Inspection on 26/10/06 for Sycamore House

This inspection was carried out on 26th October 2006.

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 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 26th October 2006 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.V317191.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.V317191.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.V317191.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. 15th June 2006 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 further residents 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 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. Current charges at the home range between £332 and £560 per week. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced, key inspection for the home for the period April 2006 to March 2007. It was carried out by two inspectors over one day in October 2006. There were 24 residents in the home at the time of the inspection. The inspectors were able to speak with 6 residents, two staff and the manager and sample care and health and safety documents. A tour of the building was carried out. There had been no complaints or issues of adult protection that had been raised about the home since the last inspection. What the service does well: What has improved since the last inspection? One member of staff had been employed since the last inspection to improve the arrangements for staffing the home. There was more variation in the meals being served than the menus suggested and residents confirmed they were happy with the food provided. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 6 Some improvements had been made to the kitchen including the fitting of fly screens at the windows. What they could do better: The manager needed to ensure that the issue regarding care plans and risk assessments for areas of health and wellbeing were addressed as this had been an ongoing issue at the home. The lack of risk management was placing residents at risk of harm, for example, a resident was setting fire to paper in their bedroom. He needed to oversee the staff when this documentation was being completed so that it included all the relevant information. The manager needed to ensure that all relevant information was obtained from the placing authority before any residents were admitted to the home. Once obtained these documents needed to be appropriately filed so that they were accessible to staff to enable them to have the information about the residents’ needs until a care plan had been drawn up. The medication system was well managed however, the staff had not completed the returns book for several months and there were no copies of recent prescriptions for the staff to check the medicines, received into the home. The home needed to purchase a separate medicines fridge for storing medicines. The manager needed to ensure that the less able residents were enabled to have a more fulfilled life. There was little evidence of any activities for them in or outside the home. The manager needed to ensure that any allegations made by residents or any one else are investigated to safeguard the residents. The home had not had any work carried out on the physical environment except in the kitchen. The general decor of the home was poor and there was a need for the bedroom furniture to be replaced where it was broken and worn. Some bedrooms needed to have the carpet either cleaned or replaced. The staff needed to ensure that infection control procedures were followed and tablets of soap removed from communal washing areas to reduce the risk of cross infection. At the time of the inspection there was a scalding risk for residents in one of the showers where the temperature of the water fluctuated from 67 degrees to 20 degrees centigrade. The inspectors were concerned and asked that a plumber be called immediately. Someone was looking into the issue when the inspectors left. The manager needed to set up a system to ensure that the hot water temperatures were maintained at about 43 degrees centigrade and that staff brought any excess temperatures to the manager’s attention. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 7 There were no records that the fire alarm and emergency lights had been tested since the end of June 2006. The fire doors needed to have intumescent strips fitted as required by the fire officers and a copy of the service of the shaft lift and bath hoist needed to be forwarded to the CSCI as they were not available at the inspection. Overall the Commission remains concerned that standards in many areas that affect residents’ well being are not being addressed. There are 32 specific areas of legal requirements that remain unmet since the last inspection. There is a sense of drift and that the home is poorly managed to effect and implement the required improvements and changes. This was discussed with the owner who has plans and ideas to develop the home, however, based on the last two years of inspection the Commission are not confident these will come to fruition for the benefit of the residents. 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.V317191.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.V317191.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): 2 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home could not demonstrate that appropriate assessments and risk management strategies had been put in place before the residents were admitted leaving the residents at risk of not having their needs adequately met. EVIDENCE: The admission process for two residents was looked at. Mr Noorbaccus said two types of care plans had been developed since the last inspection. The admission was poorly documented and appeared to indicate that the information regarding needs and risks in relation to the residents was not received in the home until several weeks after the admission leaving the residents at risk of not having their needs adequately met. Staff would have not been aware of how to meet their needs and how to manage any risks arising from their conditions. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 10 The manager stated that he had carried out a pre-admission assessment however the documentation regarding this was not found. The management of documents in the home at the time of the inspection was haphazard and information was brought to the inspector little by little by the staff. The home was in the process of updating the care plan and again this process was not well organised or managed. The manager stated that the residents had signed the third party funding agreement with the local authority and the home. The home had not yet developed a contract with the home. Sycamore House DS0000016849.V317191.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 home had continually found it difficult to formulate workable, detailed care plans for the residents and was in the process of setting up a new set of plans. Risk assessments were not in place for the risks identified and this left the residents at risk of not having their needs met in a safe and appropriate manner. EVIDENCE: The manager stated that the home had developed two care plans since the last inspection and was in the process of updating them. No care plans had been fully updated and several were at different stages of the process making it difficult for the paperwork to be found. The care plans if fully completed with the appropriate level of detail would cover several areas of need including mental health and cognition, diet and weight, food and mealtimes, dental and foot care, communication, medication, personal safety and so on. However, the areas completed so far did not include sufficient detail on how the staff were to deal with these issues. For example, for one of the residents in order for staff to maintain the resident’s Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 12 personal safety staff were to distract and remove the individual to a quiet and calm environment but did not say how this was to be done. The care plan identified that the individual could be hostile and verbally aggressive but gave no instructions on how this was to be managed. The care plans did not identify which tasks the individuals could undertake themselves, for example, could they be encouraged to make arrangements for dental or foot care or did the staff have to undertake this task. It was important for this to be included as the home was catering for two distinct groups of residents, older people who needed more assistance with tasks and younger adults who could be encouraged to undertake some tasks themselves. In addition to the older adults in the home there were some residents with a substantial level of dementia. One of the care plans sampled was for someone with dementia and the level of detail in the care plans was not sufficient for the staff to meet their needs due to the resident’s inability to say what they wanted due to short term memory loss. The care plans did not include any plans for occupying or stimulating the residents according to their needs. Care plans were rarely signed or dated so that auditing of reviews was difficult. Risk assessments did not cover all the identified risk areas, for example, mental health relapse, fire safety, challenging behaviours and smoking. There were examples documented of one resident was setting papers alight in the bedroom but there was no strategy in place to manage the risk. There was evidence that the residents’ health care needs were being met. There were examples of CPN’s and chiropodists being involved. The residents had received the flu vaccination recently, however some had refused the vaccinations and their wishes respected. These visits were generally recorded in the daily recordings for the residents and difficult to track. Issues such as nutritional assessments and tissue viability assessments had either not been completed or actions not followed up. For one resident the nutritional assessment had identified that there was some risk and needed a weekly review and supplements were to be used, there were no reviews in place. In conversation the manager stated that one resident had been provided with a pressure cushion however no tissue viability assessment had been carried out. A weekly nomad system was in use in the home for administering medication. The medication system was well managed ensuring residents receive their medicines as required. The home needed to develop protocols for the use of ‘as and when required’ medicines (PRN) to ensure that staff administer these on consistent basis. The returns book was not being completed. These needed to be completed to ensure there was an unbroken audit trail for the medicines coming into and going out of the home. The home needed to Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 13 ensure that there were copies of the most recent prescriptions available so that the medicines received could be checked against the prescriptions. There were some creams found around the home that had not been dated on opening. The medication policy needed to be adapted to apply specifically to the home. There had been some training in the handling of medicines but it was not clear whether this was accredited training. There were appropriate locks on the toilet, bathroom and bedroom doors. Several bedroom doors had been locked by residents when they went out. There were privacy screens in bedrooms that were being shared but not where double bedrooms were singly occupied. A telephone for the use of residents had been fixed to the wall in the corridor by the staircase. Weight charts were being maintained in a separate folder. Sycamore House DS0000016849.V317191.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 poor. This judgement has been made using available evidence including a visit to this service. Some residents were able to lead lives that met their needs however, more dependent residents lives did not include activities that interested them and maintained their interest and stimulation. Residents lives lacked real structure to ensure their lives were fulfilled and were punctuated by daily living activities such as eating and going to sleep. EVIDENCE: One resident speaking with the inspector stated that he went to a placement on a regular basis. He was able to travel there and back on the bus. Some residents were seen to go out alone on the day of the inspection. Residents were encouraged to go out with relatives. There was no evidence that residents unable to go out alone or with relatives were ever taken out by the staff. There were no planned activities in the home apart from watching the television and smoking. The care plans did not include any details about how the residents wanted to spend their days or any likes and dislikes or interests prior to coming into the home. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 15 There were some choices in the home for example whether residents sat in the lounge or stayed in their bedroom and to have keys to bedrooms. There were no identified choices in the care plans, menus did not identify choices were available at mealtimes, their were no activities for residents to choose to be involved in or not. The home had a two-week rolling menu and due to the fact that the cook was off sick on the day of the inspection the lunchtime meal was different to that on the menu. The meal was pork draft belly, vegetables and rhubarb crumble and custard. There were some residents who required a diabetic diet and their was a non sweetened crumble being cooked for them. The record of meals cooked indicated that a wider range of meals was being prepared than was identified on the menus. The menus needed to be updated to include a wider range of meals. The menus needed to be followed to enable the residents to know what the meal was going to be and so that they could request an alternative if they did not want the meal being prepared. Where residents were attending placements and missing there meal at the home they needed to be reimbursed for the meal they were eating out of the home. Individual records of food eaten by residents needed to be kept. Sycamore House DS0000016849.V317191.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. Residents were safeguarded by the policies in the home but practices did not follow this through. Arrangements for complaints resolution was poor and inadequate to ensure residents are enabled to voice any concerns or complaints. EVIDENCE: There had been no complaints recorded in the home and none had been lodged directly with the Commission. The complaints and adult protection procedures were not sampled on this occasion. One incident recorded in daily records indicated that a resident had accused the staff of stealing their personal effects. There was no evidence that this issue had been followed up. Although this may have been at a time when the resident was unwell the issue should have been followed up. Staff spoken with regarding adult protection were able to identify what abuse was and what actions they would take in the event that they thought there was any abuse happening. They had covered adult protection whilst undertaking NVQ level 2 or in previous employments. The staff still needed to undertake training in the prevention of adult abuse and actions to take in the event or suspicion of abuse. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 17 The recruitment procedure had improved and staff were employed only after a POVA check had been undertaken however, references were not always in place before they started work. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical environment has deteriorated due to the owners uncertainty of the future of the home leaving the residents in an environment that was uncared for and not homely with many areas of repair and decoration needed. EVIDENCE: The lighting in the entrance hall did not come on very quickly. The problem was likely to be in the switch as other lights came on. There continued to be fluorescent lighting in the lounges. In both the lounges one tube was not working. Diffusers were missing on some of the fluorescent lights. The decor of the home needed to be improved in the corridors, lounges where chairs rubbing against the wall, behind the radiator in the small lounge, in the corridor upstairs where wallpaper coming away from the walls, in bedrooms where there were marks on the walls from hands and in bedroom 1 where the wallpaper had been torn off and stuck back on. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 19 At the time of the inspection the small lounge was not in use as new beds had been stored in there. Chairs in the small lounge were torn and needed replacing as was one chair in the dining room. The conservatory was used by smokers but still no heating had been provided. The step into the garden had not yet been made safe although the inspector was informed that this was due to be done in two weeks time. Bedroom furniture needed to be replaced as several bedrooms had wardrobe doors missing, flooring in some bedrooms needed to be replaced as either it was torn or the carpets were old, bedside cabinets were damaged and secondary lighting was not available in all bedrooms. The lift floor had been repaired since the last inspection. There were several bathrooms and toilets available throughout the home. One of the bathrooms on the ground floor provided facilities for assisting residents with reduced mobility including a bath chair hoist, walk in shower, raised toilet seat and grab rails. There were two shower chairs in the bathroom, one was rusty and needed to be removed the other was plastic and needed to be cleaned. The water from the shower was a little hot but not scalding. The door to the bathroom did not have a handle on the outside. The bathroom between the two double rooms (old side of building) had a shower over the bath. Water from the shower was very hot and fluctuated from between 67 degrees to 19 degrees. The inspector requested that the plumber was called immediately. The plumber arrived during the inspection to deal with the matter. The manager needed to be put in place systems for checking water temps on regular basis. Tiles were still missing of the wall in the toilet opposite the small lounge. The light pull cord was very dirty and needed to be replaced. The home was centrally heated and radiators covered. There was an emergency call system in place in the home to enable staff and residents to call for assistance and there was a ramp into the home to facilitate entry for those with reduced mobility. Tablets of soap were found in the bathrooms. Some areas of the home were not cleaned appropriately, for example, bedrooms. Staff were seen to wear disposable aprons and gloves. The kitchen had had fly screens fitted and some tiles had been replaced since the last inspection. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedure had improved but further improvements were needed to ensure that the right people were employed and residents were safe guarded from possible harm. Staff training plans needed to be put in place to ensure that they were equipped to meet the needs of residents. EVIDENCE: Staffing rotas indicated three staff were on duty during the weekdays and four at the weekends so that one could cover the cooking as there was no cook on duty during the weekends. There was a mix of cultures of staff in the home although the residents were all of a white European background. One staff file was checked. There was a CRB and POVA check in place. One of the references was dated 2 months before the individual completed an application form at the home. The individual had previously worked in a care home but that employment had ended 4 months prior to the application form being completed. Two other references had been applied for but had not yet been returned. It was not clear whether the individual was entitled to work as the visa said limited leave to remain in the home and no recourse to public funds. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 21 There was no documented evidence that an induction was carried out at the home, however the individual confirmed that there had been a basic induction including how to shower and move residents to the dining room and a walk around the home as part of fire safety. Since the last inspection 9 of the 18 staff had undertaken manual handling training and 11 had undertaken fire training. The remaining staff needed to undertake this training and all staff needed to undertake infection control, health and safety and first aid training. The inspector was informed that medication and food hygiene was being carried out the following day. The manager needed to ensure that the medication training being given to staff was accredited training in the safe handling of medicines. In addition to the mandatory training it was important that the staff undertook training in the specific needs of the residents including dementia, mental health awareness, epilepsy and diabetes awareness. The home needed to set up a training matrix identifying training undertaken by the staff and individual training programmes for the staff. The inspector was informed that 14 of the 18 staff had undertaken NVQ training. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 22 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): 31,33,35,37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The arrangements for the good management of the home were poor and there were some issues of health and safety that put the residents at risk. EVIDENCE: The manager was well qualified and experienced to manage the home however, he was struggling to cope with the paperwork and maintaining adequate standards in the home. He needed to be able delegate tasks appropriately to the staff and then monitor that the tasks had been completed. The home had been experiencing difficulties in attracting referrals to the home and so had not been able to operate at higher occupancy levels. The manager had identified that some of the standards in the home had slipped. He was Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 23 looking into changing the registration of the home and was liaising with the CSCI regarding this issue. Care plans and risk assessments were being developed but were still not satisfactory and left residents at a potential risk of not having their needs adequately met. The care plans had been an ongoing issue over several inspections. Physically the home had deteriorated due to a lack of investment in the home. The home had not yet developed a quality assurance system and one needed to be put in place so that their was a development plan for the home based on the views of the residents. There had been two residents meetings since the last inspection. The last one was to inform the residents that the home had been taken off the market. There were no minutes of the actual discussions that had taken place. There was a discussion with the manager regarding the management of personal allowances for the residents. The manager stated that the actual monies were deposited in the Sycamore House bank accounts as it was difficult to open accounts on behalf of the residents and only a limited amount of money could be kept in the safe. A float was available in the home from which money was given to the residents. The manager was advised that these monies should not be kept in the home’s bank account. Where there were large amounts of money these needed to be returned to the local authority until they were required or the social workers must encourage the residents to open bank accounts where they were able to and the money should be deposited directly. Cards and pin numbers needed to be stored securely in the safe. The manager stated that supervisions had not been undertaken to the required levels. The majority of equipment had been maintained to ensure safety in the home, however, fire alarm tests and monthly emergency lighting tests had not been recorded since 26.6.06 although the manager said they had been undertaken. The fire doors needed to have intumescent strips fitted, the fire door on the first floor needed to be repaired so that the door could be opened from both. The yale latch on the door between the office corridor and the first floor needed to be disabled so that the latch could not be dropped and prevent anyone leaving that area. The fire extinguishers, gas equipment, portable appliances, fire alarm and nurse call systems had been serviced. The certificates for the service of the passenger lift and bath hoist were not available at the time of the inspection. Other documents that could not be found were the environmental health officers report and the details of the contents of the courses in medication and infection control to be carried out the day after the inspection. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 24 The completed accident records needed to be removed from the book and stored appropriately to comply with data protection of records. The shower on the ground floor between the two double rooms was found to be dangerous as the hot water temperature fluctuated between 67 and 19 degrees centigrade. The inspector requested that a plumber be called out. The plumber came out during the inspection to attend to the shower. The manager needed to put in place systems to monitor hot water temperatures in the home. Cleaning in some areas of the home was poor and infection control procedures were not always followed. Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 25 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 X 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 2 3 2 1 1 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 1 2 1 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 26 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 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, 01/10/05, 21/01/06 and 01/08/06 not met.) Timescale for action 01/12/06 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 27 2. OP3 14(1) The registered person must ensure that pre-admission visits and assessments are carried out wherever possible. (Previous timescales of 01/04/05, 01/09/05, 14/01/06 and 01/08/06 not met.) A record of the pre-admission visit and pre-admission assessments must be kept. (Previous timescales of 01/09/05, 14/01/06 and 14/07/06 not met.) The assessments carried out by the placing authority must have been received by the home before the resident is admitted to the home. 01/12/06 3. OP7 15(1) 4. OP7 13(5) The assessments must be available for inspection. The registered person must 01/01/07 ensure that residents’ plans are comprehensive and provide sufficient detail to enable care staff to meet the assessed needs of residents. (Previous timescales of 14/06/04, 1/10/05, 01/02/06 and 01/08/06 not met.) The registered person must 01/12/06 ensure that there is a moving and handling assessment in place for all residents indicating the actions to be taken in the event of a fall and any equipment to be used. (Previous timescale given 01/08/06. Compliance not assessed at this inspection and requirement brought forward.) Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 28 5. OP7 15(2)(b) 6. OP7 15(1) 7. OP8 12(1)(a) The registered person must ensure that residents’ plans are reviewed on a monthly basis and updated as required. (Previous timescale of 14/07/04, 01/10/05, 01/02/06 and 01/08/06 not met.) Residents must be involved in drawing up the care plan and in any reviews. (Previous timescales of 01/10/05, 01/02/06 and 01/08/06 not met.) The registered person must ensure that there is a nutritional assessment in place for all residents. (Previous timescales of 14/06/04, 01/10/05, 01/02/06 and 01/08/06 not met.) Where risks have been identified these must be followed up as identified in the plan. There must be a tissue viability assessment in place for all residents. (Previous timescales of 01/10/05, 01/02/06 and 01/08/06 not met.) Records must enable easy tracking of medical visits to residents and the reasons for the visits. (Previous timescales of 14/01/06 and 01/08/06 not met.) 01/12/06 01/12/06 01/12/06 8. OP8 12(1)(a) 01/12/06 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 29 9. OP9 13(2) The medication policy must be adapted to apply specifically to the home. (Previous timescale of 01/08/06 not met.) All creams must be dated on opening and discarded a month later. (Previous timescale of 01/08/06 not met.) The registered person must ensure that there is a protocol in place for all medicines administered on an ‘as and when required’ basis. The registered person must ensure the training provided to staff is accredited training in the safe handling of medicines. The registered person must ensure that there is a record of all medicines returned to the pharmacist. 01/01/07 10. OP12 16(2)(m) & (n) 11. OP12 OP13 12(1)(a) The registered person must ensure that copies of prescriptions are available to check medicines received into the home against. The registered person must 01/01/07 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 timescales of 01/04/05, 01/10/05, 01/03/06 and 01/10/06 not met.) Staff must include in daily 01/01/07 records any activities undertaken to show that the residents social needs are being met. (Previous timescales of 01/09/05, 01/02/06 and 01/08/06 not met.) DS0000016849.V317191.R01.S.doc Version 5.2 Page 30 Sycamore House 12. OP14 12(1)(a) 13. OP15 16(2)(i) The registered person must ensure that residents are assisted to make choices and take control of areas of life where they are able. The registered person must ensure that the menus are revised to reflect the actual meals cooked in the home. Choices must be available at all meal times. Residents must be consulted about the meals provided. Records of food eaten must be kept. The registered person must ensure that all complaints are fully investigated and records of the investigation kept. (Previous timescale of 01/08/06 not met.) 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 timescales of 01/04/05, 01/11/05, 01/03/06 and 01/10/06 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 timescales of 01/08/04, 01/11/05, 01/04/06 and 01/10/06 not met.) The step into the garden must be made safe. (Previous timescales of 21/08/05, 01/04/06 and 01/08/06 not met.) DS0000016849.V317191.R01.S.doc 01/01/07 01/01/07 14. OP16 22(3) 01/12/06 15. OP18 13(6) 01/02/07 16. OP19 23(2)(d) 01/04/07 17. OP20 13(4)(a) 01/12/06 Sycamore House Version 5.2 Page 31 18. OP20 16(2)(c) 19. OP21 23(2)(b) Torn chairs in the lounges must be taken out of use. (Previous timescale 14/01/06 and 14/08/06 not met.) The registered person must ensure that the missing tiling in the toilet on the ground floor is replaced. (Previous timescales of 01/02/05, 01/09/05, 01/04/06 and 01/08/06 not met.) 01/03/07 01/12/06 20. OP24 OP23 16(2)(c) 21. OP25 13(4)(c) The handle on the door to the bathroom on the ground floor must be fitted on. The registered person must 01/04/07 ensure that all bedroom furniture is repaired. (Previous timescales of 14/06/04, 01/10/05, 01/04/06 and 01/09/06 not met) The registered person must 01/12/06 ensure that the temperature of hot water at the point of delivery is restricted to 43 degrees in all showers throughout the home. (Previous timescales of 17/01/04, 01/09/05, 14/01/06 and 14/07/06 not met) The registered person must ensure that there are systems in place to monitor the water temperatures on an ongoing basis. The light switch in the entrance hall must be repaired. Secondary lighting that is in working order must be available to all residents in their bedrooms. (Previous timescale of 01/08/06 not met.) Fluorescent lighting must be replaced with domestic type lighting. 22. OP25 23(2)(j) 01/01/07 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 32 23. OP25 23(2)(p) 24. OP26 13(3) Heating must be provided in the conservatory. (Previous timescales of 14/01/06 and 14/09/06 not met.) Dirty carpets must be cleaned or replaced in the bedrooms. (Previous timescale of 01/09/06 not met.) Arrangements must be made to provide a wash hand basin in the laundry. (Previous timescale of 01/09/06 not met.) Tablets of soap must not be left in communal bathing facilities. The rusty shower chair must be removed and the other chair scrubbed clean. Dirty light pull cords must be replaced. The rota should identify the person undertaking the cooking at weekends and who is in charge of each shift. The registered person must ensure that all checks are in place before employing staff to safeguard the residents. (Previous timescale of 14/07/06 not met.) The registered person must ensure that all individuals are entitled to work in the country before starting employment. 14/12/06 01/01/07 25. OP27 12(1)(a) 01/12/06 26. OP29 19 01/12/06 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 33 27. OP30 18(1)(c) (i) All staff must undertake mandatory training in first aid, food hygiene, health and safety, and infection control. (Previous timescales of 01/04/06 and 01/09/06 not met.) All staff must be given induction training in the home. (Previous timescale of 01/09/06 not met.) Staff must be provided with training in adult protection, epilepsy and mental health awareness. (Previous timescale of 01/09/06 not met.) A training matrix and staff development programme must be put in place. The registered person must ensure that tasks are appropriately delegated and that checks are in place to ensure that they are undertaken. 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 timescales of 01/12/05, 01/04/06 and 01/10/06 not met.) The registered person must ensure that residents’ monies are not deposited in the business accounts and other plans are made to ensure the monies are available to the residents. Bank cards and pin numbers must be stored safely. Where residents are not having their main meal at the home due to a placement this money must be reimbursed to them to pay for their meal at the placement. 01/12/06 28. OP31 12(1)(a) 01/01/07 29. OP33 24(1) 01/04/07 30. OP35 17(2) Sch 4(9) 01/12/07 Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 34 31. OP36 18(2) 32. 33. OP37 OP38 Data Protection Act 1998 23 (4)(c) 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, 01/04/06 and 01/10/06 not met.) The accident records must be stored in compliance with the data protection act. The fire door on the first floor must be repaired. Fire alarms must be tested on a weekly basis. Emergency lighting must be tested on a monthly basis. The latch on the yale lock on the door to the office corridor must be disabled. Fire doors must be fitted with intumescent strips. Evidence that the passenger lift and bath hoist have been serviced must be forwarded to the CSCI. 01/12/06 01/12/06 01/12/06 34. 35. 36. OP38 OP38 OP38 13(4)(c) 23 (4)(c) 23(2)(c) 01/12/06 01/01/07 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sycamore House DS0000016849.V317191.R01.S.doc Version 5.2 Page 35 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.V317191.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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