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Inspection on 21/07/05 for Sycamore House

Also see our care home review for Sycamore House for more information

This inspection was carried out on 21st July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provided care for residents with enduring mental health problems and liaised with supporting professionals including social workers, CPN`s, district nurses, GP and mental health consultants. The medication systems in the home were well managed ensuring that residents receive their medication as required. Several of the residents indicated that they were able to lead a lifestyle that suited their requirements. Some residents went out on a regular basis.

What has improved since the last inspection?

The issue of odour control was better managed in the home due to some carpets having been removed and replaced with flooring that was easier to keep clean leading to a more pleasant communal environment. The flooring in the kitchen and storeroom had also been replaced. Some bedrooms had had new wash hand basins installed. In discussions with the manager he indicated that the home had acknowledged that more time needed to be spent talking to the residents and that this was happening more in the home. He also stated that all the staff had been enrolled on the NVQ 2 training programme and that the next meal of the day was being written up on the board in the dining room so that residents could tell them if they wanted something different than what was on the menu. The inspectors noted that there did not appear to be the same level of staff leaving the home leading to stability in the staff team and continuity of care for the residents.

What the care home could do better:

The home needed to continue to improve the records kept in the home including the care plans for residents, daily recordings, risk assessments and training records for staff. There was no evidence of activities for residents who were unable to go out alone leading to little stimulation for some of the residents. The home needed to be decorated throughout and some of the furniture in the bedrooms was in need of repair or replacement where it could not be repaired. The cleanliness in the home needed to be improved with particular attention being paid to high level cleaning to remove cobwebs and dust and the scrubbing of the floor tiles in the showers, bathrooms and toilet areas. There were a couple of bedrooms where odour control was an issue. The shower chairs and bath hoist chair needed to be thoroughly cleaned and staff reminded not to leave tablets of soap in communal areas of the home. Several of the pull cords to the lights were very dirty and needed to be changed. Recruitment records for staff had improved but not all the required checks were in place when staff took up employment in the home.

CARE HOMES FOR OLDER PEOPLE Sycamore House 2a/2b Havelock Road Tyseley Birmingham B11 3RG Lead Inspector Kulwant Ghuman Announced 21 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sycamore House Address 2a/2b Havelock Road Tyseley Birmingham B11 3RG 0121 707 4622 0121 707 8172 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Marblefield Ltd Mr Noorbaccus Care Home 30 Category(ies) of Mental Disorder (30) registration, with number of places Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 2. 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. 3. No other service users suffering with dementia will be admitted to the home. Date of last inspection 4 May 2005 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 service users. 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 E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over one day during July 2005 by two inspectors. This was the first of the two statutory visits for the year 2005/2006. As part of the preparation for the inspection the manager completed a pre-inspection questionnaire. The inspector had received no questionnaires completed by residents, their representatives or visiting professionals to the home prior to the inspection. On the day of the inspection the inspectors noted that these questionnaires were placed in the entrance area of the home. As part of the inspection the inspectors spoke with 7 of the residents, sampled three staff files, three residents files and other care records, the main meal of the day and carried out a tour of the building. No interviews of staff were carried out during this visit as several staff had been interviewed during a visit in March 2005. What the service does well: What has improved since the last inspection? The issue of odour control was better managed in the home due to some carpets having been removed and replaced with flooring that was easier to keep clean leading to a more pleasant communal environment. The flooring in the kitchen and storeroom had also been replaced. Some bedrooms had had new wash hand basins installed. In discussions with the manager he indicated that the home had acknowledged that more time needed to be spent talking to the residents and that this was happening more in the home. He also stated that all the staff had been enrolled on the NVQ 2 training programme and that the next meal of the day was being written up on the board in the dining room so that residents could tell them if they wanted something different than what was on the menu. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 6 The inspectors noted that there did not appear to be the same level of staff leaving the home leading to stability in the staff team and continuity of care for the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 There was information available to prospective residents enabling them to make informed decisions as to whether they should move into the home or not. There was no evidence of pre-admission visits or assessments that informed the home as to whether the resident’s needs could be met and the home could potentially admit someone whose needs could not be met by the home. EVIDENCE: The statement of purpose and service user guide had been developed and provided prospective residents with information on which to make an informed decision as to whether to move into the home or not. The statement of purpose needed to ensure that it included the actual numbers of staff on duty and information on how complainants could contact the CSCI in order to make a complaint. All the residents in the home had been placed through the local authority and although there was a contract in place between the home and the local authority and one residents file contained a 3rd party funding agreement there were no contracts or terms and conditions in place informing the residents of Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 9 any conditions of residence they would have to comply with, what issues a resident could be asked to leave and what services the fees covered. During discussions the manager indicated that he had been to assess one of the residents recently admitted to the home however, there was no evidence on the file of the information gathered on any of the files sampled. There was no evidence on the files that residents had visited the home prior to being admitted to the home. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care plans and risk assessments were not detailed enough to ensure that the care staff had sufficient detail to meet the residents’ needs and to manage with some consistence the identified risks for residents. Residents’ privacy could be further enhanced by the provision of shower curtains, privacy screens and knocking on bedroom doors at all times. EVIDENCE: The three residents’ files sampled all had a care plan on them but not all had a tissue viability or nutritional assessment in place. The care plans included very little information on them. The care plans needed to be developed so that they were working documents for use by the care staff indicating how the resident’s needs were to be met. For example, documentation for one resident indicated that he was at a very high risk regarding tissue viability and had a pressure sore. The care plan did not indicate how this care need was to be met. Discussion with the manager indicated that this was no longer an issue for the resident but did used to be managed with input from the district nursing services. This also indicated that the care plan and tissue viability assessments had not been updated. There were several residents in the home who would be capable of being involved in the formulation of the care plan according to their needs and wishes. This should be encouraged and facilitated. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 11 Risks identified in either the daily recordings made by staff or the assessments carried out at either the previous placements had not been recorded and strategies for their management were not in place. There were manual handling assessments in place but these were just tick boxes and did not state what and how any assistance required by the residents was to be given by the staff. There was evidence on the residents’ files of their health care needs being met by the GP, practice nurse, district nurses, opticians, dentists and hospital consultants. There were interactions observed during the inspection that indicated that residents were being guided towards a healthier diet by offering fruit instead of biscuits and puddings where this had been indicated as a need. The home used a weekly Nomad monitored dosage system for the administration of medication. The system was well managed with only a couple of minor discrepancies. One of these was caused by the dates being incorrectly transcribed at the top of the MAR chart. The others were caused by inaccuracies in recordings where medicines had been refused by the residents or where painkillers were being administered from boxes and possibly one tablet was being given instead of two leading to a breakdown in the audit trail. All staff had had training in the use of the Nomad system and would be undertaking accredited training as part of the NVQ 2 training. During the tour of the building there were occasions when residents were in bed and the bedroom doors had been opened without knocking first. All the bedroom doors had locks on them however some of them were not suitable (mortice type locks) as they could not be opened in an emergency if the resident left the key in the lock. These locks needed to be replaced. There were no curtain screens available in any of the shared rooms although none of them were doubly occupied at the time of the inspection. There were no shower curtains in the shower rooms leaving the residents exposed and lacking in privacy. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Some residents lived fulfilled lives however others lacked stimulation and activity leading to some boredom. Residents were encouraged to maintain contact with friends and relatives. Residents’ dietary needs were being met. There were some practices in the home that limited the choices and control by the residents over their lives. EVIDENCE: Residents spoken to said they were very happy at the home and were able to have a flexible routine. Residents stated they got up for breakfast and then went back to bed for a little while. Some residents spent a lot of time in their bedroom whilst others spent the majority of their time in the lounges. Some residents were able to go out unescorted and went out as suited their needs. Staff were heard to offer to take out one of the residents but the resident declined to go. Some of the residents played cards and dominoes but these were usually those who had been out during the day and able to decide for themselves. There were some residents who were unable to say what they wanted to do and it appeared that there were no organised activities for them either on a group basis or on an individual basis. The daily records for the residents rarely indicated any activities. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 13 There was a notice in the home that stated that there allocated days for bathing and shaving in the home. For example, ‘all men to be shaved on Wednesday and Sunday’. This would indicate a degree of institutionalisation of routines in the home and the frequency, time and type of shave should be discussed with individual residents and recorded on their care plans. There had been some involvement of the local church in the home and services were being held in the home. There was evidence that there was contact with relatives and families. There were visitors in the home on the day of the inspection and there was documented evidence of visits by families and telephone contact with the residents. The pay phone had been pulled off the wall by a resident and was now kept in the office. This may mean that at times the phone is not accessible to residents when the office is locked, as there are documents kept in the office. The home needed to look into ways in which the residents can access a telephone and make telephone calls in private, as there are telephone points in the bedrooms. The inspectors shared a meal with the residents and found the meal to be balanced, nutritious and well cooked. The menus for Week 1 were provided by the home and were last revised in November 2004. This set of menus indicated that there were a variety of meals on offer at the home. One of the residents commented that he did not like meat and did not eat the lamb chop at lunchtime, but he did not want to ask for anything else. He stated that he liked eggs and sausage and got eggs quite regularly although this was not reflected on the menus provided. There were no explicit choices indicated on either the menus or the board in the kitchen. There were two residents observed to require a liquidised meal. One of them was able to eat this unassisted and the other was provided with the appropriate assistance. The inspectors discussed blending the foods separately and putting them on a plate instead of blending the whole meal together however, the cook indicated that this had been attempted but the residents did not like it that way. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 There are systems in place to ensure that residents are safeguarded and protected. EVIDENCE: There was a suitable complaints procedure in the home and on display. There had been one complaint regarding the home that had been lodged with the CSCI. The complaint was in respect of a breakdown in the relationship between the home and a resident’s relative leading to the involvement of the police and a move from the home for the resident. Following the complaint an adult protection issue was raised regarding the home however, the issue remained unresolved due to the length of time that had passed since the incidents were alleged to have occurred. There was an adult protection policy and whistle blowing policy available in the home. The home should develop a procedure for the staff to follow in the event of an incident or allegation of abuse. The registered manager indicated that there were two copies of the Birmingham multi-agency guidelines on adult protection available in the home. One of these should be made accessible to staff. Solicitors and the court of protection were involved with residents where required. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The home was in need of general re-decoration and replacement of some bedroom furniture to provide the residents with a homely and comfortable environment to live in. There were adaptations in place to assist the residents. EVIDENCE: The home is an extended and adapted property. The home is need of general re-decoration throughout. 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 makes safe observation of the residents who are not in the lounges problematic. Removal of the carpet on the ground floor has meant that the problem experienced by the home in managing the offensive odours on the ground floor has been resolved. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 16 There were two 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. There was access into the garden via step down from the conservatory. The slabs of concrete forming the step was not very stable and needed to be made safe. The gardens were not accessible to the residents as the grass and bushes had not been cut back. 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. 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. One of the showerheads could not be hung up as the adjustable bar was broken. 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. One of the lights in the lift was not working. Bedrooms were all of a suitable size. Several of the bedrooms had furniture where doors or handles were missing. There was centralised lighting and a light over the wash hand basins. There needed to be lighting by the bedside so that residents could read and switch of the light without getting out of bed. Some of the bedrooms did not have all the furniture laid down in the National Minimum Standards and this needed to be discussed with the residents and recorded to ensure that their needs were being met. There was central heating throughout the home and the residents could control the temperatures, window openings were appropriately restricted and accessible to the residents. Radiators and hot pipes must be risk assessed and guarded where a risk to residents is identified. The cleanliness in the home needed to be improved. There were cobwebs seen on several light shades and walls in bedrooms. The tiles in the bathrooms and toilets needed to be scrubbed clean, especially where the walls meet the floor. The bath hoist chair and shower chairs needed to be cleaned, especially on the underneath and staff must be reminded not to put tablets of soap in the bathrooms. Liquid soap was available. There were two bedrooms where odour control was an issue. Staff needed to be encouraged to use the mechanical sluice on the first floor and not the sluice manual sluice facility in order to reduce the risks of cross infection due to the droplets of water formed as part of the manual sluice procedure. There were wall tiles missing in one of the Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 17 toilets and some wall tiles cracked and broken in the shower room on the first floor. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 There were adequate numbers of staff on duty at the home however, the records did not show that the residents in the home were protected by the recruitment procedures and that staff were trained and competent to do their jobs. EVIDENCE: The staffing rotas indicated that in addition to the manager, there was also the deputy manager on duty, and 2 or 3 carers on duty, however, on the day of the inspection the deputy manager and support worker who were indicated on the rota as working were in fact not in the building. The rota must indicate where changes to the staffing complement have been made. At the week ends where there is no cleaner or cook on duty the rota must indicate who is responsible for cleaning and cooking. Two waking night staff are duty each night. The home had a number of staff that had been employed there for a significant period of time which provided continuity of care for the residents. Examination of three staff files indicated that it was not always clear what the relationship of the referee to the employee was. The last employer was not always approached for a reference and where employees had brought CRB’s with them a further CRB and POVA check had not been instigated. This left the potential of unsuitable people to be employed in the home. There were no records of induction training for new staff. For other staff there was no evidence available for inspection of any training carried out apart from Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 19 fire training. Staff had been enrolled to undertake training for NVQ level two but there was no evidence that any had achieved this level of training. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37,38 The home had a stable management team however, robust recruitment procedures, leadership and training were needed in order to ensure that staff provided appropriate care in a safe environment. Health and safety were generally well managed. 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 records and recruitment procedures needed to be improved. Staff were not receiving supervision. There appeared to be an open and inclusive atmosphere in the home and less turnover of staff. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 21 There were good records for the personal allowances of the residents. Health and safety in the home was generally well managed. The requirements made by the environmental health officer needed to be met in full, there were some issues that remained outstanding from the engineer’s visit in April 2005. The bath hoist needed to be serviced as did the nurse call system which was now outside the guarantee period. The registered manager needed to check with the fire officer whether there needed to be any indication that there was oxygen in any of the bedrooms. The fire records were appropriately maintained, however, it was recommended that the staff sign to say they took part in the fire drill. Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 2 COMPLAINTS AND PROTECTION 2 2 2 3 2 2 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 2 2 x 3 1 3 2 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 23 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 1 Regulation 5(1) Requirement The statement of purpose must be amended to include the number of staff on duty and the contact details for the CSCI as part of the complaints procedure. 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 timescale of 1.4.05 not met.) The registered person must ensure that pre-admission visits and assessments are carried out wherever possible. (Previous timescale of 1.4.05 not met.) A record of the pre-admission visit and pre-admission assessements must be kept. 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 14.6.04 not met) Timescale for action 1.10.05 2. 2 5(1) 1.10.05 3. 5 14(1) 1.9.05 4. 7 15(1) 1.10.05 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 24 5. 7 13(4) 6. 7 15(2)(b) 7. 8. 7 8 15(1) 12(1)(a) 9. 10. 8 8 12(1)(a) 12(1)(a) 11. 12. 9 9 13(2) 13(2) 13. 9 13(2) 14. 9 13(2) The registered person must ensure that risk assessments for residents cover all identified areas of risk and include strategies for dealing with them. (Previous timescale of 14.6.04 not met) The registered person must ensure that residents plans are reviewed on a monthly basis and updated as required. (Previous timescale of 14.7.04 not met) Residents must be involved in drawing up the care plan and in any reviews. The registered person must ensure that there is a nutritional assessment in place for all residents. (Previous timescale of 14.6.04 not met) There must be a tissue viability assessment in place for all residents. The registered person must ensure that guidelines are in place for blood sugar levels and blood pressures that are being monitored for residents. (Previous timescale given 1.4.05. Not checked for compliance at this visit.) The tablets dispensed, recorded as given and remaining in the boxes must tally 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.) The registered person must ensure that all staff handling medicines undertake accredited training in the safe handling of medicines. (Previous timescale of 14.6.04 not met) There must be a system in place to indicate if a different number 1.10.05 1.10.07 1.10.05 1.10.05 1.10.05 1.10.05 1.8.05 1.9.05 1.12.05 1.9.05 Page 25 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 15. 10 12(4)(a) 16. 10 16(2)(b) 17. 18. 19. 20. 10 10 10 12 12(4)(a) 13(4)(c) 12(4)(a) 16(2)(m) & (n) 21. 12 12(1)(a) 22. 12 12(1)(a) 23. 18 13(6) 24. 19 23(2)(d) of tablets have been given than directed by the GP. The registered person must ensure that there are screens in place in shared rooms. (Previous timescale of 23.11.04 not met.) The registered person must ensure that the telephone is accessible to service users at all times and enable them to make calls in private. Privacy curtains must be available for residents using the showers. All bedroom door locks must be of a type that can be opened in an emergency. Bedroom doors must be knocked before entering. 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 1.4.05 not met.) Staff must include in daily records any activities undertaken to show that the residents social needs are being met. The home must be organised so that the care needs of the residents are met in accordance with their wishes not the routines of the home. 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 1.4.05 not met.) The registered person must ensure that any areas including lounges, bathrooms, bedrooms and corridors, requiring 1.8.05 1.9.05 1.9.05 1.10.05 1.8.05 1.10.05 1.9.05 1.9.05 1.11.05 1.11.05 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 26 25. 20 23(2)(p) 26. 27. 21 21 13(4)(a) 23(2)(b) 28. 21 13(4)(c) 29. 21 23(2)(b) 30. 24 16(2)(c) 31. 25 13(4)(c) 32. 26 13(3) redecoration are dealt with during the refurbishment programme and water damaged ceiling tiles must be replaced. (Previous timescale of 1.8.04 not met) The fluorescent lighting in the lounge must be replaced with lighting more domestic in nature. (Previous timescale of 1.2.05 not met.) The garden area and the step into the garden must be made safe. The registered person must ensure that the missing tiling in the toilet on the ground floor are replaced. (Previous timescale of 1.2.05 not met.) 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 17.1.04 not met) The showers must be fully operational and adjustable in height to meet the needs of the residents. The registered person must ensure that all broken bedroom furniture is repaired. (Previous timescale of 14.6.04 not met) The registered person must ensure that all radiators and hot pipes are covered. (Previous timescale of 14.7.04 not met. Compliance not checked at this visit.) 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. 1.11.05 21.8.05 1.9.05 1.9.05 1.9.05 1.10.05 1.11.05 14.8.05 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 27 33. 34. 26 27 16(2)(k) 12(1)(a) Staff must be encouraged to use the mechanical sluice facility. The odour control in the two bedrooms identified must be attended to. The rota must accurately reflect the staff on duty in the home. (Previous timescale of 21.12.04 not met.) At the week ends where there is no cleaner or cook on duty the rota must indicate who is responsible for cleaning and cooking. The registered manager must ensure that a minimum of 50 of staff are trained to NVQ level 2. The registered person must ensure that all the information required by Schedule 2 is obtained before any new staff are appointed. (Previous timescale of 20.2.04 not met) The registered person must ensure that there is evidence of the training undertaken by staff including induction training. Previous timescale of 20.4.05 not met.) The registered person must ensure that there is a system in place in the home for reviewing and improving the quality of care provided. (Not assessed during this inspection) 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 1.4.04 not met) The registered person must ensure that the premises risk assessment covers all identified risks. (Previous timescale given 1.2.05. Compliance not checked 1.9.05 1.9.05 35. 28 18(1)(a) 1.12.05 36. 29 19(1)(b) 1.9.05 37. 30 18(1)(a) 1.10.05 38. 33 24(1) 1.12.05 39. 36 18(2) 1.12.05 40. 38 13(4) 1.9.05 Sycamore House E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 28 at this visit.) 41. 42. 43. 44. 38 38 38 38 13(3) 23(2)(c) 23(2)(c) 23(4)(c) (i) The requirements of the Environmental Health Officer must be met in full. The bath hoist must be serviced and evidence forwarded to the CSCI. The emergency call system must be serviced and evidence forwarded to the CSCI. The manager must ensure that all fire doors close on automatically on the door rebates. 1.10.05 1.9.05 21.8.05 21.8.05 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 18 18 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 E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local 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 E54_S16849_SycamoreHse_V232208_210705stage 4.doc Version 1.30 Page 30 - 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!