Inspection on 21/11/07 for Sycamore House

This inspection was carried out on 21st November 2007.

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 17/04/07

Sycamore House 26/10/06

Sycamore House 15/06/06

Sycamore House 20/12/05

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 Key Unannounced Inspection 21st November 2007 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.V355979.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 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.V355979.R01.S.doc Version 5.2 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.V355979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. The home may accommodate one named service user aged 48 years at time of admission who is suffering from enduring mental health issues. 17th April 2007 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 admit any more people who suffer 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 the people living in the home. 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. There was no information about fees in the service user guide and individuals will need to ask the home for this information. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 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 in November 2007. Prior to the fieldwork being undertaken the home completed an Annual Quality Assurance Assessment (AQAA) which gave some information about the home. The home was asked to distribute some surveys to the people living in the home and professionals visiting the home. No completed surveys had been received at the time of writing this report. As part of the inspection process the files of three people living in the home and two files of people working in the home were looked as well as several other documents relating to health and safety and the management of the home. The manager was spoken with at length and 5 of the 20 people living in the home were spoken with. At the time of the visit to the home there were refurbishment works being carried out on the home so that only some areas of the home were looked at. There had been complaints about the home since the last key inspection and no adult protection issues had been raised. What the service does well: What has improved since the last inspection? The care plans had been updated and contained some good information on them but further improvements were needed. A refurbishment programme had been started. Some railings had been put along one wall of the corridors. The dining room had been decorated and new table, chairs and curtains had been purchased. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 6 The two lounges had been decorated, although only one could be used by the people living in the home at the time of the inspection due to the storage of furniture in the second one. The fluorescent lighting in the lounges and dining room had been replaced with domestic type lighting. People living in the home had access to keys to bedrooms if they wanted them. Privacy curtains and window dressings were seen in the bedroom looked at and where they were needed. What they could do better: Care plans although improved needed to be further improved to ensure that all areas of need were detailed with information for staff on how to assist the people living in the home. Risk assessments needed to be clear about what the staff needed to look out for that would indicate that a particular area of need was not being well managed. Care plans and risk assessments needed to be updated when needs changed. The staff needed to ensure that important information was passed onto the registered person such as when individuals were refusing to have their blood sugar levels monitored. The management of medicines in the home was not very good. Considering the small amounts of boxed medicines in the home the errors was surprising. Staff needed to ensure that the appropriate codes were used on the MAR charts and medicines that were brought in mid cycle or carried over from one month to the next were recorded on the MAR charts. There needed to be greater interaction between the staff and the people living in the home throughout the day. Social activities needed to be organised for those individuals who were unable to go out alone or who did not have anyone who could take them out. The registered person needed to ensure that the views of the people living in the home were taken into account when deciding menus, activities, decor changes, daily routines and so on. The people living in the home said they were happy with the food but there should be stated choices available at all meal times and the menus needed to be varied and nutritious. The registered person and staff needed to refer any possible adult protection issues to the appropriate social workers. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 7 The registered person needed to ensure that all incidents that had an effect on the well being of any of the people living in the home was notified to the Commission. The recruitment procedures needed to ensure that all checks had taken place and clearances returned before the individuals started work. Staff needed to have the required mandatory training updates. The registered person must ensure that the management and leadership in the home are improved and that he is aware of all the issues arising in the home. Some health and safety issues needed to be addressed. 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 House DS0000016849.V355979.R01.S.doc Version 5.2 Page 8 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.V355979.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information given to people thinking about moving into the home did not include information about the fees charged. Assessments of people moving into the home were carried out by the home before they were admitted and a statement of terms of conditions of residence were given that indicated the fees to be paid. EVIDENCE: Two files were looked at to examine the admission process. It showed that the individuals had been given a copy of the terms and conditions of residence at the home which identified the fees and who was paying them. They were both signed but not dated. The individuals were admitted on a trial basis however, only one had had a review after this period. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 10 Some good information was provided from the hospital on discharge of one of the individual’s however this had not been carried forward onto the care plan for the staff to be aware of. The homes own assessment did not mention one individual’s mental health status or detail any cultural needs such as skin or hair care. For the other person there was some quite good detail regarding risks relating to some health matters but it stated that some ‘behaviours’ had not been discussed with him although it was apparent that it was very important that these were discussed with the person to indicate that they were not acceptable behaviours. The service user guide did not give any information on what the fees at the home were. This information needed to be provided so that people could have access to this information before deciding whether to move into the home or not. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The content and structure of care plans had improved however, risk management plans were not always in place to minimise any identified risks. The health care needs of the people living in the home were being met. The management of medicines in the home needed to be improved to ensure people were safeguarded.. EVIDENCE: Since the last inspection a new manager had been employed who had updated the care plans before leaving. The care plans identified the needs and were an improvement on the previous documentation available in the home. They covered areas such as social and occupational care, nutritional care, family contact, mobility, personal hygiene and spiritual and emotional well being. Three files were looked at and some very good information was seen on them, for example, there was good detail about the care for someone who was diabetic, however, the plan needed to go on to identify what the staff should Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 12 look out for if the diabetes was not being well managed and what to do. The records showed that the individual had been refusing blood sugar monitoring tests but it did not say what staff had done to follow this up. The care plan indicated that the individual had some cultural requirements with respect to diet however the records of food did not evidence that these needs were being met. There was no information in the care plan regarding the individual’s requirements in respect to hair and skin care. There was a nutritional assessment in place however the plan indicated by the score was not being followed. The care plans were being reviewed on a regular basis. For another individual there were some episodes of inappropriate touching, there were some instructions for staff on how to manage this informing them not be alone in enclosed spaces, for all incidents to be recorded and for contact to be made with the social worker. The appropriate social workers had not been informed of the incidents. The appropriate notifications had not been sent to the Commission. The risk assessment regarding this issue had not been discussed with the individual although it was imperative that the individual was made aware that the behaviour was not acceptable. No moving and handling assessment of this individual was found on his file although there was a sheet to indicate that a review was being undertaken on a monthly basis. For the third individual a basic daily living and needs assessment had been completed on discharge from hospital indicating that the person was fully reliant on staff, unstable on his feet, confused and on liquid or semi-solid food but the care plans had not been updated to reflect these changes. The individual’s mobility and nutritional requirements had not been reviewed on return from hospital. Despite the care plans not having been updated the individual had improved significantly due to the assistance provided by the staff. The manager had started to review the care plans however, rather than updating the existing care plans and updating the information a new daily living and needs assessment was being completed. The updated ones seen at the inspection included less information than was available on the care plans. It appeared that generally the people living in the home were having their medical needs met via the GP, practice nurse, CPN, Chiropodist, optician and attending hospital appointments where needed. However, staff needed to Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 13 ensure that the manager was made aware of any issues that arose such as individuals refusing blood sugar monitoring so that the issues could be followed up. The home used a weekly dosette box system for managing medicines in the home. On checking these were found to match with the medication administration charts (MAR). There were some boxed medicines in the home. Some of these were audited and it was found that these did not tally as the amounts carried from one month to the next were not recorded. There were found to be some stocks of medicines in the medication cupboard but there was no way of knowing how many tablets should be in the home as there was no record of what had been received. There were medicines that had to be given as and when required. There were no protocols available for the staff to indicate when these should be given. In one instance this resulted in the individual being given them all the time. It they were needed all the time this needed to be discussed with the GP and the prescribing instructions changed. Where prescribing instructions had been changed by the GP the instructions needed to be clearly recorded on the MAR chart and signed by a second member of staff to ensure that the correct instructions had been recorded. Where people were refusing medicines the appropriate code needed to be entered on the MAR chart. Copies of the prescriptions were not kept with the MAR charts so it was not possible for staff to check what had been received from the chemist was correct. There was nothing seen during the inspection to indicate that peoples dignity and privacy were not being protected. There were privacy screens available in shared bedrooms and some people who lived in the home had keys and were able to lock their bedroom doors. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were some activities available for the more independent people living in the home but little evidence that arrangements were made for people who were less able. People living in the home said they were happy with the food provided but there needed to be less repetition in some aspects of the food. EVIDENCE: Some people living in the home were able to go out alone and they could have visitors to the home. One person told the inspectors of visits to and from her daughter and another person’s records evidenced visits to the home from a family member. At the time of the inspection only one lounge was in use as the other lounge had furniture stored in it from the rooms where building works were taking place. There were some activities in the home including card games however, during the inspection no activities apart from the television being on were observed. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 15 At various times of the day staff were seen to be sitting in the lounge with the people living there but there appeared to be little interaction between them. There was evidence available of two meetings having taken place with the people living in the home since the last inspection. The first one was basically to introduce the new staff to them including the manager and deputy manager. The second meeting was held to inform them of the refurbishment and building works to be carried out. The Annual Quality Assurance Assessment stated ‘Service users are encouraged to participate in menu planning and to give feedback about the foods in the home’. There was no evidence in the meetings held that the menu or food in the home were being discussed. It was also not possible to evidence that the people in the home were given information about shopping, church, meetings, chiropody etc. The people living in the home told the inspectors that they were happy with the meals being provided and that there was plenty of food available. There was a list of people who had diabetic needs but there was no evidence to show that they were having any foods that were different to the other people in the home. The inspectors were told that items such as custard had sugar added after some had been taken out for the individuals who required it not sweetened. There were no artificial sweeteners available in the home. The food records for a seven-day period indicated that there was variety in the main meal of the day although there were no specified choices available. The food records stated that mixed vegetables was on the menu each day and did not state what the vegetables were. The puddings could be seen to be repetitive as it stated cake and custard on 3 days and fruit and jelly on two days. At teatime rice pudding was served four times. Supper records were not detailed and were not always completed. Three evenings were not recorded at all and two evenings it just stated paste sandwiches. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There had been no complaints about the service since the last inspection. The home had not been proactive in raising possible concerns about behaviours to the appropriate authorities. EVIDENCE: Since the last inspection there had been an incident between two of the people living in the home. The matter had been referred to the appropriate authorities and the alleged perpetrator had been moved from the home. Examination of care records during this inspection indicated that the manager had again failed to raise some concerns regarding the behaviour of one of the people living in the home with the appropriate authorities and had not informed the Commission through the regulation 37 notifications system to alert them of the incidents. The manager was unaware of the issues until raised with him during the inspection. At the time of the last inspection it was noted that staff had received training in adult protection however it cannot be determined that the staff are putting into practice what they have learnt. No complaints had been raised with the Commission regarding the service since the last inspection and none were recorded in the home. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A refurbishment programme was underway at the home. Some improvements had been completed but a lot of work remained outstanding. EVIDENCE: Building works were in progress in one side of the building at the time of the inspection and no people were living there. People who had previously occupied those rooms had been transferred to other rooms in the home whilst the refurbishment was taking place. The inspectors were informed that the whole of the building was being updated and eventually there were would be 14 rooms with en-suite facilities and 12 without leading to an overall reduction in number of places in the home and all the bedrooms would be for single occupancy only. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 18 Some areas of the home had already been updated including the lounges and dining room where new curtains, furniture and lighting had been installed. The inspectors looked into two bedrooms briefly and it was apparent that not much had changed at the time of this inspection. They were informed that all the bedroom furniture was being replaced and was on order. There had been support rails fitted down one side of the corridors. It was advised that rails should also be fitted to the other side to provide support to people living in the home so that there was support for them whichever direction they were moving in. Bathroom facilities, nurse call systems and the passenger lift provided some adaptations to help those individuals with limited mobility and remained the same as at the last inspection. The privacy curtain in the toilet by the main lounge was found to be very stained. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were adequate numbers of staff available on duty in the home. Staff had not had the required training updates to ensure they remained competent and knowledgeable. The recruitment procedures needed to be improved to ensure that the people living in the home were safeguarded. EVIDENCE: On the day of the inspection there were three care staff on duty during the day, plus the manager, cook and domestic. The inspectors were told there were always three staff on duty during the day. There was a cook and domestic assistant for five days of the week. Care staff carried out these duties on the other days. There were 2 waking night staff on duty during the nights. The training records indicated that not all staff had had the required mandatory training updates in moving and handling, fire safety, infection control and food hygiene. Four of the ten care staff had completed NVQ level 2 although some from abroad may have had equivalent qualifications but this was not clearly recorded. A training matrix should be put in place that will inform the manager of training needed by the staff. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 20 Induction training was not in accordance with skills for care and there were not always induction records available. Recruitment records indicated that robust procedures were not in place. For one individual the POVA first check had not arrived until one month after starting work and the worker registration certificate appeared to be invalid as it was only valid whilst working for another company. Another file had only one reference available although other checks were in place. Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The leadership in the home was poor. The systems in place for the manager to know what the pertinent issues in the home were at any particular time were inadequate. It was important that an effective management team was put in place to oversee the running of the home. EVIDENCE: The overall management of the home continues to raise some concerns. The current manager has been looking to put in place a new manager and deputy manager. A manager and deputy manager had been appointed following the last inspection but they had both left a short time after being appointed. During their time at the home a number of the care plans had been rewritten in a format that provided more information than was available in the home Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 22 previously. Another prospective manager was due to visit the home shortly after this inspection but no information had been received by the Commission at the time of writing this report of whether the applicant was suitable or whether they wanted to take on the position. The registered manager had tried to delegate some tasks to the care staff but had failed to monitor and check on the progress of these tasks and on occasions did not appear to recognise the need for this to be done. The manager seemed to be unaware of some of the issues arising in the home until they were brought to his attention by the inspectors. On some occasions vital information had not been passed onto the manager and there were no systems in place for the manager to pick up on issues on a regular basis. There was a lack of leadership from the manager. There were no audits being carried out by the manager to make him aware of how the home was progressing. There would appear to have been only one staff meeting in the home since the last inspection although the manager stated that more had taken place. The manager stated that he had been unable to meet the requirement for staff to have a minimum of 6 supervisions sessions throughout the year. The staff continued to provide day-to-day care for the people living in the home however the activities were limited. During past inspections it had been noted that few accidents had been recorded in the home. Since the time the acting manager and deputy had been in post a number of entries had been made in the accident book. At least two of these had involved a third party for treatment and notifications should have been sent to the Commission but were not. The manager did not handle the monies for many of the people living in the home. During discussions it came to light that where monies were being withdrawn from post office accounts the money was not being kept in the home but was being put into the business accounts for Sycamore House and then taken out as required by the individuals. These monies needed to be kept accessible in the home or the amounts withdrawn as required by the individuals. The manager needed to invoice the individuals for the amounts he had provided initially if he could not go to the post office on a weekly basis. According to the information provided by the manager to the Commission via the AQAA it would appear that the gas equipment in the home had not been serviced since January 2006 and the hoists had not been serviced since November 2006. These issues needed to be addressed as a matter of urgency. The inspectors are aware that the boilers are being replaced however the safety of appliances must be assured. Sycamore House DS0000016849.V355979.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 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 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 x 2 1 1 1 Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 13(4)(c) Requirement Risk assessments must include details of what staff were to look out for to indicate that medical conditions were not being well managed. Timescale for action 01/01/08 2. OP9 13(2) This would ensure that the people living in the home were monitored appropriately and any actions needed would be taken. 01/01/08 Medicines must be booked in on receipt and any carry over of medicines from one month to the next must be recorded on the MAR chart. (Previous timescale of 01/06/07 not met.) There must be protocols in place for all medicines that are to be given on an as and when required basis. Changes in prescribing instructions needed to be countersigned by a second member of staff to ensure accuracy. Copies of prescriptions must be kept with the MAR charts so that Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 25 staff can ensure that the correct medicines are being administered. This will ensure that the people living in the home receive their medicines as prescribed. 3. OP15 17(2) Sch 4(13) The food records must show the special diets catered for. The registered manager must ensure that the menus are varied and nutritious. This will ensure that the people living in the home have their dietary needs met. The registered person must ensure that details of all incidents of possible adult protection are forwarded to the appropriate social workers. (Previous timescale of 30/5/07 not met.) The registered person must ensure that the recruitment procedures are robust and protect the people living in the home. This will ensure that only suitable people are employed in the home. The registered person must ensure that new staff receive induction training in line with skills for care competencies. This will ensure that people with the right skills and knowledge care for the people living in the home. The registered person must ensure that all staff have received the required updates to their training to ensure that they DS0000016849.V355979.R01.S.doc 01/01/08 4. OP18 13(6) 01/01/08 5. OP29 19(4) 01/01/08 6. OP30 18(1)(a) 01/01/08 7. OP30 18(1)(c)(i ) 01/03/08 Sycamore House Version 5.2 Page 26 are knowledgeable about currents standards and requirements. This will ensure that people with the required skills and knowledge care for the people living in the home. 8. OP31 12(1)(a) The registered person must ensure that tasks are appropriately delegated and that checks are in place to ensure that they are undertaken. Previous timescales of 01/01/07 and 01/06/07 not met. The registered person must ensure that he keeps himself informed about issues arising in the home. The registered person must ensure that notifications are forwarded to the CSCI in compliance with the care homes regulations. Previous timescale of 14/05/07 not met. The registered person must ensure that the gas equipment and hoists are serviced. Evidence that this has been undertaken must be forwarded to the CSCI. This will ensure that the equipment in the home maintained in a safe condition. 21/11/07 9. OP37 37 01/01/08 10. OP38 23(2)(c) 01/01/08 Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP1 Good Practice Recommendations The range of fees charged in the home should be shown in the information given to people before they decided whether to move into the home or not. This will ensure that people have all the necessary information needed to decide on whether to move into the home or not. Care plans must include information about cultural needs of the people living in the home. This will ensure that the people living in the home receive person centred, holistic care. The registered person must ensure that residents are consulted regarding activities and social interests and make arrangements to enable them to engage in activities in the home and the local community. Staff must include in daily records any activities undertaken to show that the residents social needs are being met. This will ensure that the people living in the home lead meaningful lives. 4. OP30 A training matrix must be put in place that indicates what training updates are needed by the staff. This will ensure that the staff receive the training they need to carry out their roles safely. A new manager must be put in place as soon as possible. This will ensure that the home is managed and improve as is required. The registered person must ensure that there is a system in place in the home for reviewing and improving the quality of care provided and takes into account the views of the users of the service and their representatives. This will ensure that the service is developed with the Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 28 2. OP7 3. OP12 5. OP31 6. OP33 views of the people living in the home taken into consideration. 7. OP34 The manager must ensure that the money taken out of the accounts for people living in the home is accessible to them at all times. This will ensure that the people living in the home have access to their monies at all times. The registered person must ensure that all staff are supervised, with written records, for a minimum of 6 sessions in any 12-month period. 8. OP36 Sycamore House DS0000016849.V355979.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000016849.V355979.R01.S.doc Version 5.2 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. 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