Inspection on 28/02/05 for Sycamore Heights

Care Homes For Adults (18 ­ 65)Sycamore Heights89-91 Priest Avenue Canterbury Kent CT2 8PPUnannounced Inspection28th February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Sycamore Heights Address 89-91 Priest Avenue, Canterbury, Kent, CT2 8PP Email address Tel No: 01622 769100 Fax No:Name of registered provider(s)/company (if applicable) MCCH Society Limited Name of registered manager (if applicable) Mr Alan John Jones Type of registration Care Home No. of places registered (if applicable) 6Category(ies) of registration, with (number of places) Learning disability (6) Registration number H050000568 Date first registeredDate of latest registration certificate 19th August 2003Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply? Date of last inspectionYES NO 14/02/04 If Yes refer to Part CSycamore HeightsPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 328th February 2005 12:15 am Wendy GabrielID Code098219Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionSycamore HeightsPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSycamore HeightsPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Sycamore Heights. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Sycamore HeightsPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Sycamore Heights is registered to provide care for up to six people with a learning disability. The home is a pair of semi-detached properties that have been converted into one house. There are six single bedrooms. Two bedrooms are eventually to be converted into an office and a private room for residents and their visitors. The house has gardens to the front and rear and there is parking in the road to the front of the property. There are currently 11 members of staff employed and 4 of these are to transfer to a supported living scheme within the next month. The owning company, MCCH, also provides a `Visiting peoples team who are on call to the homes within the company to ensure activities are undertaken if any home is temporarily short staffed. The team is comprised of staff employed by the company and includes a member of staff from each of the homes within the company. Two elderly Service Users are due to transfer to another more suitable environment and this will alleviate the previously assessed high dependency needs. The Registered Manager confirmed that the maximum number of Service Users in the home would then remain at four.Sycamore HeightsPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The Inspector carried out an unannounced inspection at 12.15 and was pleased to note that the Service Users were occupied in various activities prior to starting their lunch. There were six Service Users in the home that day as several out of home activities had been cancelled due to the severe weather conditions. There were three support workers on duty including a senior. The Registered Manager who was out of the home on homes business returned later that lunchtime. Following discussions at the previous inspection, two residents with age related needs were due to be moved to more suitable accommodation within the following three weeks. Evidence of this being a planned move was seen in reviews including the Community Psychiatric Nurse and Canterbury District Disability Team. Requirements made at the previous inspection indicated that the home was to ensure that the premises, facilities and aims and objectives met the needs of the Service Users especially in regard to two elderly residents. With the planned departure of the two elderly Service Users to more suitable accommodation, this standard has been met. A further recommendation made at the previous inspection was for the home to consider incorporating into assessments and contracts the circumstances of the termination of the accommodation and a strategy to deal with ageing Service Users. The Registered Owner stated that discussion had taken place but no changes had yet been decided on. He agreed to write a suitable policy detailing the above in respect of Sycamore Heights to be added to the relevant documents. The Registered Manager has completed the Registered Managers award and was awaiting the outcome at the time of the inspection. He has also completed his NVQ Assessors award and is expecting to complete the NVQ4 in care by April 2005.Sycamore HeightsPage 6 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2,3,4,5,6, The home needs to consider incorporating within its initial assessment of a prospective resident and in any contract that determines the circumstances of the termination of the accommodation, and a clear strategy to deal with them growing older. Consideration of this needs to be clearly documented in order that the individual service plan does not drift into an inequitable situation and the home adaptations being inappropriate for the residents care needs.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Sycamore HeightsPage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 2 13(2) 13(4)(c) YA2020 YA4242 Medication administration records are to be completed where required. Windows to be assessed for restrictors. Immediate. 31/03/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 YA4141 YA30 Ensure all records are signed and dated. Toilet in bathroom is to have lime scale removed.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Sycamore HeightsPage 8 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES NA NA NA NO NO YES NO YES YES NA NA NA YES NA YES 3 X X NA NA YES YES 11 X 28/02/05 12.15 3Sycamore HeightsPage 9 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Sycamore HeightsPage 10 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Standard 1 was not inspected at this time. x Standard met? 0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 2 Key findings/Evidence Standard met? Although this standard was not inspected; the Inspector discussed with the Registered Manager, the recommendation made at the previous inspection to include a strategy to deal with Service Users growing older. The Registered Manager agreed to write a suitable policy to be added to relevant recorded material.Sycamore HeightsPage 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? As noted in the inspection findings, the home will now more easily be able to meet the assessed needs of the Service Users when the elderly residents no longer reside there. Care plans identify aims and objectives and strategies to meet the identified needs. See standard 2 for recommendation made.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Standard 4 was not inspected at this time.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? The following was noted at the previous inspection: `The Registered persons provide residents with a statement of the terms and conditions under which accommodation is provided and details of how it can be terminated. The documents did not detail the events of ageing and whether the home would suitably accommodate a resident with care problems associated with growing older. The document contains details of the cost of the accommodation and is reviewed annually. See standard two for recommendation made.Sycamore HeightsPage 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? Care plans should identify social and health needs and record the procedures in place to address these. The care plans in the home are regularly reviewed and are altered when required to suit the changing needs and aims and objectives of the individual Service Users. The staff use the care plans as a useful tool to manage the sometimes, complex behaviours of Service Users. There was evidence in the plans of the input of Health care professionals. The management of two elderly Service Users has been identified and put into practice. As identified in the previous inspection; `the registered persons need to devise a clear strategy plan that is covered in a procedure and policy relating to admission process. The current assessment of this standard indicates no significant changes to the previous inspection. See standard 2 for recommendation made. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The Registered Manager stated that he is currently seeking support from an advocacy scheme to replace the previous scheme. Due to the varied communication skills of the Service Users the staff have one to one meetings with Service Users to ascertain their views on issues about their individual lifestyles.Sycamore HeightsPage 13 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Standard 8 was not inspected at this time.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Individual assessments are made for the safety and welfare of the Service Users. Care plans indicate staff input to meet the varying needs of Service Users. There was recorded evidence of advice given by Health care professionals towards increasing the autonomy of Service Users in their daily lifestyles.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has an up to date renewal of the data protection act. Staff were aware of the importance of confidentiality and spoke to the Inspector with sensitivity about Service Users and recorded information. The room currently used as an office and a sleep in room for night staff can be locked, however, the Registered Manager informed the Inspector that another room is to be used as a main office with further secure provision for confidential information. Staff would then have dedicated lockable space for their personal belongings during their shifts.Sycamore HeightsPage 14 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The Inspector saw written evidence of the support given by a suitable Health care professional towards developing and maintaining living skills identified by the staff for the benefit of one Service User. The Registered Manager informed the Inspector that after the elderly Service Users moved on to more suitable accommodation, he believed the dynamics of the home would change enabling more programmed interaction between staff and Service Users within the registration category for the home.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Care plans include weekly planners for individual Service Users that detail their daily activities. One Service User goes to college once a week and another is due to start college later in the year. As indicated in the Inspectors summary, the owning company, MCCH, also provides a `Visiting peoples team who are on call to the homes within the company to ensure activities are undertaken if any home is temporarily short staffed. The team is comprised of staff employed by the company and includes a member of staff from each of the homes in the company.Sycamore HeightsPage 15 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The `Visiting peoples team undertake to organise events including voluntary community activities, whereby a Service User would be part of a local community scheme accompanied by a support worker. Individual Service Users would be assessed to be eager to join and to be capable of the tasks involved.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Weekly planners indicate the variety of leisure activities the Service Users have access to. Staff confirmed that there were regular one to one trips out of the home with the Service Users and this was also recorded. Care plans indicate various activities including attending Canterbury Gateway Club, where a range of social activities including discos are arranged. The gym, swimming and ten-pin bowling are popular and `music therapy is included on individual activity programmes. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Families and friends are welcomed into the home at reasonable times. Some Service Users will visit their families in their own homes. The Inspector was told that a sitting room is to be created for Service Users to meet with their visitors in private. The Registered Manager and staff informed the Inspector that a Service User had recently been happily reunited with his long lost family. There was evidence of support offered by the family for the well being of the resident.Sycamore HeightsPage 16 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Standard 16 was not inspected at this time.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Menus are varied and offer nutritious and well-balanced meals. Lunch was being prepared at the time of the Inspectors visit and Service Users ate their meal in the warm dining area of the home. The mealtime was unhurried and relaxed. The kitchen was clean and well organised at the time of the inspection. The fridge contained a variety of food. Temperatures are maintained and recorded of both fridge and freezer.Sycamore HeightsPage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Following the previous inspection, the needs of two older Service Users have been reviewed and a planned move over a period of time, to a more suitable environment i.e. with no stairs and with suitable adaptations has been made. The home has involved other agencies such as Health care professionals in establishing the move. There was written evidence of the involvement of the Community Psychiatric Nurse in assessing and planning actions for staff to support and further the abilities of a particular Service User who had presented with complex needs. Staff were observed interacting with Service Users in an appropriate and sensitive manner. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Standard 19 was not inspected at this time. Standard met? XX 0Sycamore HeightsPage 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? No Service Users self-administer their medication. The home completes suitable administration for medication and a senior support worker confirmed that medication is administered directly from its container. The medication administration records showed a couple of gaps where either a signature or a key letter had not been inserted, a medication given as required had not been detailed on the medication administration records. The senior support worker agreed to remind staff to accurately record all details as required. The medication administration records include a photograph of each Service User and details of the medication to be given. The Inspector advised the Registered Manager that the Commission for Social Care Inspection specialist pharmacy Inspector was available to inspect and discuss the homes administration procedure. The Registered Manager said that this would be welcomed at the home as another means of improving their service. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 2 Key findings/Evidence Standard met? The Registered Manager agreed to provide a suitable policy and procedure to be incorporated in the initial assessment of a prospective Service User. Documents are to detail the strategy for coping with ageing Service Users including termination of accommodation.Sycamore HeightsPage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 0 Key findings/Evidence Standard met? Although this standard was not fully inspected, staff who spoke to the Inspector were clear about the complaints procedure and understood the whistle blowing procedure. One member of staff confirmed that he had recently attended adult protection training and was able to clearly indicate the route to take to forward a complaint.Sycamore HeightsPage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? There are procedures in place for maintaining the welfare of Service Users and safeguarding them from abuse. Staff confirmed adult protection training had been undertaken and the Inspector had sight of a yearly training programme (2004-2005) for all staff that included Adult protection and Challenging behaviour. Service Users personal finances go straight to them into their own accounts. All staff have to undertake CRB checks.Sycamore HeightsPage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? At the time of the inspection the home was clean and comfortably maintained. The Registered Manager confirmed that a programme of redecoration had been planned for the coming year including redecorating some bedrooms. The lounge and dining area were being fully utilised at the time of the inspection. The Inspector was unable to inspect accurately the condition of the outside of the premises due to snow covering the grounds and parts of the building.Sycamore HeightsPage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite 4 20 0 0 0 YES NO NO 6 0 0 03 Key findings/Evidence Standard met? An escorted tour was undertaken of most of the premises. One Service User invited the Inspector to look at her bedroom and very happily indicated the personal items including art and craftwork she had made and pictures and photographs that were important to her. There was evidence of soft toys, games, TVs and music equipment in some rooms. Bedrooms seen were well furnished in a homely manner and were lockable although at this inspection it was unclear if Service Users held the keys. As noted in the inspectors findings, two bedrooms are to be vacated and will become respectively; another office and a visitors room for use by Service Users. This will leave the remaining bedrooms with a floor space that meets the requirements of the Commission for Social Care Inspection.Sycamore HeightsPage 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The Inspector saw several of the bedrooms on her accompanied tour of most of the premises. A Service User invited the Inspector to visit her bedroom and was able to see the variety of personal possessions held dear by that resident. Bedrooms seen were individual and well furnished to meet the needs of the Service Users. They were comfortable, cleanly decorated, homely and warm.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? There are four toilets, one bathroom and one shower room in the home. One w.c. in the bathroom was noted to have a discoloration in a lime scale build up, the support worker agreed to ensure this was cleaned adequately. The bathing and toilet facilities were otherwise clean and tidy.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There is a lounge with a dining room leading directly off for use by the Service Users. The proposed provision of a dedicated private sitting room for Service Users to meet their visitors will enhance the standard offered by the home. At the time of the report; the planned transfer of two elderly residents was due and the problem of lack of suitable facilities for coping with an ageing resident as discussed at the previous inspection would therefore be solved. (See standard 2).Sycamore HeightsPage 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Standard 29 was not inspected at this time.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 2 Key findings/Evidence Standard met? At the time of the inspection the home was free from unpleasant odours and was clean and hygienic. As previously discussed a wc is to have lime scale removed. The home operates and records a system for checking water temperatures around the home.Sycamore HeightsPage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Standard 31 was not inspected at this time.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? Although this standard was not fully inspected staff confirmed that NVQs 2 and 3 are promoted and the Registered Manager has achieved the NVQ assessors award. There was a list of varied training courses arranged, including mandatory courses, for staff throughout the year 2004-2005.Sycamore HeightsPage 26 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX0 Key findings/Evidence Standard met? The Registered Manager confirmed there were currently 11 members of staff employed at the home including four who were preparing to transfer to another home within the company MCCH, with the two elderly Service Users who were also transferring.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard 34 was not inspected at this time.Sycamore HeightsPage 27 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard 35 was not inspected at this time.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? Although this standard was not fully inspected a member of staff stated that the Registered Manager was supportive to both staff and Service Users.Sycamore HeightsPage 28 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The Registered Manager confirmed that he had completed the Registered Managers award and was awaiting the final result. He also confirmed that the NVQ4 would be completed by April 2005. The Registered Manager has achieved the NVQ Assessors award.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard 38 was not inspected at this time.Sycamore HeightsPage 29 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? Although the Service Users do not have meetings, the staff hold individual one to one meetings with the Service Users to meet the varying levels of communication. These are documented. There is a key worker system in the home.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Although this standard was not inspected at this time the previous inspection report indicated That; `there is an extensive range of written policies ad procedures designed to assist in the effective administration of the home, and to provide a foundation for the consistent provision of personal care services.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records are maintained to meet this standard.Sycamore HeightsPage 30 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Up to date maintenance certificates for the home were seen to be in order. Windows are to be assessed for restrictors to ensure the safety is promoted of all persons in the home. Monthly visits by a representative of the owning company are well documented.Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met? Standard 43 was not inspected at this time.Sycamore HeightsPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorWendy GabrielSignature Wendy Gabriel Signature SignatureRegulation Manager Brian Wintle-Smith Date 10.03.05Sycamore HeightsPage 32 Public reports It should be noted that all CSCI inspection reports are public documents.Sycamore HeightsPage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 28th February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleSycamore HeightsPage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 8th April 2005 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOSycamore HeightsPage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, of Sycamore Heights, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, of Sycamore Heights, am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: ALAN JONES Alan Jones Registered Manager 07.04.05Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Sycamore HeightsPage 36 Sycamore Heights / 28th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023712.V213546.R01© This report may only be used in its entirety. 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