Inspection on 15/08/06 for Sycamore Lodge Care Home

This inspection was carried out on 15th August 2006.

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

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

Other inspections for this house

Sycamore Lodge Care Home 21/08/07

Sycamore Lodge Care Home 10/03/06

Sycamore Lodge Care Home 29/11/05

Sycamore Lodge Care Home 19/01/05

Sycamore Lodge Care Home 15/06/04

Sycamore Lodge Care Home 21/05/03

Sycamore Lodge Care Home 17/06/02

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

CARE HOMES FOR OLDER PEOPLE Sycamore Lodge Care Home 2 Burringham Road Scunthorpe North Lincolnshire DN17 2BB Lead Inspector Eileen Engelmann Key Unannounced Inspection 15th August 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 Lodge Care Home DS0000002807.V308650.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 Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Lodge Care Home Address 2 Burringham Road Scunthorpe North Lincolnshire DN17 2BB 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) 01724 856963 F/P 01724 856963 sycamorelodgehome@hotmail.com Mr Sukhuinder Marjara Mrs Margaret Williams Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 Brief Description of the Service: Sycamore Lodge is situated in the Ashby area of Scunthorpe, it is close to the local amenities and on a number of bus routes. The home provides care including nursing for up to 40 service users over the age of 65. Accommodation is provided on two floors; there is stair and passenger lift access to the first floor. There are thirty single rooms and five shared rooms; en- suite facilities are provided in eight of the single rooms. The home has a good variety of day space; there are two lounges, a dining room and a conservatory. All rooms are decorated and furnished to a good standard. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is on display in the reception area of Sycamore Lodge. Information given by the manager on 28/04/06 within the Pre-Inspection Questionnaire indicates the home charges a range of fees from £327.00 to £375.00 per week and that there are additional charges for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these can be found in the Service User Guide. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the registered manager, staff and residents of Sycamore Lodge. The inspection took place over 1 day and included a tour of the premises, examination of staff and resident files and records relating to the service. Three of the staff on duty and four of the residents were spoken to; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to a selection of relatives, residents and staff and their written response to these was good. The inspector received 14 back from relatives (70 ), 16 from staff (43 ) and 19 from residents (48 ). The provider completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. The provider, manager and staff have worked hard to meet the requirements and recommendations from the last inspection report (March 06). The service has met all the key standards at this visit and has exceeded the standard in four areas. The management team are aware that it is important that the home continues to develop its practice and give residents a high quality service. What the service does well: The home’s statement of purpose, and service user guide are given/explained to each resident living at the home. Information within the documents gives residents a good idea of the service provided and four individuals said ‘ we were able to talk to the manager and staff before coming into the home and find out more about what living at the home would involve and how our needs and interests would be met’. Staff provide a good level of support and care that helps the residents in their daily life. One individual wrote ‘the nursing support is good and has significantly improved my health, whilst I have been in the home’. Another person commented that ‘the care is excellent and staff are always there when needed’. Visitors to the home are made welcome and the home has a relaxed atmosphere that encourages families and friends to join in with activities and other social events. Residents commented that they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes were catered for and they had plenty to eat and drink throughout the day. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 6 Resident’s comments indicate they hold the staff in high regard, one individual said that ‘the staff are friendly, helpful and always supportive’. Two residents said that they ‘enjoy living at the home and that it has a very comfortable and pleasant atmosphere’. The home works hard to improve the quality of its service by asking the opinions of the staff, residents and relatives. Changes to practices in the home are documented, and show how the manager and provider use the information received to make sure the home meets the needs and expectations of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. Quality in this outcome area is good. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The statement of purpose and service user guide can be found in the manager’s office and are available on request from the manager. A copy of the last inspection report (March 06) is on display in the reception area of the home. The manager has acted on a recommendation made in the last inspection report, and advocacy information about local services is now available in the service user guide. Comments in the residents surveys showed that individuals coming into the home are provided with good information about the home and the service it provides. One resident has recently come to stay at Sycamore Lodge; their family were able to look around the home and were provided with sufficient information and advice to help them decide if the home was right for the Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 9 individual. This person said ‘I have been made to feel extremely welcome and the staff and manager have helped me settle in’. Since the last inspection the home has introduced feedback sheets to be completed by all people newly admitted to the home. These are part of the quality audit system and comments from the sheets help the provider and manager see if the admission process is working and how well it has been carried out by the staff. Each resident has their own individual file and four of those looked had a need assessment completed by the funding authority and the home has also completed its own needs assessment before a placement was offered to the resident. The home develops a comprehensive care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the resident and family. Those residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. Discussion with the manager indicated that she has been working hard to develop the skills and knowledge of the staff around care and provide residents with a better service delivered by well-trained staff. Checks on the staff files, indicates that staff support and guidance through supervision is carried out regularly, ensuring staff are able to meet the needs of the residents in full, and to a high standard. The training records indicate that a range of subjects have been studied by the staff including safe working practices and dementia care. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of the residents. Information from the Pre-Inspection Questionnaire and discussion with the residents indicates that the majority of the residents are white/British nationality. Those who are from other ethnic groups are well looked after, their dietary needs are met by outside catering and their religious needs are understood and respected by the staff. Comments from the relatives and residents surveys indicate they are pleased with the care being given and have a good relationship with the staff. Sycamore Lodge Care Home DS0000002807.V308650.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. EVIDENCE: The home continues to produce and keep clear and well-written care plans for the residents. Individual care plans are in place for all residents and the four examined set out the health, personal and social care needs identified for each person. The plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. Risk assessments were seen to cover pressure sores, nutrition, moving/handling and activities of daily living and all of the care plans have been signed by the resident or their family. Information about the resident’s social interests, likes and dislikes, spiritual needs and wishes regarding death and dying are all included within the individuals care plan. Individual choices and decisions about how care is to be given were also well documented and for two individuals is very specific and detailed so staff can provide continuous care to meet their needs. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 11 It was noted that although the key workers regularly recorded in the care plan, the trained nurses were not always making a daily entry. It is recommended that this practice should be altered so there is always at least one entry about the care given every 24 hours. Four residents said that they have good access to their GP’s, chiropody, dentist and opticians, with records of their visits being written into their care plans. Information from the plans showed that individuals are able to access medical professionals as needed, including the Community Psychiatric Nurse, Speech therapist, Dieticians and the District Nurse. They all attend outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the residents and relatives indicate there is a high level of satisfaction about the nursing care given at the home. One individual wrote ‘the nursing support is good and staff are quick to call the Doctor as needed’. Another person commented that ‘the care is excellent and staff are always there when needed’. Entries in the care plan specify where individuals have dietary needs, including thickened fluids, supplement drinks and pureed diets. The staff weigh everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. Information from the pre-inspection questionnaire indicates that currently there are four residents with pressure sores, but these wounds are documented in the care plans and wound care given as appropriate. Input is available from the tissue viability nurse, where requested, and the District Nurse sees to the residential individuals. Since the last inspection (March 06) the manager has worked hard to meet the requirements and recommendations made in the last report. Transcribed medication now has two staff signatures when it is written onto the sheet and the manager completes a weekly audit to ensure the records are kept up to date and staff are using the system correctly. A record has been produced to show what medications are leaving the home with residents who are going into hospital, this gives a clear audit trail for anyone wishing to check stock levels for accuracy. It was noted that medication already held in the home when a new delivery is receipted in is not added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All four of the residents spoken to prefer to have staff administer their medication. Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. Resident and relative comments show that overall they are very satisfied with the care and support offered by the staff. Chats with the residents revealed Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 12 that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Two individuals spoken to said ‘ the staff are lovely, they are always around to offer help and support when we need it and are very considerate of our feelings’. Three people wrote that ‘ residents sometimes have to wait a long time for toileting especially at meal times’. Four surveys said that ‘ staff respond quickly to call bells and we are very satisfied with the care given’. One person commented that ‘the home is first class and I am extremely happy with the care I receive’. Observation before the lunchtime meal showed that staff worked quickly and efficiently to toilet and see to the care needs of all the dependant residents before lunch was served. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. Residents are provided with choice and diversity in the meals and activities provided by the home. Relatives and visitors are made welcome at the home and good links to the community enrich the residents social and leisure opportunities. EVIDENCE: Information gathered from the surveys and discussion with four residents indicated that levels of satisfaction with the activity programme and social events provided at the home ranges from ‘very satisfied to there is nothing to interest me’. At the last inspection (March 06) the provider and manager recognised that there was a need to provide a consistent range of activities for the residents. Recently the home has taken on an activities co-ordinator who spends 2 days (10 hours) a week organising and carrying out specific social events and entertainment. On the day of this visit she was busy in the main lounge with a group of residents playing skittles, darts and dominoes. Residents said ‘the lady is wonderful, she brightens up the day and we enjoy taking part in the activities’. Information about forthcoming events shows that there is a regular stream of outside entertainment coming into the home, including clothes shows, music Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 14 events and trips out (the home uses Age Concern transport). Residents had enjoyed a trip to Normanby Hall the week before this visit. Resident meetings take place three monthly, and this is used as an opportunity for individuals to express their ideas of what activities and trips out they want and to give their feedback on events that have taken place. The meetings have been hampered by a lack of attendance in the past and the manager is hoping to hold smaller group meetings or document her daily talks with the residents in order to gather information and input for the quality audit process. There were a number of visitors to the home during the afternoon and one individual said ‘ the staff are very welcoming and include you in all aspects of the residents care. The atmosphere within the building is friendly and makes you feel at home’. Open visiting hours at the home enable individuals to come at times suitable for the residents and which fit into their own busy work schedules. Information from the residents’ files indicates that there are a number of individuals who follow different spiritual faiths, including Catholic and Church of England. The manager said that there are regular church services (monthly) within the home and the catholic priest visits weekly to give communion to those who want to partake. Information about advocacy services is on display in the home and includes leaflets made available to the residents and relatives from the manager. Discussion with the manager indicated that no one at the home is currently using an advocacy service, although these have been accessed in the past. Four residents spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. Residents spoken to are satisfied that they can access their personal allowances when needed. All the residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. Discussion with the residents showed that they are aware of their care plans and able to contribute to them and access them through their key workers. Comments from the surveys received from staff, residents and relatives indicate that overall there is a good level of satisfaction with the meals provided by the home. One individual said ‘the food is lovely, choices are good and there is plenty of it’, another commented that ‘I had a cooked breakfast this morning and it was very tasty’. Observation of the midday meal showed it to be well prepared and presented, and the kitchen staff had made an effort to provide soft/pureed diets in an attractive way. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to residents who need help with eating and drinking. Menus are available on the dining tables and a chalkboard on the wall gives information about the choices on offer each day. Jugs of squash were seen in the dining room and lounges and residents said ‘we can help ourselves or the staff will get us a glass and those who need assistance have regular drinks offered’. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: Checks of the complaints record shows that the home has not had any formal complaints since the last inspection. Discussion with the manager indicates she would deal with any ‘niggles or grumbles’ on a daily basis. The home has a complaints policy and procedure that is found within the statement of purpose and service user guide. It is also on display within the home. Four residents showed a clear understanding about how to make their views and opinions heard and said ‘the manager comes round every day to see us and will discuss any problems at this time. She will take immediate action, if needed, to resolve any issues brought to her attention’. The staff on duty displayed a good understanding of the vulnerable adults procedure and three residents spoken to said they ‘felt safe at the home’. Staff training files show that Protection of Vulnerable Adults from Abuse training has taken place and is an ongoing process, and information from the staff surveys indicates they are confident about the whistle blowing procedure and discussing any concerns with the management team. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint, and management of resident’s money and financial affairs. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 26. Quality in this outcome area is good. The standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: The manager has a record of the ongoing maintenance and renewal programme within the home and this indicates that the provider is committed to improving the facilities and environment within the home. Since the last inspection (March 06) there has been considerable investment spent within the service. All lounges have been refurbished with new and comfortable armchairs and the carpets have been replaced. The corridor leading from the conservatory has been re-carpeted, the walls and paintwork have been redecorated. New tables and chairs have been purchased for the dining room and the floor has been laminated. The high fence outside of the conservatory has been replaced with a smaller fence, letting more light into the area. Staff have been provided with a new mobile unit in the grounds of the home, which provides them with a non-smoking staff room (other facilities are available for smokers). Ongoing redecoration is evident throughout the home and the Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 17 provider is already planning upgrades for different areas. Ten bedrooms have been refurbished with new beds and furniture; others are to be completed over the next year. Inspection of the home showed that it has been designed and built to meet the needs of disabled individuals. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious and have enough room for people in wheelchairs or with walking frames to pass by comfortably. The home is built on two floors with flat walkways inside and out, providing safe and secure footing for people with limited mobility. Access to the upper floor is by use of a stair lift or the passenger lift. Discussion with the staff indicates that there is a wide range of equipment provided to help with the moving and handling of the residents and to encourage their independence on the lodges. This includes mobile hoists, stand aids, slide sheets, moving belts and handrails. Comments from the staff indicate that they would like to have another hoist and more slide sheets, as the demand for their use is high. The manager should assess if equipment is being used efficiently and if there is a need for further provision. Four residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more homely’. All bedrooms are supplied with door locks and lockable storage space to ensure resident’s valuables are kept safe. The rooms are decorated to a high standard and supplied with sufficient furnishings to meet the requirements of the residents and standard 24. The environment is clean, warm and comfortable and no malodours were present. Comments from the surveys indicates that the residents find the home to be spotlessly clean and are satisfied with the laundry service provided by the home. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. The standards of recruitment, induction and training of staff are very good with appropriate checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that residents are protected from risk and looked after by motivated and knowledgeable people. EVIDENCE: Inspection of the duty rota and discussion with the manager indicates that the staffing levels at the home remain the same as at the last inspection. In general there are two nurses and six care staff on duty in a morning, two nurses and five care staff in the afternoon and one nurse and three care staff at night. Observation of the staff showed that the home is busy, but well organised. Comments from the surveys and discussion with the staff indicated that there are some concerns about the levels of staff on duty. Staff said they feel rushed and ongoing problems of staff sick leave and holidays are creating unfair pressure on the staff, and there is a lack of quality time spent with the residents. Individuals felt that there should be a bank of staff who could be called on if people call in sick, this would relieve the expectations that existing staff will fill in any gaps. Staff comments also said that the home is a great place to work, colleagues are friendly and management is supportive. Residents and relatives commented that the staff are ‘caring and helpful, they are obliging and quick to respond to calls for assistance’. Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 19 The above comments were shared with the provider and manager, and it was recommended that they audit the staff opinions around the cover for sickness and absences, to help them review the existing management strategies and make any changes as needed. Information from the pre-inspection questionnaire and staff rotas about the number of staffing hours provided and the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. There is an induction and foundation course that meets National Training Organisation specification for new members of staff, and 73 of the care staff have achieved an NVQ 2 or 3. The home provides a mandatory staff-training programme and additional, more specialised training that reflects the different care needs of the client group. There is no evidence that staff have received training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. Information in the staff training files and discussion with the staff indicates uptake of training has been good over the past 12 months and there is a staff training matrix in place to monitor this. Discussion with the manager and checks of the staff information in the preinspection questionnaire indicates that the home does not employ any male care staff. The manager said that she has tried to recruit male carers in the past, but this has proved difficult, as there have been few suitable applicants. She is aware that this may affect resident’s wishes regarding gender choice for giving of personal care, and this is discussed before an individual is offered a placement at the home. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home employs four staff from overseas and these individuals have been in post for some time. Staff comments indicated that it is hard work when new staff are on shift; and if they have language problems because English is not their mother tongue then the staff and residents find it hard to communicate with them. No negative comments from the residents or relatives, about communication barriers, were received. It was recommended that the manager considers the staffing levels when introducing new staff into the team and looks at how skill mix issues and communication problems can be overcome to promote a good working relationship for all staff members. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police/Criminal Record checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 20 audits with the Nursing and Midwifery Council to ensure they are able to practice. Sycamore Lodge Care Home DS0000002807.V308650.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents, staff and relatives. EVIDENCE: The registered manager of the home has been employed in the home for seven years; she was appointed manager and completed registration with the Commission in 2003. The manager has completed her Registered Managers Award and updates her skills and knowledge through regular attendance at training sessions. Certificates on the wall of the home and discussion with the Provider and Manager indicate that the North Lincolnshire Council has awarded the home its Gold Standard for Quality Assurance, this award was achieved in 2002 and has Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 22 been reaffirmed by the council since this time. The home is also accredited with Investor in People Status since 2002 and this too has been reaffirmed. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. Discussion with the provider and manager indicate that the home is improving its quality audit practices to introduce more robust systems that feedback information on more of the practices within the home. There is an Annual Development Plan in place and the manager is gathering information for the production of this years report. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Checks of the financial records showed that residents are able to have Personal Allowance accounts in the home. These records are hand written and each person has their own account sheet, which is updated each week by the manager/administrator. Information from the manager indicates that the residents have a family member or representative who looks after their monies and these individuals make sure the Personal Allowances are sent/brought into the home. Each resident has their own wallet for their money and receipts of all transactions undertaken are kept in their file. Checks of these showed them to be accurate and up to date. The home does not keep large amounts of cash on the premises and if a person’s allowance builds up it is returned to the family/representative for ‘safe-keeping’. Staff supervision files show that individuals receive formal supervision with their line managers on a regular basis. The 1-1 sessions with the staff are structured and cover all aspects of practice, philosophy of care in the home and any career or training/development needs of the individual. The provider is carrying out monthly regulation 26 visits to the home and provides the Commission with copies of the reports generated from these visits. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Sycamore Lodge Care Home DS0000002807.V308650.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 X X 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No. 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations Staff must record at least once in 24 hours within the care plan, outlining the care given on a daily basis. Medication already held in the home when a new delivery is receipted in should be ‘brought forward’ on the medication record sheets. This should be done so as to ensure a running total is available at all times. The provider and manager should audit the staff opinions around the cover for sickness and absences, to help them review the existing management strategies and make any changes as needed. The manager should consider the staffing levels when introducing new staff into the team and look at how skill mix issues and communication problems can be overcome to promote a good working relationship for all staff members. Staff should receive training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. DS0000002807.V308650.R01.S.doc Version 5.2 Page 25 3 OP27 4 OP27 5 OP30 Sycamore Lodge Care Home Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sycamore Lodge Care Home DS0000002807.V308650.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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