual leave. The training matrix details they are currently undertaking NVQ Level 4 training. The acting manager has been forwarded an application to formally register with the Commission, however it is unclear as to whether or not this has been submitted for processing. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 21 Despite assurances from the acting manager with regards to addressing previous identified shortfalls, little progress appears to have been made and this is clearly demonstrated throughout the main text of the report. It is evident that resident’s interests are not always safeguarded and/or promoted. This is of concern and should issues continue not to be addressed or dealt with in a timely manner, the Commission will issue Statutory Requirement Notices. On inspection of a random sample of monetary records and receipts for individual residents, these were observed to be satisfactory with records and monetary totals tallying. Minutes of staff meetings/senior meetings were available. Evidence suggests that these are happening approximately every three months. The acting manager must ensure that all staff (night staff) also have the opportunity to attend these meetings. On inspection of several staff files, it was evident that formal staff supervision has begun. Records for some staff were not available. The acting manager is reminded that all staff working at the care home should receive at least 6 supervisions annually. The homes administrator advised that `satisfaction surveys` are forwarded to 3 resident’s relatives each month to seek their views as to the service provided at Sycamore Court. Inspectors were advised that the surveys are returned to the acting manager for analysis. It is unclear as to what happens next within the homes processes. A limited number of records as required by regulation were inspected. The majority of records were seen to be satisfactory. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 22 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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 1 X 3 Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4 and 5 Requirement Ensure that the Statement of Purpose and Service Users Guide is reviewed and updated to reflect accurate information and information pertaining to fees. Ensure that all residents are assessed prior to admission and there is clear evidence to indicate that the care home is suitable to meet individual residents needs. Previous timescale of 1.12.05 to 7.6.06 not met. Ensure that all residents have a detailed and comprehensive plan of care specifying their needs care needs and how these are to be met by care staff. Previous timescale dating back from 15.8.03, 1.12.05 and 1.8.06 not met. Ensure that risk assessments are devised for all areas of assessed risk. Previous timescale dating back from 15.8.03, 1.12.05 and Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 24 Timescale for action 01/05/07 2. OP3 14 14/04/07 3. OP7 15(1) 14/04/07 4. OP7 13(4) 14/04/07 5. OP8 12(1)(a) 1.7.06 not met. Ensure that the healthcare needs/personal care needs of individual residents are identified, recorded and met by care staff. 14/04/07 6. OP9 13(2) Previous timescale of 1.11.06 not met. Ensure that appropriate 14/04/07 arrangements are made for the recording/administration of medicines received into the care home. This refers specifically to omissions on the MAR sheet and medication being administered to residents within a reasonable timeframe. Previous timescale of 7.6.06 not met and 1.11.06 not met. Ensure that all staff who administer medication to residents are competent and appropriately trained. Ensure that all residents residing at the care home receive a programme of activities both `in house` and within the community which meets their needs. 7. OP9 18(1)(c) and(i) 16(2)(m) &(n) 01/06/07 8. OP12 14/04/07 9. OP14 12(2) 10. OP16 22 Previous timescale of 1.7.06 not met. Ensure that residents are 14/04/07 enabled to make decisions and choices about their health and welfare. Ensure that the homes records of 14/04/07 complaint contain information relating to the details of the investigation, action taken and outcomes. Previous timescale of 7.6.06 not met. Ensure that all staff receive training relating to protection of DS0000018123.V324723.R01.S.doc 11. OP18 13(6) 01/07/07 Page 25 Sycamore Court Version 5.2 vulnerable adults and challenging behaviour. Previous timescale of 1.7.05, 1.12.05 and 1.9.06 not met. Ensure that all staff working in the care home are competent. This refers specifically to some staff working excessive hours. Previous timescale of 1.11.06 not met. Ensure that staffing levels are appropriate to meet the needs of residents. Previous timescale of 13.9.04, 7.5.05, 1.11.05 and 14.6.06 not met. Ensure that all staff newly appointed staff receive an induction and that their criminal record bureau check is available for inspection. Ensure that all staff working at the care home receive appropriate training to the work they perform. 12. OP27 18(1)(a) 01/05/07 13. OP27 18(1)(a) 21/04/07 14. OP29 19 14/04/07 15. OP30 18(1)(c)& (i) 01/08/07 16. OP31 10(1) 17. OP36 18(2) Previous timescale of 1.10.06 not met. Ensure that the manager is 14/04/07 competent and skilled to manage the care home so as to protect and safeguard the welfare of residents. Ensure that all staff are 01/05/07 appropriately supervised. Previous timescale of 1.6.05 and 1.7.06 not met. Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations 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. The list of staff names, signatures and initials of those people who administer medication should be updated and reviewed. Daily care records should be detailed and robust to reflect how residents spend their day. The homes complaints procedure needs to be amended to reflect that the commission no longer investigates complaints. 50 of all care staff should attain/achieve NVQ Level 2. 2. 3. 4. 5. OP9 OP7 OP16 OP28 Sycamore Court DS0000018123.V324723.R01.S.doc Version 5.2 Page 27 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.V324723.R01.S.doc Version 5.2 Page 28 - 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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