Inspection on 08/08/07 for Sycamore Heights

This inspection was carried out on 8th August 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore Heights 24/07/08

Sycamore Heights 28/09/06

Sycamore Heights 28/02/06

Sycamore Heights 28/02/05

Sycamore Heights 13/07/04

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

CARE HOME ADULTS 18-65 Sycamore Heights 89-91 Priest Avenue Canterbury Kent CT2 8PP Lead Inspector Sandra Crosby Key Unannounced Inspection 8th August 2007 09:00 Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 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 Heights DS0000023712.V345927.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 Adults 18-65. 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 Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Heights Address 89-91 Priest Avenue Canterbury Kent CT2 8PP 01227 471074 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) priestavenue@mcch.org.uk MCCH Society Limited Post Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2006 Brief Description of the Service: Sycamore Heights is registered to provide care for up to five people with a learning disability, though the intention is to restrict this to four. The registration certificate will require amendment to reflect this, in due course. The registered provider is Maidstone Community Care Housing Society Ltd (hereafter referred to as MCCH), which is a registered charity / industrial and provident society. The property itself is separately owned by Sanctuary Housing Association, which is registered with the Housing Corporation under Section 1 of the Housing Act 1996. MCCH is effectively acting as an agent for Sanctuary Housing Association for the shared tenancy agreements it has with the residents at Sycamore Heights, and shares a key objective with it, specifically the provision of housing accommodation with care and support. The property comprises two adjoining semi-detached two-storey houses, which have been converted into one. Although each has retained its original front door, a notice directs all visitors to Number 81. There are currently five single bedrooms. There is a choice of communal areas, including a visitor’s room. There is a dedicated office for staff use. The home is not suitable for people with significant mobility impairment without substantial adaptation. There are gardens to the front and rear and unrestricted kerb-side parking at the front plus garage space for two vehicles. There is also a bus stop within close walking distance. The home is staffed on a 24-hour basis, and MCCH provides a Visiting People Team to ensure activities do not have to be cancelled for want of available staffing. The current fees for the service at the time of the visit were not available by the time of the issue of this draft, because of the complexities of the block contracting arrangements. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. There is currently no e-mail address for this home. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection visit was unannounced and carried out on Wednesday 08 August 2007 between 08.45 and 13.30. The Inspector spoke mainly with the Acting Manager, the two support workers who were on duty and two of the service users. Various records were viewed and an accompanied tour of some areas of the premises was undertaken. The Acting Manager who assisted with the inspection process manages another MCCH home and is currently working at Sycamore Heights three days a week until the newly appointed manager returns from sick leave. The home has had three changes of manager in the last year and it was indicated that during this time the home had not always maintained sufficient staffing levels and that this may have affected the normal routines of the service users and staff at the home. The AQAA documentation that homes are required to complete was only recently sent to the home, so information that would normally be used to inform the inspection process was not available to be included in this inspection report. Due to the short notice given to plan the visit, although Service User Surveys and Relative Surveys have been sent out, only one has been received to date and this provides a mixture of positive and negative ticks to the questions asked. What the service does well: The location of this home is generally suitable for its stated purpose, convenient for visitors and the property is being maintained to a very satisfactory standard. The social, health and personal care needs of the residents are mainly well addressed, when staffing levels are sufficient. Overall, the Company works to achieve a high level of compliance with the National Minimum Standards throughout the inspection process. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were inspected at this visit Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide may not provide prospective residents with the information they need to make a decision about moving into the home. The MCCH can show good evidence of pre-admission and post admission assessments to ensure the home can meet prospective residents’ needs. EVIDENCE: The home maintains weighty master copies of the Statement of Purpose / Service User Guide source material, the contents of which can be extracted and copied as required. Extracts from both documents are already readily available in easy read text and illustrated with photographs or diagrams / symbols. It was indicated that staff would look for opportunities to explain the detail. The Inspector was told that work is ongoing to update the Statement of Purpose and Service User Guide for the home, to provide documentation in a form that residents would be better able to understand. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 9 Three of the four current residents were admitted long before the emergence of the Care Standards Act 2000 and the National Minimum Standards (the most recent of which was in 1991), so this aspect of the service could only be assessed in respect of the fourth. There was good evidence of professionals’ assessments of the most recent resident’s needs prior to his transfer to this home (i.e. in his previous residential placement), and of some accessible documentation to assist his understanding of the care planning process. This it was indicated had been properly underpinned by a range of risk assessments, and followed up with review after his admission. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care which residents receive, is based upon their individual needs. The principles of respect, dignity and privacy are put into practice. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 11 EVIDENCE: The format of the service user plans used by the home is a comprehensive person-centred one, clearly designed to address the health and social care needs of the residents. It was indicated that due to the management and staff changes at the home over the last year that although the documentation contained all components as required by regulation, there was information discussed that should have been recorded and was not, and the reviews were not always regularly completed. The files need reviewing and old information filing in order for the documentation to be more easily managed. It was found that information had been recorded in the communication book that should have been recorded in the service user plans, and following discussion with the Acting Manager it was agreed that this practice would be stopped. The home maintains a range of charts and programmes of activities as well as personal and healthcare needs, including practical guidelines on behaviour management. This is all usefully underpinned by risk assessments to safeguard residents in their daily routines. There are risk assessments to cover the residents as individuals, their activities and their environment (on and off site), to maximise their capacity to be independent. The residents were observed being supported in their daily routines, and observed interactions between staff and the residents were appropriately familiar and respectful during this visit. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16 and 17 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. When staffing levels are appropriate Residents are able to choose their life style, social activities and to keep in touch with family and friends. Residents receive a healthy and varied diet according to their requirements and choice. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 13 EVIDENCE: Abilities, activities and personal preferences are properly identified as part of the admission process and are subject to day-to-day consultation and review thereon. However, it was indicated that at times there has been insufficient staffing levels at the home and this may have had a detrimental effect in that the staff do not always have the scope to support residents to exercise their choices as they have been used to. Examples of activities include: shopping, visits to the seaside, cafes and pubs; swimming, musical events, bowling, horse riding i.e. mainstream community resources not confined to or identifiable with disabilities. The home also offers support to residents in maintaining their practical life skills – self-care, light laundry duties, use of the kitchen and other household chores, these activities being underpinned by a comprehensive range of risk assessments. Previously one resident has been supported to move onto more independent living. Families and friends are welcomed, and their involvement in the care planning processes is encouraged. There are open visiting arrangements, and previous feedback from relatives confirmed that they were always made welcome. Dietary needs and preferences are also established as part of the care planning process, and confirmed or amended on a day-to-day basis. Each resident is supported to choose a meal each week, and to help shop and prepare for it, as far as they are able or willing. The home is committed to healthy eating, and some fresh fruit and vegetables were in evidence (though another shopping trip was due). The dining room is a congenial setting and staff eat with the residents. Residents can choose where and when to eat. Records are kept of the options actually chosen by individuals, as required. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s 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. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is offered in a way to protect resident’s privacy and dignity and promote independence. The health needs of residents are met, and the medication system at this home is mainly well managed promoting good health. EVIDENCE: The home’s care planning and risk assessment processes assess the extent to which each resident requires assistance with their own personal care, and their choice and control are effectively promoted by staff as far as possible. All the bedrooms are single occupancy and there are enough toilet and personal care facilities to generally guarantee their availability and privacy. Staff are available on a 24-hour basis to support service users. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 15 The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician etc. Records have been set up to document access to a range of other healthcare professionals, should that become appropriate. All the four residents have the same GP practice, which has demonstrated specialist knowledge, so that the residents healthcare needs can be properly met. There was discussion in relation to a health care matter that required attention, it was indicated that action had now been taken, although this was not recorded in the service user plan but was seen in the staff communication book. It may be that the home needed to seek professional advice sooner in relation to this issue. The home uses the Boots Monitored Dosage System and the arrangements for their storage, administration and recording were judged generally satisfactory. However it was noted that hand written changes had been made with no information as to who had authorised the change, there was also a few gaps seen in the record keeping. The home maintains information on the medication prescribed (including likely side effects), medical alerts and other advice, along with risk assessments – all of which is judged good practice. The home keeps a copy of the Royal Pharmaceutical Society Guidance to underpin practice. Staff confirmed ongoing investments in their training. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place, and there are policies and procedures in place to protect residents from abuse, neglect and selfharm. EVIDENCE: MCCH has its own policies on complaints and whistle blowing, which are generally compliant with this standard. Two concerns recorded in the last two months in one service users plan indicated that they had been unable to go out due to ‘lack of staff’. It was indicated from this inspection visit that the home has experienced difficulty over the last year in maintaining appropriate staffing levels at times. MCCH also has its own policy on safeguarding adults, and there is an accessible version for the residents and staff confirmed their commitment to challenge and report any incidents, should they occur. The home also has a copy of the Kent and Medway Multi Disciplinary protocol, to ensure a timely and co-ordinated response. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,26,27,28,29 and 30 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical layout of the Home enables service users to live in a generally well-maintained and comfortable environment, which promotes independence. EVIDENCE: The location and layout of this home are judged generally suitable for its registered purpose – though some concerns have been expressed for the security of the property and site, particularly when there are lone workers. The Acting Manager said that the company were looking at this issue. The furniture is domestic in style, and comfortable. Homely touches include one service users artwork. There are some grab rails (which were installed for previous residents) but adaptations are not currently warranted. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 18 The communal areas of this home are spacious and most windows offer pleasant views of the gardens. The grounds are well maintained, although work needs to be undertaken in the front garden. There are focal areas in the rear garden to draw attention to, including a timber summerhouse. The seating in the dining and lounge areas is appropriate for the residents who use them. The kitchen is light, airy, clean and well maintained. There is a communal bathroom / WC on the ground floor of No.89 and a communal shower / WC on the ground floor of No.81 – plus a communal WC on the first floor of each property i.e. reasonably accessible to bedrooms and communal areas. Each facility was clean and generally well maintained. All the bedrooms in this home are single occupancy and all were clean, tidy and personalised. In terms of furniture and fittings, where they did not fully comply with the provisions of the National Minimum Standards, their nonprovision was justified. On the day of this visit all areas of the home were judged clean, tidy and well maintained. Comfortable temperatures and lighting levels were maintained throughout and all maintenance records inspected were up to date and systematically presented. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are not always available to assist residents. Staff are appropriate people and in the main suitably skilled. EVIDENCE: At the time of the inspection visit that there were two support workers on duty, however the Inspector was told that there would only be one support worker on duty that afternoon. Arrangements were made to address this issue. It was previously reported that MCCH has scaled down the number of staffing hours since the last manager left, which means the home is becoming more reliant on lone working shifts (including relief bank staff) – so their scope to support residents with competing interests (on and off site) can fluctuate on a day-to-day basis. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 20 This is not judged an ideal arrangement, while the home remains registered under the Care Standards Act, and was raised as an issue at the last inspection and at this inspection visit, particularly as support staff are tasked to do all the cooking and cleaning. No staff files were viewed as the Acting Manager said that there had been no new members of staff, however it is known that the Company operates a thorough recruitment system, and full compliance with regulations has been evidenced at previous inspections. The Acting Manager stated that staff receive supervision with written records kept, and it has been previously reported that staff who met with the Inspector confirmed that they had supervision sessions, usually monthly (i.e. in excess of the National Minimum Standard) and that these sessions usefully covered all those elements prescribed by the standard: specifically, the translation of the home’s philosophy and aims into work with individuals; monitoring or work with individual residents; support and professional guidance; and the identification of training and development needs. Records and staff also confirmed a sound level of investment in training. The Acting Manager was requested to complete and updated staff training matrix for the staff at the home. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,38,39,40,41,42 and 43 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents may not currently benefit from a well run home due to the management of the service. Resident’s rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of residents are mainly promoted and protected. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has had a number of management changes over the last year, and it is indicated that this has had an affect on staff morale, together with the indication of at times insufficient staffing levels. Once the home has a manager in place the processes for managing the home will be generally accessible, transparent and there are clear lines of accountability within MCCH. The previous report stated that the organisation as a whole maintains a proactive overview of organisational issues. MCCH produced an Implementation Manual, listing 18 goals based on its Modernisation Strategy Document “Creating Community” which was based on staff conferences in October and November 2002. Each house was then set goals, which it was tasked to provide implementation plans and to report back on progress. This is judged an inclusive approach – although there were no progress reports for the current year available for inspection. MCCH also has a proactive approach to quality assurance, which places its stakeholders at the centre. See section on “Individual Needs and Choices” for details on the way this principle is being applied on a daily basis, and there been satisfaction questionnaires. MCCH has a range of policies governing health and safety matters, which are underpinned by a robust level of investment in training. Staff are required to sign checklists as evidence of their compliance with health and safety related ones. All maintenance records seen were up to date and systematically stored. The home has the requisite insurance cover arrangements. The Acting Manager was requested to check the findings of the current electrical certificate for the home. The Acting Manager said that regular Regulation 26 visits were being undertaken with written records kept. At the time of the visit the Inspector was only able to evidence hard copies of these up to April 07. A format for these visits is currently being introduced, and this will provide information that will be able to be used in the AQAA documentation that homes are required to complete once a year. The residents are all white British and both genders are represented. The staff group is also predominantly white British but shows an appropriate gender split as well as some cultural diversity – indicating a commitment to Equal Opportunities in the organisation. Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 2 3 3 2 2 1 Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 24 NO 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 YA6 Regulation 15 Timescale for action The registered manager 31/12/07 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 Action to be taken to put the service user plans in order and for all appropriate information to be recorded in the individual service user plans 2. YA19 12(1)(a) The registered person ensures 31/08/07 that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them The registered person shall make 10/08/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home Requirement 3. YA20 13(2) Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 25 4. YA22 22 Complaints Procedures. 31/08/07 References to the Commission’s old title will require updating, and prospective complainants should have contact details for their local Commission office rather than its Head Office. Original timeframe - 31/03/06 – 31/10/06 The premises are kept clean, 30/09/07 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. Provide fly screens to kitchen windows or an insectocutor in order to prevent the spread of infection in the food preparation area Original timeframe - 30/06/06, 30/11/06 5. YA30 16 6. YA33 18(1) The home has an effective staff 31/08/07 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 Sycamore Heights DS0000023712.V345927.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. 2. 3. Refer to Standard YA28 YA33 YA24 Good Practice Recommendations The staff sleep-in room should be redecorated MCCH should consider employing ancillary staff Consideration should be given to improving the security of the property and site, particularly where staff are required to work on their own – this is being looked into Sycamore Heights DS0000023712.V345927.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Heights DS0000023712.V345927.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!