Inspection on 20/12/05 for Sycamore House

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 House 16/04/09

Sycamore House 23/04/08

Sycamore House 21/11/07

Sycamore House 17/04/07

Sycamore House 26/10/06

Sycamore House 15/06/06

Sycamore House 21/07/05

Sycamore House 23/11/04

Sycamore House 29/04/04

Sycamore House 27/01/04

Sycamore House 16/12/03

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE Sycamore House 2a/2b Havelock Road Tyseley Birmingham West Midlands B11 3RG Lead Inspector Kulwant Ghuman Unannounced Inspection 20th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sycamore House Address 2a/2b Havelock Road Tyseley Birmingham West Midlands B11 3RG 0121 707 4622 0121 707 8172 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) Marblefield Limited Mr Abdool Azad Noorbaccus Care Home 30 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (30) of places Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to provide care for up to 18 service users who are over 65 years of age and up to 12 service users who are over 53 years of age and who had a mental health disorder. Of the 18 service users over 65 years there are 5 named individuals who suffer from dementia and continue to be accommodated at Sycamore House until such time that the home is no longer suitable. No other service users suffering with dementia will be admitted to the home. 21st July 2005 Date of last inspection Brief Description of the Service: Sycamore House offers residential care for up to 30 older adults. It caters for a mixed client group, including service users over 65 years of age in need of care due to old age and mental health. The home is not registered to care for service users with dementia. The home has an owner manager who is a registered nurse, although the home does not offer nursing care. The home is situated in a residential street, close to public transport links to the city centre. There are some small local shops within walking distance. The property is an extended and converted building that offers communal lounges and dining space on the ground floor and bedrooms spread over the ground and first floors. No rooms are en-suite and bathing and toilet facilities are shared. The kitchen and laundry facilities are on the ground floor and are not generally accessed by residents. There is a shaft lift connecting ground and first floors on one side of the building only. There is a garden area to the side of the property and parking is on street. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over one day during December 2005. This was the second of the two statutory visits to the home. In order to get a full overview of the home this report should be read in conjunction with the report of the inspection of 21st July 2005. During this inspection a tour of communal areas of the home was carried out, discussions were undertaken with the manager and three of the 22 residents, two resident files were sampled along with some servicing and other care records. What the service does well: What has improved since the last inspection? What they could do better: Care planning documentation in the home needed to be improved in the detail included and in consistency of documentation in the files. There was no evidence of activities or stimulation for the residents who spent most of their time in the home. There was a need for general decoration in several areas of the home. Cleanliness needed to be improved in some areas of the home. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 6 There should be an increased variety in the meals provided. The home had made very little progress on the requirements made at the last inspection. 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 House DS0000016849.V274756.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4,5 There was some information available for residents and their relatives to help them decide whether the home was suitable for their needs, however, there was no information available regarding the fees to be paid or evidence that they were aware of the terms and conditions of residence at the home. The assessment carried out by the home needed to be more detailed to ensure that the residents’ needs could be met by the home. EVIDENCE: The home had made the amendments required to the service user guide and statement of purpose. The files of two residents were sampled, one of a recent admission and one who had been there some months. One of the files included a statement of terms and conditions but it had not been completed, the other did not have one on the file. It could not be determined therefore if the resident or their representative was aware of the terms and conditions of residence in the home including the fees to be paid. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 9 There was no recorded evidence that residents had visited the home prior to admission to the home. The inspectors were informed that for one of the residents a relative had visited the home before the resident was admitted. For one resident there was evidence that the manager had been to assess them however, the records of this assessment were not detailed and did not show how it was decided that the resident’s needs could be met by the home. One of the residents had been admitted out of category as they had been diagnosed as having dementia even though there was a good assessment provided by the placing authorities. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 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 the following standard(s): 7,8,10 The care planning and risk assessment processes were not detailed enough to enable residents’ needs to be met. The records did not show that the residents’ health care needs were being met in all cases. There were some concerns about whether the residents were treated with respect and their privacy upheld. EVIDENCE: There was no care plan available on the file sampled belonging to a resident who had been at the home some months. At the previous inspection this resident’s file had been sampled and a brief care plan had been seen. This was no longer on the file and no new care plan was in place. For the other file there was an assessment/care plan in place. The assessment identified some of the areas where assistance was required but did not clearly identify in the services to be provided how this assistance was to be given. Examination of the records indicated that there were risks associated with either the residents’ behaviours or needs. For example there was evidence that one of the residents could try and get out of the windows and was a Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 11 smoker. There were no risk assessments and strategies for managing these issues in place. Not all the files had a nutritional or tissue viability assessment in place. There was some evidence in the daily records that indicated that residents were seen by the GP or practice nurse however, it was not possible to track why they were seen, what the medication was for and whether there was any follow up where this had been indicated as being needed. The inspectors were concerned to find that the care plan did not mention that one of the residents was having fits or how they were being managed. The daily records indicated that fits were occurring regularly and sometimes for prolonged periods of time however, the records did not indicate what actions the staff had taken. In discussion with the manager it was noted that he was not aware of all the occasions on which the fits had occurred. There was recorded evidence that the dentist and optician saw the residents. The manager stated that screening had not been provided in shared rooms, the shower on the ground floor had a shower curtain in place, and the mortice locks had been changed on bedroom doors. Other indicators that residents privacy and dignity were not fully observed were a list of residents who needed to be toileted, a note to staff asking them not to write on radiator covers and residents arms and for night staff to ensure that residents had their underclothes on in the morning. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 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 the following standard(s): 12,15 Residents appeared to be generally happy with the home. Some residents went out alone but there was no evidence of any stimulation for those residents spending the majority of their time in the home. Residents stated that meals were repetitive and this was confirmed by the documentation seen. EVIDENCE: Two of the residents spoken with stated they were happy at the home; one was not so happy and would prefer to go home. Some residents were able to go out unescorted to the shops, library and walking the dogs. One resident who used to go to a day centre was no longer able to attend that centre and the home had been unable to find an alternative centre to attend. The manager stated that the residents were not interested in playing games and there were no activities taking place in the home. There was some involvement from the local church providing communion for some of the residents. The telephone used by residents was kept in the office. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 13 Residents stated that the menus were repetitive but that food was available late in the evening if required. Documentation available in the home indicated that the menus needed to be more varied. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21,22,25,26 Generally the home provided comfortable surroundings for the residents but several areas of the home needed to be redecorated and investment put into the home to ensure that the bedroom furniture is fit for purpose. Some aspects of cleanliness needed to be improved in the home. EVIDENCE: The home is an extended and adapted property. The home was in need of general re-decoration throughout. Issues identified at the last inspection had not been attended to including the lounge and corridors. All parts of the ground floor were connected but the first floor consisted of two separate areas, only one side of which was accessible via the shaft lift. The other side of the home was therefore only accessible to residents with unimpaired mobility. The size and layout of the premises made safe observation of the residents who were not in the lounges problematic. Removal of the carpet on the ground floor had meant that the problem experienced by the home in managing the offensive odours on the ground floor Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 16 in the past has been reduced although there was a slight odour on entering the home at the time of this inspection. There were two functional lounges that residents could sit in and a conservatory where residents who chose to smoke could sit. The lounge areas had fluorescent lighting and this needed to be replaced with more domestic type lighting. In the second lounge two of the lights did not have diffusers on them. Two of the chairs in the main lounge needed to be removed as the covering was torn and could cut or catch residents’ skin. There was access into the garden via a step down from the conservatory. The slabs of concrete forming the step were not very stable and needed to be made safe. The conservatory was found to be cold at the time of the inspection and the manager needed to ensure that there was adequate heating in this area for the residents who smoked. There were a number of bathing facilities in the home. There were assisted bathing facilities but both of these were located on one side of the building. The bathing facilities on the older part of the building were in need of decoration, particularly the ground floor bathroom where the wallpaper was peeling away from the wall at the time of the last inspection. This bathroom was not seen at the time of this inspection however; the manager had stated that decoration had not taken place in the home. The showers throughout the building did not have the temperature of the hot water restricted to 43 degrees centigrade and could pose a risk to the residents. This issue had been raised at the previous inspection. There were screws protruding from a wall panel in the shower room on the ground floor. There were a number of adaptations in the home including passenger lift, assisted bathing facilities, emergency nurse call system and wooden ramp to assist entry into the home. There were no mobile hoists in the home. Bedrooms were not inspected on this occasion. The manager stated that most of the broken furniture had been replaced except the wardrobe doors. Replacement of the wardrobes would mean a refurbishment of the whole bedroom. There was central heating throughout the home and the residents could control the temperatures, window openings were appropriately restricted and accessible to the residents. The opening of the window in the shower room on the first floor appeared to be too large. Radiators and hot pipes had been covered in the old part of the building. The manager needed to risk assess the other radiators that were said to be low surface temperatures but which were found to be quite hot at the top in the shower room on the ground floor. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 17 The cleanliness in the home needed to be improved. Attempts had been made to remove dust from the light shades but this had not been successful as observed on the light shade in the stairs in the old part of the building. The flooring in the toilets and showers needed to be thoroughly scrubbed clean. The bath hoist chair and shower chairs were very dirty underneath the seat. The sluice needed to be serviced. One of the toilets on the ground floor was locked and out of order at the time of the inspection. The privacy curtain and light cord were very dirty in the toilet by the main lounge. There was no soap in one toilet and a tablet of soap in one of the shower rooms. Solid soap should be returned to the residents bedroom after a bath or shower and liquid soap provided for hand washing to minimise the risk of cross infections. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 There were adequate numbers of staff on duty at the home however the staff had not updated mandatory training and this could leave them and the residents at risk of injury. EVIDENCE: The staffing rota indicated that the deputy manager was in the home five days a week and there were two carers on duty with her. In the evening there were three carers on duty and two staff during the night. Examination of the rota indicated that the office assistant was helping the care staff at the weekends. Discussions with the manager indicated that he had not had any induction into the care role and another CRB was needed, as the role he was undertaking was different. The manager stated that he would be taken off the rota, as new staff would be coming into the home from India in January/February. There had been no new staff recruited to the home since the last inspection. Six of the fourteen staff had achieved NVQ level 2 or 3. The other staff had been enrolled on NVQ training. The manager stated that he had had problems getting assessors to assess the NVQ training. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 19 The shortage of assessors had meant that the staff had not been able to complete the Safe Handling of Medicines training either. Staff had not updated mandatory training apart from food hygiene that had been undertaken by the cook, manager and deputy manager. The inspectors were particularly concerned that the staff had not undertaken moving and handling training as the records sampled had indicated that staff were assisting residents off the floor when they had fallen. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 The management of the home needed to be improved so that the requirements made at the last inspection were attended to and the residents lived in a home where their health and safety was safeguarded. EVIDENCE: The registered manager had been managing the home for several years. He was undertaking the registered managers award but was having difficulties in finding an assessor. There had been some improvements in the organisation of the records but the care planning documentation needed to be further developed and staff training needed to be improved. Staff were not receiving supervision. There was no system in place to review and improve the service provided at the home. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 21 There were some issues of health and safety that needed to be improved including the provision of risk assessments and strategies for managing risks for residents, fire risk assessment, the hot water being delivered from the showers restricted to 43 degrees, fire alarm tests to be carried out weekly (even in the absence of the deputy manager), fire drill to be carried out every six months, the gas service was overdue and it was not clear whether the works required following the service of the lift had been undertaken. Issues of infection control needed to be addressed via cleaning of the bath hoist and shower chair, cleaning of light pull cords and privacy curtains in toilets and scrubbing of the tiled floors in showers and toilets. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 1 1 1 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 2 3 X X 2 2 STAFFING Standard No Score 27 3 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X 1 X 1 Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 24 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 OP2 Regulation 5(1) Requirement The registered person must ensure that the residents are made aware of the conditions of residence and that the contracts are appropriately completed at the time of entry to the home or when new contracts are put in place. (Previous timescales of 01/04/05 and 01/10/05 not met.) The registered person must ensure that pre-admission visits and assessments are carried out wherever possible. (Previous timescale of 01/04/05 and 01/09/05 not met.) Timescale for action 21/01/06 2. OP5 14(1) 14/01/06 3. OP7 15(1) 4. OP7 13(4) A record of the pre-admission visit and pre-admission assessments must be kept. (Previous timescale of 01/09/05 not met.) 01/02/06 The registered person must ensure that residents’ plans are comprehensive and provide sufficient detail to enable care staff to meet the assessed needs of residents. (Previous timescale of 14/06/04 and 01/10/05 not met) The registered person must 14/01/06 ensure that risk assessments for residents cover all identified areas of risk and include DS0000016849.V274756.R01.S.doc Version 5.1 Page 25 Sycamore House 5. OP7 15(2)(b) 6. OP7 15(1) 7. OP8 12(1)(a) 8. OP8 12(1)(a) 9. 10. OP8 OP9 12(1)(a) 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) 14. OP10 12(4)(a) strategies for dealing with them. (Previous timescale of 14/06/04 and 01/10/05 not met) The registered person must ensure that residents’ plans are reviewed on a monthly basis and updated as required. (Previous timescale of 14/07/04 and 01/10/05not met) Residents must be involved in drawing up the care plan and in any reviews. (Previous timescale of 01/10/05 not met.) The registered person must ensure that there is a nutritional assessment in place for all residents. (Previous timescale of 14/06/04 and 01/10/05 not met) There must be a tissue viability assessment in place for all residents. (Previous timescale of 01/10/05 not met.) Records must enable a tracking of medical visits to residents and the reasons for the visits. The tablets dispensed, recorded as given and remaining in the boxes must tally. (Compliance not assessed at this inspection.) The registered person must ensure that there is a sheet in place recording the signatures of all staff handling medicines. (Previous timescale of 14.6.04 not met. Compliance not assessed at this inspection.) The registered person must ensure that all staff handling medicines undertake accredited training in the safe handling of medicines. (Previous timescale of 14/06/04 and 01/12/05 not met) There must be a system in place to indicate if a different number of tablets have been given than directed by the GP. (Compliance not assessed.) The registered person must DS0000016849.V274756.R01.S.doc 01/02/06 01/02/06 01/02/06 01/02/06 14/01/06 01/08/05 01/09/05 01/04/06 01/09/05 01/02/06 Page 26 Sycamore House Version 5.1 15. OP10 12(4)(a) 16. OP12 16(2)(m) & (n) 17. OP12 12(1)(a) 18. 19. OP15 OP18 16(2)(i) 13(6) 20. OP19 23(2)(d) 21. OP20 23(2)(p) ensure that there are screens in place in shared rooms. (Previous timescale of 23/11/04 and 01/08/05 not met.) The registered person must ensure that residents are treated with respect and their dignity and privacy maintained. The registered person must ensure that service users are consulted regarding activities and social interests and make arrangements to enable them to engage in activities in the home and the local community. (Previous timescale of 01/04/05 and 01/10/05 not met.) Staff must include in daily records any activities undertaken to show that the residents social needs are being met. (Previous timescale of 01/09/05 not met.) The registered person must ensure that the menus are varied. The registered person must ensure that staff receive training in the prevention of adult abuse and the duties of staff in the event of an allegation or suspicion of abuse. (Previous timescale of 01/04/05 and 01/11/05 not met.) The registered person must ensure that any areas including lounges, bathrooms, bedrooms and corridors, requiring redecoration are dealt with during the refurbishment programme and water damaged ceiling tiles must be replaced. (Previous timescale of 01/08/04 and 01/11/05 not met) The fluorescent lighting in the lounge must be replaced with lighting more domestic in nature. (Previous timescale of 01/02/05 and 01/11/05 not met.) DS0000016849.V274756.R01.S.doc 14/01/06 01/03/06 01/02/06 01/02/06 01/03/06 01/04/06 01/04/06 Sycamore House Version 5.1 Page 27 22. 23. 24. 25. OP20 OP20 OP21 OP21 23(2)(p) 16(2)(c) 13(4)(a) 23(2)(b) 26. 27. OP21 OP21 23(2)(b) 13(4)(c) 28. OP24 16(2)(c) 29. OP25 13(4)(c) 30. 31. 32. OP25 OP25 OP26 23(2)(p) 13(4)(c) 13(3) Missing diffusers on fluorescent lights must be replaced. Torn chairs in the lounges must be taken out of use. The step into the garden must be made safe. (Previous timescale of 21/08/05 not met.) The registered person must ensure that the missing tiling in the toilet on the ground floor are replaced. (Previous timescale of 01/02/05 and 01/09/05 not met.) The toilet by the second lounge must be repaired. The registered person must ensure that the temperature of hot water at the point of delivery is restricted to 43 degrees in all showers throughout the home. (Previous timescale of 17/01/04 and 01/09/05 not met) The registered person must ensure that all bedroom furniture is repaired. (Previous timescale of 14/06/04 and 01/10/05 not met) The registered person must ensure that all low surface temperature radiators are risk assessed and guarded where hot. Heating must be provided in the conservatory. The registered person must ensure that window openings are restricted to 4 inches. The bath hoist chair, shower chairs and floor tiles must be thoroughly cleaned. Bars of soap must be removed from communal bathing and toilet facilities. (Previous timescale of 14/08/05 not met.) 14/01/06 14/01/06 01/04/06 01/04/05 07/01/06 14/01/06 01/04/05 01/04/06 14/01/06 14/01/06 14/01/06 Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 28 The mechanical sluice facility must be serviced and staff encouraged to use it. The light pull cords and curtains on toilet doors must be cleaned. At the week ends where there is no cleaner or cook on duty the rota must indicate who is responsible for cleaning and cooking. (Previous timescale of 01/09/05 not met.) The registered manager must ensure that a minimum of 50 of staff are trained to NVQ level 2. All staff must undertake mandatory training in first aid, food hygiene, health and safety, moving and handling and infection control. The registered person must ensure that there is a system in place in the home for reviewing and improving the quality of care provided. (Previous timescale of 01/12/05 not met.) The registered person must ensure that all staff are supervised, with written records, for a minimum of 6 sessions in any 12-month period. (Previous timescales 01/04/04 not met) The registered person must ensure that the premises risk assessment covers all identified risks. (Previous timescale given 01/02/05 and 01/09/05. Compliance not checked at this visit as it was unknown which file it was in.) The registered person must ensure that the protruding screws in the shower room on the ground floor are made safe. Fire alarm tests must be carried out weekly even during the deputy manager’s holidays. DS0000016849.V274756.R01.S.doc 33. OP27 12(1)(a) 14/01/06 34. OP28 18(1)(a) 01/04/06 35. OP30 18(1)(c) (i) 01/04/06 36. OP33 24(1) 01/04/06 37. OP36 18(2) 01/04/06 38. OP38 13(4) 01/04/06 39. OP38 13(4)(c) 14/01/06 40. OP38 23(4)(c) (v) 14/01/06 Sycamore House Version 5.1 Page 29 41. 42. OP38 OP38 23(4)(d) 23(2)(c) Fire drills must be carried out every six months. Evidence that the gas equipment has been serviced must be forwarded to the CSCI. 01/02/06 14/01/06 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. Refer to Standard OP18 OP18 Good Practice Recommendations The registered manager should develop a procedure for staff to follow in the event of an incident or allegation of abuse. The multi-agency guidelines on adult protection should be made accessible to staff. Sycamore House DS0000016849.V274756.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000016849.V274756.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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