Inspection on 21/07/08 for Sycamore Lodge

This inspection was carried out on 21st July 2008.

CSCI found this care home to be providing an Adequate service.

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.

Other inspections for this house

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE Sycamore Lodge 1 Edgecote Close Acton London W3 8HP Lead Inspector Clare Henderson-Roe Key Unannounced Inspection 11:10 21 & 22nd July 2008 st 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 Lodge DS0000071570.V366679.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 Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Address 1 Edgecote Close Acton London W3 8HP 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) 020 8752 8280 campionm@servitehouses.org.uk Servite Houses Campion John Mead Care Home 77 Category(ies) of Dementia (77), Old age, not falling within any registration, with number other category (77) of places Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 77 New Service Date of last inspection Brief Description of the Service: The home has been purpose built to meet the National Minimum Standards for Older People. It is situated in a residential area of Acton, and is easily accessed via public transport. There are shops and a Post Office within walking distance to the home. The home comprises of 5 units, 3 of which can accommodate 15 residents and 2 of which can accommodate 16. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each unit has a communal sitting/dining area with a kitchen area plus a separate quiet room and activities room. Two of the units are registered to provide dementia care and three units are registered to provide general care. Each unit is individually staffed. The home accommodates residents placed by the Borough of Ealing. At the time of inspection all 5 units were open. The following information regarding fees has been provided by Servite Houses: ‘Sycamore Lodge was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a unitary charge, which covers all the services the council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 5 The fee payable to the council by residents who fund themselves in full is £526.00 per week for residential care. The fee payable to the council by residents who fund themselves in full is £651.00 per week for nursing care. Deducted from that will be the ‘free nursing care’ amount of £125.00 (high) and £83.00 (medium and low). Private funders are also welcomed for which a fee is negotiated based on individual care/nursing needs.’ Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 26 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication management & records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 14 staff and 1 visitor were spoken with as part of the inspection process. The Annual Quality Assurance Assessment (AQAA) was also completed and has also been used to inform this report. A number of our surveys for residents, staff, healthcare professionals and care managers had been sent to the home prior to the inspection for distribution, the majority of which were found at the home and had not been completed, so we are unable to include comments in this report. What the service does well: What has improved since the last inspection? Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 7 This was the first inspection of this home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sycamore Lodge DS0000071570.V366679.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 Lodge DS0000071570.V366679.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): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: The home has a comprehensive pre-admission assessment document and completed assessments were viewed on each unit. With one exception these had been well completed. Copies of resident assessments carried out by Social Services were available for all resident files viewed, and provided a comprehensive picture of the residents’ needs. Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In most cases the service user plans were reasonably completed, however omissions in information could lead to individuals personal and healthcare needs not being fully met. Shortfalls were identified in the management of medications, which could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Information regarding end of life care wishes is limited and this needs to be addressed to ensure that residents wishes are ascertained, recorded and respected. EVIDENCE: On the personal care units 5 service user plans were viewed in detail and sections of 2 others were viewed. These were well completed and provided a good picture of the residents needs. There was evidence that residents had been involved in the assessment process and had provided information included in sections of the service user plans, and had signed to evidence their involvement. There was evidence of monthly reviews and updates. Risk assessments for falls had not always been completed. Monitoring forms for Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 11 recording falls were available, one of which had been completed. The importance of completing risk assessments for falls for all residents was discussed with the Registered Manager. Risk management plans were in place for other risks identified. Assessments for moving & handling, nutrition and pressure sore risk had been completed. The District Nurses complete the continence assessments for the personal care units. On the nursing care units 4 service user plans were viewed. With one exception on the dementia care nursing unit the care plan information was personalised and included medical care needs and clearly identified how each need is to be met. The shortfalls for the one service user plan were discussed with the Registered Manager and these were to be addressed. Risk assessments for falls had been completed as had risk management plans for other risks identified. There was evidence of residents and their representatives being involved in the formulation and review of the service user plans. Wound care documentation was viewed. Individual care plans and wound progress records were available for each wound. Photographs had been taken of the wounds. Pain assessments had been carried out. Nutritional assessments and continence assessments had not been completed in some of the service user plans viewed. Moving & handling assessments were available and moving & handling equipment in use for each individual had been identified. For one resident for whom bedrails were in use an assessment had not been carried out, although there was evidence of written consent for their use having been obtained. There was evidence of input from healthcare professionals. Medication management was viewed on each unit. Lists of staff signatures and initials were available with the exception of the general nursing unit, and this is to be addressed. Appropriate single use lancing devices for blood glucose monitoring were in use. Administration records were complete and where a medication had been omitted for some reason, coding with an explanation for the omission had been used. However one coding being used ‘m’ for ‘make available’ had not been identified and this needs to be addressed. Receipts had not been recorded on several of the medication administration records (MAR) viewed, and medication stock balances ‘carried forward’ had also not always been recorded. Records of disposal were available, however an issue was identified where a medication had been dropped and disposed of, but this had not been identified on the MAR. It was found that up until very recently the dispensing chemist had been collecting unused medications for disposal. This is in breach of the Waste Regulations, under which all medication waste from a care home with nursing is regarded as clinical waste and must be destroyed according to the regulations. At the time of inspection it was apparent that not all staff were aware of the required system for disposal and the importance of ensuring all staff are up to date with current practice requirements was discussed. Where recorded, room temperatures were regularly above the safe level of 25° centigrade and the air conditioning fans available do not appear adequate to Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 12 keep the temperature under control. In some instances records of room temperatures were not available. Minimum, maximum and actual temperatures for the medications fridges had only been recorded on one unit. On the other units the actual temperature only had been recorded and all issues with temperature recording need to be addressed. Entries in the controlled drugs register viewed on a nursing unit were complete and up to date. Liquid medications to include eye drops had been dated when opened. On one unit staff were using out of date eye drops for one resident. For residents admitted for respite care they sometimes come in with liquid medications that have been opened, and the need to find a satisfactory way of identifying and recording this was discussed. With the exception of one unit there were good records being maintained for identifying the stock of medications supplied in boxes, which is good practice. For residents on medications with very specific administration instructions, these had not always been recorded on the MAR or the instruction label on the box. The importance of ensuring full dosage and administration instructions are included for every medication being administered was discussed. Allergies had not been identified on the MARs and this must be addressed with the dispensing chemist. One resident on a personal care unit with diabetes was prescribed insulin twice a day. The district nurse was drawing up insulin twice a week in two different doses for each day and leaving in the fridge for care staff to select and administer in their absence. Advice from the National Patient Safety agency is that insulin should not be prepared more than 24 hours in advance. The Royal College of Nursing also views the practice of pre-mixing/pre-loading insulin as necessary only after all other options have been exhausted. This is to meet manufacturers recommendations, to prevent errors in selecting the wrong dose and also to allow timely changes in dosage adjustments. For one resident who was selfmedicating one of their medications there was no record of the dosage. On investigation this information had not ever been ascertained by the home. In addition, a risk assessment for self-medicating had only been part completed, and both these findings gave cause for concern. The Area Manager has since confirmed that this was addressed following the inspection. The units had up to date copies of the British National Formulary, containing information about all medications. Medications are being securely stored on each unit. It is acknowledged that the home is in the process of changing GP and that due to differing start dates for medications it is not easy to carry out a complete audit of medications at this time, however this must be addressed and a full medication audit carried out for the home to ensure all aspects of medication management are up to date and in order. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Staff were interacting well with residents and there was a happy atmosphere throughout the home. Residents looked well cared for and were dressed to reflect individuality. Staff knock on residents doors prior to entering the room and throughout were seen showing respect and a caring approach to the residents. Staff are available to speak Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 13 with residents in their own languages and gender care preferences are clearly identified in the care plans. The care plans for health deterioration and end of life care wishes contained limited information and in one instance information did not appear fully accurate. The importance of providing residents and their families with the opportunity to discuss this topic was discussed and all staff need to be provided with the skills and confidence to approach this topic. It is acknowledged that this is a sensitive area of care, and if people do not wish to discuss it as yet then this can be recorded. The home has a guest room available so that if necessary a visitor can stay overnight and be close to their loved one. Sycamore Lodge DS0000071570.V366679.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Some information regarding advocacy services is available and this is to be further developed to ensure the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet residents individual dietary needs. EVIDENCE: The home has an activities co-ordinator who has a very positive approach to her area of care. Life histories are being done for each resident and some completed ones were seen and were very comprehensive, providing a good picture of each individual, from which a specific activities programme can be tailored to meet the needs of the residents. A general activities programme is available and is on display throughout the home, providing a varied selection of activities throughout the week. Residents were seen joining in activities, both group and individual, and were enjoying themselves. A record of activities is kept for each resident. One of the small lounges has been made into a library and there are plans for another to be a films room. There is a music Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 15 session every 2 weeks and this took place on the second day of the inspection, and was much enjoyed by the residents. We were informed that training is being planned for care staff in the provision of activities for residents. The home has an open visiting policy and visiting is encouraged. A visitor spoken with said that they are made very welcome at the home and kept up to date with their relatives’ condition. Refreshments to include meals are available and offered to visitors. Residents can receive visitors in one of the communal rooms or in their bedrooms, as they so wish. The home has some information regarding Advocacy Services and some residents do have an allocated advocate. All the residents are placed by Ealing Social Services, and residents have access to the Care Managers at Social Services should they have any issues with which they need assistance. We discussed the obtaining of further information regarding advocacy services and ensuring that contact details for key agencies are displayed in the home. We viewed the kitchen. The area was clean and tidy and records were up to date. The home has a 4 week menu and choices are available at all meals. Where residents have specific preferences or nutritional needs related to medical conditions, these were recorded in the care plans. Residents spoken with said that they enjoy the food and are offered a choice, and documentation was available to evidence this. Each unit has a kitchenette area where drinks and snacks can be prepared. Staff were observed assisting residents in a sensitive manner and there was a good, social atmosphere at mealtimes. We sampled the lunchtime meal and this was well presented, as were those served to residents, to include liquidised meals. Sycamore Lodge DS0000071570.V366679.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a system in place for the safeguarding of service users from abuse, understood by staff, thus protecting residents. EVIDENCE: The home has received 2 complaints and these had been investigated and responded to appropriately, with documentary evidence available. There is a ‘user friendly’ complaints procedure displayed throughout the home. We discussed the displaying of a list of ‘useful contacts’ to include CSCI and other organisations should people wish to contact any of them. Contact details are available on the complaints procedure contained in the Service User Guide. The home has procedures in place for safeguarding adults and also follows the London Borough of Ealing Safeguarding Adults procedures. Some incident reports were viewed and these contained information regarding resident aggression towards staff. The importance of reporting any such incidents to the safeguarding adults team was discussed. Staff spoken with said that they would report any concerns and also understood Whistle Blowing procedures. Sycamore Lodge DS0000071570.V366679.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, 21, 22, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has been purpose built to a high standard, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home is purpose built and was opened in March 2008. The premises have been equipped and furnished to a high standard, and the units are homely and welcoming. 3 units have 15 bedrooms and 2 units have 16 bedrooms. All units have a sitting/dining room and separate activity and quiet rooms. The home has a day centre, outpatients clinic and Primary Care Trust (PCT) offices attached to it. There is a secure garden and work is planned to provide a second garden area. An area of concern was the car park, which has very limited parking available to serve the home, day centre, outpatients clinic and PCT offices. We experienced problems parking on both days of inspection. The Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 18 Area Manager said that Servite Houses are very aware of the parking problems and are looking into ways to alleviate them. The bathrooms are spacious and well equipped to meet the needs of the residents. Each bedroom has an en suite to include assisted shower facilities, and staff commented on the positive outcomes for residents in having this facility for each individual. The corridors are wide and there are handrails on each side. There is moving & handling equipment available and staff stated that the equipment available meets the needs of the residents. On the nursing unit the beds are adjustable and on the residential units the beds currently meet the needs of the residents. The bedrooms are spacious and furnished to a high standard, and residents are encouraged to personalise their rooms, giving a homely feel. All the bedrooms are single and the en suites include toilet, wash hand basin and assisted shower facilities. The home has a separate laundry room with 2 washers and 2 dryers, all of industrial standard. There are clear laundry programmes on display and the washing machines have appropriate wash programmes to manage soiled or infected laundry. The home has a policy to ensure that all personal laundry is returned to the resident within 24 hours. Protective clothing to include disposal gloves and aprons was available in the home. The home was clean and fresh throughout, and infection control was being well managed. Sycamore Lodge DS0000071570.V366679.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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place and are followed, thus safeguarding residents. There is a training programme, to provide staff with the skills to meet the needs of residents. EVIDENCE: The staffing levels on each unit was appropriate to meet the needs of the residents. Staff spoken with said that they have enough staff to care for the residents effectively. On both days of inspection interviews were taking place for the 3 Servite Homes in this area, and representatives from each home were on the interview panel. The Area Manager said that these recruitment days would be held every 3 months to ensure an ongoing system of recruitment. The AQAA identified that over 50 of the care staff are trained to NVQ level 2 or above. The Area Manager said that further NVQ in care training is being planned. We viewed 3 sets of staff employment records. In one instance only one reference was available, however the second reference has since been located and evidence forwarded to us. The records viewed therefore contained the information required under Schedule 2 of the Care Homes Regulations 2001. Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 20 The home has a comprehensive induction programme that includes the Skills for Care common induction standards. Staff spoken with said that they had received thorough induction training and had worked supernumerary shifts alongside experienced staff. There was evidence of training in topics relevant to the diagnoses of the residents, with ‘dementia care mapping’ training arranged for August 2008. Shortfalls in health & safety training have been commented on under Standard 38. Sycamore Lodge DS0000071570.V366679.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, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team is developing in order to provide effective management for the home. Systems for quality assurance are developing however improvements are needed to current processes in use to provide accurate review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are in place, however shortfalls identified could place residents, staff and visitors at risk. EVIDENCE: The Registered Manager has been a home manager since 2001. He has completed the Registered Managers Award and is also qualified to NVQ level 4 in care. The Registered Manager is aware of the importance of gaining more knowledge in aspects of nursing care. Staff spoken with said that the Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 22 Registered Manager is approachable and supportive. The home also has a registered nurse who is Head of Nursing and is in the process of recruiting a Head of Care. Both these posts are management positions and they will work on a supernumerary basis. The rosters viewed did not include management cover for the home and the need to include the management hours on the roster was discussed. The need to include management hours at weekends and other ‘out of hours’ times should also be considered. The Registered Managers office is located on the third floor, and the importance of ensuring that residents and visitors are clearly informed about where and how to access the Registered Manager was discussed. The home has been registered since March 2008 and the Registered Manager said he is in the process of building up the quality assurance programme for the home. A comprehensive monthly audit is carried out for the London Borough of Ealing, which covers in detail all aspects of the home. Although this does include auditing of some medication it was clear from the shortfalls identified at the inspection that a robust system of audit and review for medications needs to be put in place and implemented without delay. A requirement has been made under Standard 9. Regulation 26 visits are carried out monthly on behalf of the Registered Provider and copies of the reports are available. Staff meetings take place and minutes are available. The Area Manager said that they are planning a meeting for relatives. The AQAA completed by the Registered Manager did not contain information regarding all the key standards and some information was very brief. The importance of completing this document in full was discussed. The home holds clear records of income and expenditure for residents for whom monies are held on their behalf. The administrator was sorting out payments for hairdressing and did so in a methodical and clear manner. Receipts were available for all expenditure and the records were accurate and up to date. Samples of installation, servicing and maintenance records were viewed and those seen were up to date. The home has recruited a maintenance person and is awaiting employment check information. The monthly water temperature checks were not commenced until June 2008 and the importance of ensuring these are completed in full each month was discussed. The last Fire Risk assessment was carried out in May 2008 and the list of items to be actioned is to be completed within 6 months of that date. Risk assessments for safe systems of working and equipment were in place and had been updated in June 2008. The home has a comprehensive training manual for fire safety and there was evidence of regular fire drills taking place for day and night staff. Several of the bedroom doors were not closing fully and this included doors on rooms where residents smoke. Action was taken promptly and maintenance work was carried out to address this on the second day of inspection. Residents are allowed to smoke in their bedrooms, however doors are often left open and the smoke permeates into the corridors, affecting others who do Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 23 not smoke. Action must be taken to ensure that the smoke is contained in and thereafter effectively dispersed from the bedrooms. The training matrix forwarded to us by the Registered Manager reflected that not all staff had received training and updates in some health & safety topics to include moving & handling within the required intervals, and this must be addressed. Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 4 3 X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 13(4) Requirement Risk assessments for falls must be completed for each resident so that the risk is identified and action can be taken to safeguard residents. Assessments to include nutrition and continence must be completed and kept up to date, to reflect the condition and needs of each resident in each healthcare area assessed. Assessments for bedrails must be completed prior to their use to ensure their suitability for the resident concerned. Where codes are used to indicate the omission of a medication there must be clear instructions to identify what each code is being used for. Records of all receipts and disposals of medication must be kept in order to provide a clear trail of each residents medication. The minimum and maximum temperatures of the fridges must be recorded on all units. Action must be taken to maintain the DS0000071570.V366679.R01.S.doc Timescale for action 15/08/08 2. OP8 17 15/08/08 3. OP8 13(7) 01/08/08 4. OP9 13(2) 22/07/08 5. OP9 13(2) 22/07/08 6. OP9 13(2) 01/08/08 Sycamore Lodge Version 5.2 Page 26 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) 10. 11. OP9 OP11 13(2) 12 12. OP33 24(3) 13. OP38 23(4) 14. OP38 12 15. OP38 18 temperature in the medications rooms below 25° centigrade so that medications are stored at safe temperatures. Those responsible for the administration of medications must be aware of any specific administration requirements and these must be recorded on the MAR. That the practice of supporting residents in the residential unit, with insulin drawn up 3-4 days in advance, is reviewed with the district nurse team. The home must have in place robust systems for the auditing of medication in order to safeguard residents. For residents who self-medicate there must be a clear risk assessment in place. Information regarding residents wishes in the event of deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their wishes are respected. The CSCI Annual Quality Assurance Assessment must be completed in accordance with the available guidance in order to provide a comprehensive assessment of the home. The fire doors throughout the home must be maintained in full working order at all times to safeguard residents, staff and visitors. A robust system must be put in place to ensure that the effects of smoking are restricted to the designated smoking rooms only, to safeguard other residents, visitors and staff. All staff working in the home must receive training and updates in health & safety topics DS0000071570.V366679.R01.S.doc 01/08/08 01/08/08 01/08/08 22/07/08 01/09/08 01/09/08 22/07/08 15/08/08 01/09/08 Sycamore Lodge Version 5.2 Page 27 to include moving & handling at the required intervals. 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 OP18 Good Practice Recommendations That all incidents of aggression be reported to the Safeguarding Adults Team in order that this can be discussed and an action plan put in place. Sycamore Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Lodge DS0000071570.V366679.R01.S.doc Version 5.2 Page 29 - 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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