CARE HOMES FOR OLDER PEOPLE
Sycamore & Poplars Care Centre High Street Market Warsop Nottinghamshire NG20 0AA Lead Inspector
Karmon Hawley Unannounced Inspection 24th November 2005 10:00 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 & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 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 & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sycamore & Poplars Care Centre Address High Street Market Warsop Nottinghamshire NG20 0AA 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) 01623 847303 01623 847396 the.sycamores@ashbourne.co.uk Exceler Healthcare Services Limited Julia Mary Stanley Care Home 74 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (40) of places Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 24 beds in the category of OP are reserved for nursing. Service users must be within categories OP(40), DE/E(34) Date of last inspection 26/07/05 Brief Description of the Service: Sycamore and Poplars Care Centre was opened in 1991 and consists of two buildings, which share the site. Sycamore unit caters for up to 40 service users, offering both nursing and personal care, whereas Poplars unit offers dementia care for up to 34 service users. The home provides short and long term care and operates a respite service and will accept emergency admissions. The home is located in the centre of Warsop and is close to shops, pubs, the post office and other amenities. Sixty-nine of the homes bedrooms are single and seven of the bedrooms have ensuite facilities, six of which are single rooms and the other a double room. Bedrooms are located on two floors on both units and access is facilitated by a shaft lift. The home has a garden area that is well maintained and easily accessible. There is a good-sized car park to the front of each building. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of six randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Seven service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those service users spoken with were happy with the care received and the standards within the home. The manager, the administrator and a senior care assistant assisted in the inspection process and three other members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and promoted a caring atmosphere. What the service does well: What has improved since the last inspection?
There have been many improvements since the last inspection. All upstairs bedrooms in the Poplars unit have been redecorated and the upper floor corridor in the Sycamore unit is in the process of being redecorated ensuring a well-maintained environment. Staff morale is stated to have improved due to the positive changes the new acting manager has put into place and this was evident during the inspection. Staff training has continued to develop and additional training beside the mandatory has been implemented, ensuring staff
Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 6 are able to deliver a good quality of care. Malodour has been eradicated in the Sycamore unit, thus ensuring a more pleasant environment for service users, staff and visitors. The identified trip hazard noted in the previous inspection has been repaired and thus made safe. The maintenance man has now been on an approved electrical course so he may carry out the portable appliance testing on equipment thus ensuring safety is maintained. 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 & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 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 & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed during this inspection. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 9 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 Service users health, personal and social care needs are set out in an individual plan of care, however needs may not be fully met due to the over sight in the information available within risk assessments, and the corresponding of daily records and care plans. Service users remain at risk due to the homes procedures in the administration of medicines. EVIDENCE: Service users undergo various assessments with regards to manual handling, nutrition, mental health and the activities of daily living, which underpin the plan of care. There was evidence to demonstrate that service users and relatives are given the opportuintiy to be involved in the plan of care. Plans of care in place were in depth, individual and extremely personalised. Personal choices and preferences were recognised and it was evident that these were maintained. Risk assessments were in place however with regards to two service users who had diabetes there was no risk assessment available for one and the information in the other did not fully outline the management of the risk. Daily running records were maintained and contained information with regards to significant events. In one plan observed where a service user had been diagnosed with methacillin resistant staphylococcus areus this had been noted in the daily notes and a risk assessment had been put into place
Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 10 however this was not reflected in the plan of care. Reviews were evidenced to take place, however despite significant changes being recorded on the care plan these were not fully discussed in reviews. There was evidence available within the service users plans of care to demonstrate that the multidisciplinary team are liaised with and they visit the home. Service users were able to substantiate this and discussed how the optician and other services visit them. Staff substantiated that specialist services visit the home as needed and service users also access these within the community; equipment and aids are supplied as necessary. Medications were checked on the day of the inspection. There were gaps within records where medications had been both given and not signed for and not given and signed for. On one medication chart observed a medicine had not been signed for a whole week despite having been administered on several occasions. Where handwritten entries had been made these were not always signed by two members of staff. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 11 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 Service users are enabled to maintain contact with family and relevant others and find a lifestyle, which matches their expectations and preferences and satisfies their needs. EVIDENCE: Service users spoken with stated that the routine within the home was flexible and they may choose how they spend their time. There are no restrictions on visiting and trips outside the home are often arranged. Visitors may be received in private if desired and staff are respectful in maintaining privacy. An activities coordinator is employed and a range of activities are available on an individual and group basis. Service users stated they joined in activities and they enjoyed them. The local community become involved within the home when main events take place such as fetes/book sales. There is a varied and flexible menu available and service users stated that food was at a good standard and plentiful. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 12 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): 16 Service users and their relatives and friends can be confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: There have been no complaints received since the last inspection, however two investigations with regards to concerns brought to the mangers attention have been investigated, one, which was unsubstantiated and resolved, and another that resulted in a staff member being dismissed. The manager followed procedures with this regard and kept the Commission for Social Care Inspection informed appropriately. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 13 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): Service users live in a clean, pleasant and well-maintained environment. EVIDENCE: Not fully assessed during this inspection. The malodour in the Sycamore unit has been eradicated. Redecoration has taken place in bedroom in the Poplars unit and the upper corridor in the Sycamore unit is currently being redecorated. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 14 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): 28,29,30 Service users are in safe hands and supported by the homes recruitment policy and practices. Staff are trained and competent to carry out their jobs. EVIDENCE: 7 care staff have attained the National Vocational Qualification level two and 17 are registered or working towards the qualification. There is an in depth induction programme at a recognised standard, there was evidence available to demonstrate new staff complete this programme. Four staff personnel files were examined and demonstrated that all required information is in place with regards to this standard. Staff training in regards to mandatory training is at 100 percent, additional training in the following areas has also taken place: safe handling of medicines, senior care workshops, care planning, roles of key workers, dementia, a certificate in aggression management and palliative care. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 15 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 Service users live in a home that is run in their best interest and managed by a person who is fit to be in charge, of good character and able to discharge her responsibilities fully. EVIDENCE: The acting manager has been in post now for five months, she is a registered nurse and has previous experience as a care manager of a 90 bedded home and as a community nurse. Whilst at Sycamore and Poplars she has undertaken all mandatory training and a course in palliative care. She is awaiting registration to commence the National Vocational Qualification Registered Managers Award. An application for registration has been submitted to the Commission for Social Care Inspection. Staff when spoken with spoke very highly of the acting manager and stated that many improvements have been made and the atmosphere and staff morale has improved. Service users also spoke highly of the acting manager and expressed positive feedback with the management of the home.
Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 16 Quality assurance questionnaires are carried out every three months; this involves service users, relatives and visiting professionals. Feedback observed was of a positive nature. The manager also carries out in house audits of all areas of the home on a monthly basis to ensure quality is maintained, evidence of these was available for inspection. Monthly statistics are also kept with regards to weights, pressures sores and staff training and sent to the head office. Action plans are drawn up if required to address any deficits. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X X Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 14 (4,c) Requirement Timescale for action 30/12/05 2 OP7 14 (4,c) 3 OP9 13 (2) The registered person is required to ensure that appropriate risk assessments and management plans are in place to fully protect service users. To ensure that safety is 30/12/05 maintained significant changes in care needs must be reflected in plans of care. The registered person is required 24/11/05 to ensure the safe administration and recording of medication. 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 OP7 Good Practice Recommendations To carry out monthly reviews of plans of care and ensure an appropriate written entry is available to demonstrate any significant changes and to reflect the service users current condition. Sycamore & Poplars Care Centre DS0000024656.V269089.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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