Inspection on 07/05/05 for Sycamore Court

This inspection was carried out on 7th May 2005.

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

The inspector 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 15/05/06

Sycamore Court 14/10/05

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 Bernadette Little Unannounced 7th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sycamore Court Address Magpie Lane Little Warley Brentwood Essex CM13 3DT 01277 261680 01277 202028 sycamorecourt@schealthcare.co.uk Southern Cross Healthcare (West) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter Edward Watchorn CRH Care Home 39 Category(ies) of OP Old Age (39) registration, with number of places Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Care Home Old age, over sixty five years not falling within any other category 39 places in total Date of last inspection 13th September 2004 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. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, undertaken on a Saturday. It lasted seven and a half hours. During the inspection, there was a tour of the premises and records and documents were looked at. Time was spent in the lounges and dining rooms, and with people in their own rooms, chatting and taking note of the ordinary routines of life in the home. Seven residents, six visitors and seven staff were spoken with. The staff, residents and visitors, and in particular the senior member of staff on duty, were most helpful, and this was greatly appreciated. The registered manager was on long term sick leave but was expected to return to Sycamore Court by the end of May 2005. The acting manager did not usually work at weekends and staff contacted her by telephone. As she was some hours driving distance away, the decision was made that she would not return to attend the inspection. What the service does well: What has improved since the last inspection? Sycamore Court had employed new permanent care staff since the last inspection. This meant they were using very few agency staff and residents said that this was better for them. Another person had also come to work at the home to help residents with pastimes and offer them different things to do. This member of staff works at the weekend so there was now interesting things to do then, as well as during the week. Recent records of pre-admission assessment (when the home make sure that Sycamore Court is the right place for each person to come to) were better, because they had been done before the person came to live there. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 6 What they could do better: 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 I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5 and 6 Sycamore Court offered a good level of information to people thinking of using the homes’ services. It could have evidenced this better by making sure that the Commission could access all the information that needs to be available for inspections. EVIDENCE: A Statement of Purpose and Service User Guide were available in the entrance area. The Service User Guide is included with the homes information wallet, which also had details of the fees, a copy of a menu and an activities programme. Completed copies of the home’s contract with residents were not available, as they were locked in the residents file in the office. Some relatives spoken with believed that the home had given the family a contract, at the end of the six week trial period. A blank copy of the amended contracted should have been sent to the Commission after the last inspection. Three of the four pre-admission assessment forms seen on the files looked at, had been done on the same day as the person moved into the home. The other one was more recent and showed that it had been done before the resident Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 9 moved in. There was no evidence on file to say that, having assessed their needs, the home had assured the person that it could meet them. The person registered was reminded of this in the last inspection report. None of the residents spoken with had visited before moving into the home, as some of them were unwell or in hospital, but their family did. Relatives spoken with said they had been invited to visit before making a decision to choose Sycamore Court. One relative said they felt reassured when they telephoned to make and appointment to visit, and were invited to just call in at any time to look around. Sycamore Court did not offer intermediate care. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The care plans did not have enough information. Residents’ healthcare needs were met. Some other details on residents’ medication needed to be with the medication records. Residents’ dignity and privacy was generally respected. EVIDENCE: The care plans looked at did not include all areas of people’s needs, for example, when a person got agitated or wandered. Where there was a possible risk for a resident, for example with the use of bed rails, records did not show that enough thought had been given to all the things that needed to be considered. There was little evidence to show that residents had been involved with their care plan. Advice had been given on these issues at the last inspection. Many care plans covered several areas, which was good, but they did not tell staff clearly how to do the things needed to look after that person. The person registered was reminded of this in the last inspection report. The senior staff said that changes were planned to improve the care plans but that training needed to be arranged for the staff first. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 11 Residents spoken with said they see a variety of healthcare professionals depending on their ailments and needs. Records showed this, and included details on the outcomes of appointments etc. A GP surgery was held at Sycamore Court on a weekly basis and residents had regular checks and medication reviews. The medication recording, storage and administration seen, was to a safe standard. This included controlled drugs. Staff said they had had training in medication. A copy of the set of rules for PRN (as required) medications, advised on at the last inspections, was not kept with each person’s Medication Administration Recording sheets. The risk assessments and decisions about residents’ looking after some of their own medication will be checked during the next inspection. Residents said that staff always knocked at their bedroom doors or made sure that doors to toilets and bathrooms were shut when private care was being given. Staff also said that this happened and one staff explained they had been told about this in their induction training. One incident was seen where a confused resident left the toilet door open onto a corridor. Staff had passed by and not helped the person. The senior staff dealt with this straight away when it was reported to her. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Sycamore Court provided a good range of social, religious and recreational activities. Visitors were welcomed. Residents were happy with the choices available and encouraged to keep their independence. The menu gave variety and choice. The home should re-think the way food is served to residents. Staff needed more awareness of residents individual dietary needs. EVIDENCE: A planned programme of activities for weekdays was displayed. An activities person was also recently employed for six hours at weekends. A record of activities in each residents care plan file showed events such as religious services, bingo, outside entertainers, dogs to pat, seated exercises, visitors, arts and crafts, concerts, as well as some one to one time for chats. Some of these were seen during the inspection. Residents said they enjoyed the activities and could also choose to stay in their rooms and be quiet, watch television or read the books that the library service brought. Staff said that they did have some time to sit and talk with residents when it was quiet. A number of visitors were seen at Sycamore Court and some were spoken with. Visitors said they felt welcome. A visitor brought books, flags and music to remember VE day. They, and other visitors, did a sing-along and dancing in the upstairs lounge. Residents sang, waved their flags, laughed and joined in. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 13 Residents said they could choose when to go to bed or get up and what to wear. The menu offered a real choice at each meal. Information on the days menu was in the entrance hall and the dining room. Neither of these was accurate and the size of the writing was quite small. All the residents spoken with said that they were satisfied with the food and were given choices. The record of the food chosen by, and served to, residents showed this, and that people could have a cooked breakfast if they liked. This record also showed where residents had a particular dislike of something or had a particular dietary need. The cook said there were no residents with special dietary needs, but confirmed that some residents were diabetic. Care staff offered peaches with cream to two residents, who were able to tell staff they could not have the cream. The senior staff later said this could, in one case, be perhaps because a resident had gallstones. This was not clear in the care plan, but ‘no fat’ was on the record of food chosen by/served to residents. Some, but not all, dining tables were set with cloths and condiment. Tables seated no more than four people and this made it seem a bit more homely. Residents were not given the choice to serve at least some of their meal themselves at the table and this should be reconsidered, depending on their abilities. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had a complaints procedure. Its full usefulness could not be looked at properly, as there was no access to records of any complaints or compliments. Staff needed to be provided with training on how to keep residents safe. EVIDENCE: Sycamore Court had a clear written procedure for people to follow if they wanted to make a complaint. There was a copy of it in the entrance hall and in the Service User Guide and Statement of Purpose. All the residents and visitors spoken with about this said they would feel safe to tell staff in the home if they were worried about anything. The last inspection report said that all complaints needed to be looked into fully and records must be kept to show this was done properly. These were not available at the time of this inspection as the office was locked. The home had written information on Protection of Vulnerable Adults. Staff spoken with had not had any training on keeping older people safe from abuse. This was required in the last inspection report. Most staff asked knew how to report any concerns using the home’s ‘whistleblowing’ policy and felt confident to do this. Staff had not had training on how to manage agitation or aggression and different ways were used. Some staff did not really show a full understanding of these issues and all staff needed to be offered some training. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26 Sycamore Court provided residents with a good standard of accommodation and facilities. The use of space in the dining room at mealtimes needed more thought. A more rigorous cleaning routine for carpets needed to be in place. EVIDENCE: The premises, furniture and decoration were maintained to a high standard throughout. All residents had a private bedroom, and an ensuite WC and wash basin, with wide doors that gave good access. There were separate bathrooms, and toilets that were clearly marked and near to the communal lounges and dining rooms. The garden sloped and some residents may need support. There were patios with furniture to sit out on. Residents downstairs no longer eat in the quiet room. Staff said this was because they got a bit forgotten and their food got cold. Advice was provided on how this could be better managed. The dining room downstairs looked quite crowded at lunchtime. Some residents were in a corner and restricted for access if there was an emergency and staff needed to get to them. Staff Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 16 agreed with this view. Some also said that it was easy to ‘catch’ or hurt themselves, for example on wheelchairs, due to the lack of space. There was one dining table in the smoking lounge upstairs and two residents ate there. The room was fitted with an extractor and there was no smell of cigarettes or smoke at that time. The carpet in this room was badly burnt in several places, as was the small table. The room looked unkempt and unattractive. Other carpets were badly stained in some areas and this took away from the general pleasant look of the home. Visitors spoken with agreed with this. The carpets in some rooms had not been vacuumed, for example prune stones were found on the floor in the dining room late in the morning. Some bedrooms upstairs were fitted with a bolt at a high level on the outside, that staff put in place when those residents left their room each day. When questioned on the reason for the bolts, staff explained that this was to stop other confused residents wandering into the room. A relative said that they had asked for this to be fitted. All bedrooms were fitted with key locks that operated from the outside. Guidance was provided on using these and placing the key in a safe place near each room, where staff could easily reach them. Residents spoken with said they were very happy with their own, and the communal rooms at Sycamore Court. Windows and patio doors gave views over the countryside. Bedrooms were personalised, residents had brought some of their own things, including beds, favourite armchairs, display cabinets and photographs. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staffing levels, recruitment practices and staff training could not be evidenced as safe. Day staffing levels were not being met and the roster was inaccurate. Domestic staff rosters were not accessible. Staff recruitment records were not accessible. Staff training records were not accessible. Training needs to be offered to all staff. Staff were working long shifts, which was not considered to be safe practice for residents or staff. EVIDENCE: The agreed minimum staffing levels at Sycamore Court were two senior and four care staff, split over each of the two floors during the day, and a total of one senior and three care staff at night. On the day of the inspection there was one senior and four care staff on duty. The roster stated that there were two seniors on duty. The other senior staff that should have been on duty was said to have called in sick five days previously. The senior staff on duty said that one of last nights senior carers had helped with the morning medication round, to make sure residents got their medication on time. The staff signing in book showed that a senior had done a twelve hour awake night shift and was still on duty in the home during the following day. It was confirmed that every other weekend, this staff member did a twelve hour awake night shift, followed by a six hour shift. It was not possible to get clarification whether this six hour shift was totally in the laundry or was also to include caring for residents. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 18 The roster showed one senior and three carers on duty that afternoon. The senior in charge explained that she had telephoned two of the new staff that morning and they were able to come in to cover the shift. The roster for the following day showed one senior and five care staff, including an unnamed agency staff. The majority of staff were working twelve hour shifts and explained that the difficulty with transport made this necessary. Discussion with staff, visitors and residents showed that this was not the only time that minimum staffing levels had not been met at Sycamore Court. These issues had been raised in the last inspection report. The person registered had agreed in writing to inform the Commission whenever minimum staffing levels were not met. This had not occurred. There was one domestic staff on duty between 8am and 2pm, who was also the kitchen assistant for breakfast and lunch. This did not give them enough time to make sure that the home was kept clean and vacuumed. Staff, residents and rosters available confirmed that some staff had left and new staff recruited. Residents said they were happier there was very little use of agency lately, as they did not like having to get used to all different people looking after them. The rosters available showed one agency staff shift this week. Staff training records were not available for inspection. Staff spoken with had had different opportunities for training. New staff had had training on fire, moving and handling, care of the residents and food hygiene during their first month. A senior staff said that all staff were up to date with training on food hygiene, fire and moving and handling. Information was displayed on planned infection control training. Access to training was more difficult for part-time staff. Some staff had not had training on, for example Parkinson’s disease, or diabetes which were care needs of residents at Sycamore Court. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34, 35, 36 and 38 This inspection showed that while some things like the maintenance of the premises were well managed, other things, like staffing levels, care of residents possessions, and access to their money, were not. There was some lack of trust in the senior staff. There was no reason to suggest that the home was not financially viable. The final judgement on the management and administration section of the report was very limited by the lack of access to many of the records. EVIDENCE: The registered manager was on long term sick leave and the deputy manager was acting as the manager in his absence. The Commission had been told about this, and that the operations manager would be supervising and supporting the deputy manager to make sure that the home was properly managed. In recent months, the person registered had not sent the reports of the monthly visit they must do to the home, to the Commission. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 20 There was evidence of poor communication about the staff sickness and a failure to make sure that there was enough staff to cover the shifts over the weekend. Staff spoken with said either they had not had any supervision or had not had supervision ‘for ages’. There was no access to records of any money looked after for residents and so no access for residents to their money if they wanted it. Seven watches, four hearing aids and three pairs of glasses were found in the bottom of the medication cupboard. They were not labelled and staff did not know who they belonged to. The office was locked, with a padlock. Staff explained that this was because someone had used the computer and ‘messed up’ the system. Staff explained that if a resident was taken to hospital in an emergency, they could not send a copy of the care plan and the person’s current medication with them for the medical staff, as the photocopier was locked in the office. Accident records were not accessible. The person registered should consider why senior staff in charge of the home were trusted to be responsible for so many vulnerable people and their medications and possessions, but not with a key to the office. Guidance was offered on using a system that would respect confidentiality while allowing access to the Commission, for example with staff records. A current certificate of liability insurance was displayed. Staff said they had access to ample supplies and equipment to do their work, for example, protective aprons and gloves. The premises appeared safe on inspection. Access to safety inspection certificates was not available. A record of fire drills and regular checks of the fire alarm, emergency lighting and fire extinguishers was available. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 x 3 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 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 2 3 3 3 2 x 2 STAFFING Standard No Score 27 1 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x x 3 2 1 1 x Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 5(1)b Requirement The person registered must ensure that the rights and obligations of the resident and the person registered are included in their terms and conditions. (Previous timescale of 30.06.2004 and 13.09.04 not evidenced as met) The person registered must confirm in writing to the service user that, based on detailed assessment, the care home is suitable to meet the service users needs.( Previous timescale of 13.09.04 not evidenced as met) A written service user plan must 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. This includes detailed risk assessments.(Previous timescales dating back from 15.08.03 not met) The person registered must evidence that the service user is involved and consulted regarding their care plan. (Previous timescale of 13.09.04 not met) Risk assessments must include Timescale for action 1 July 2005 2. 3 14 1 July 2005 3. 7 15(1) 1 July 2005 4. 7 15 1 July 2005 5. 8 13(4) 15 June Page 23 Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 6. 16 22 7. 18 13(6) 8. 26 23(2)d 9. 27 18(1)a 10. 27 17(2) Schedule 4 (7) 37(1)e 11. 27 12. 27 18(1) 13. 29 19 and Schedule appropriate detail to ensure the health and safety of service users. This includes bed rails. The person registered must ensure accurate recording of complaints and evidence thorough investigation (Previous timescale for compliance of 13.09.04 unable to be confirmed) The person registered must ensure the safety and protection of residents and provide all staff with training on Protection from abuse and management of behaviour that challenges The person registered must ensure that all parts of the home are kept clean. This refers to the cleaning of the carpets to remove stains and to ensuring adequate domestic staffing hours The person registered must maintain adequate minimum staffing levels at all times. (Previous timescale of 13.09.04 not met) The person registered must keep an accurate record of the staff working at the home, the hours they work and their role. 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.(Previous timescale of 13.09.04 not met) The person registered must ensure that competent staff are on duty at all times. This refers to staff working excessive hours.(Previous timescale of 13.09.04 not met) The person registered must evidence robust recruitment 2005 7 May 2005 1 July 2005 1 June 2005 7 May 2005 7 May 2005 7 May 2005 7 May 2005 7 May 2005 Page 24 Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 2 14. 30 18( c ) 15. 31 8(1) & 9(b) 26 16. 31 17. 35 17(2)c Schedule 4 18(2) 18. 36 procedures (Previous timescale of 15.8.03 not met) and make the required records relating to staff available for inspection.(Previous timescale of 13.9.04 not met) The person registered must ensure that staff at the care home undertake appropriate training to the work they perform to ensure the safety of service users and have the necessary skills and expertise to meet the specialist needs of service users. (Previous timescale of 13.09.04 not met) The person registered must evidence effective management of the home.(Previous timescale of 13.09.04 not met) Monthly reports must be undertaken by the registered provider, as required by Regulation. Copies must be sent to the Commission for Social Care Inspection The person registered must ensure that all money or valuables looked after for residents are recorded The person registered must ensure that staff are provided with appropriate supervision 1 July 2005 7 May 2005 1 June 2005 7 May 2005 1 June 2005 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 9 14 15 Good Practice Recommendations A copy of the protocol for As Required (PRN) should be kept with each persons medication administration records Residents should have information on the days menus and the choice to serve themselves if they are able Staff should have more information on and awareness of I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 25 Sycamore Court 4. 5. 20 24 the dietary needs of residents The use of the dining space should be reconsidered to ensure adequate and safe space for residents and staff Bolts should not be used on residents bedroom doors. Keys to the existing locks should be readily available and accessible to residents able to use them, and to staff to use for residents where needed. Sycamore Court I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on Sea 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 I56 S18123 Sycamore Court V226017 070505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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