CARE HOMES FOR OLDER PEOPLE
Sycamores and Poplars Care Centre High Street Market Warsop Nottinghamshire NG20 0AA Lead Inspector
Karmon Hawley Unannounced 26/7/05 10.30am 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 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. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sycamores and Poplars Care Centre Address High Street Market Warsop Nottinghamshire NG20 0AA 01623 847303 01623 847396 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Exceler Healthcare Services Ltd Julia Mary Stanley CRH 74 Category(ies) of DE/E 34 registration, with number OP 40 of places Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: A maximum of 24 beds in the Op category are reserved for Nursing. Date of last inspection 11thOctober 2004 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 owned by Ashbourne Healthcare, which is a national organisation. The home is located in the centre of Warsop and is close to shops, pubs, the post office and other amenties. Sixty nine of the homes bedrooms are single and seven of the bedrooms have ensuite facilties, six of which are single rooms and the other a double room. Bedrooms are located on two floors on both units and access is facillitated 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. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day, four service users case notes and other related documentation related to care, staffing and the environment were examined. Four service users, one relative, one friend and two staff members were spoken with. The general manager assisted with the inspection, however she is leaving employment at the home, therefore the newly appointed manager who was present assisted in the inspection process. What the service does well: What has improved since the last inspection?
A policy with regards to the distribution of mail has been implemented ensuring service users receive mail at all times and relatives and a plan of care is put into place if assistance with mail is required. Staff training with regards to the protection of vulnerable adults and the promoting of choice for service users has been improved upon ensuring a quality care is delivered. Mealtimes have been reorganised so service users are served in a more comfortable and structured manner. Additional keypad locks and risk assessments have been put into place to ensure the added safety of service users. Service users views are included in audits carried out ensuring service users opinions are considered. Policies and procedures are now available in each unit ensuring staff have easier access to these thus promoting working practices. Staff now ensure they continue to carry out maintenance checks in the absence of the maintenance man to ensure the continued safety of service users.
Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 6 Water tank testing has commenced to further protect service users from the risk of legionella. 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. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 standard(s) 3,5 Service users can be assured their needs will be appropriately assessed and met and they are enabled to make an informed choice prior to entering the home. EVIDENCE: The general manager or unit manager visit prospective service users within the community and carry out pre admission assessments to ensure needs can be met. The assessment covers the requirements of the standard. Relatives and prospective service users may visit the home or spend time at the home prior to admission. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 standard(s) 7,9,10 Service users needs may not be fully met due to the lack of assessment and care planning. Service users may be at a degree of risk due to the procedures taking place with regards to the safe administration of medication. Service users can be assured they will be treated with respect and their right to privacy upheld. EVIDENCE: Service users undergo various assessments to assist in determining needs such as manual handling and pressure area care, information is then used in conjunction with an assessment underpinned by the daily activities of living to form the care plan. Four case files were examined, two of which were new admissions into the home. The two new admissions had not undergone appropriate assessments; one did not have a risk assessment in place or an appropriate plan of care. The other two examined identified assessments had been undertaken and appropriate care plans and risk assessments were in place which were in depth and individualised. There was evidence of appropriate liaison with health care specialists and aids and equipment in use. Medication polices were in depth, all procedures were satisfactory with the exception of the administration of medicines were several discrepancies were found.
Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 10 Staff undertake resident welfare training which cover the core values and principles of care. Consultations are carried out in service users own rooms and privacy is upheld at all times. Service users spoken with were able to substantiate this and that staff knock on doors prior to entering a room. A new policy with regards to mail has been introduced and again service users were able to confirm that this policy is maintained. There are no restrictions on visitor. Some service users have their own telephone whilst other may use the office telephones if required. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 standard(s) 14,15 Service users are enabled to exercise choice and control over their lives and receive a wholesome appealing and balanced diet. EVIDENCE: The general manager stated that a few service users handle there own finances otherwise relatives handle finances on service users behalf. The administrator within the home deals with all service user finances kept on the premises. There are lockable facilities provided. Service users may bring in personal possessions if they wish and there was evidence of this within service users room. The manager stated that if service users wished to have access to their notes this would be facilitated, there was evidence that a service user had signed her care plan. Four meals are offered and also drinks and snacks throughout the day. The menu offers an excellent choice and a wholesome diet. Special diets are catered for if required. Kitchen records were observed and a tour of the kitchen demonstrated a well-organised and clean working area. Service users spoken with stated meals were of a good standard and choice was offered. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 standard(s) 18 Service users are protected form abuse. EVIDENCE: An adult protection and whistle blowing policy is available for all staff and these are also condensed in the staff handbook issued on joining the company. Staff spoken with were able to discuss these policies and demonstrate understanding. There are also policies on gifts to staff and mail to further protect service users. Ninety percent of staff have completed the resident welfare training which includes adult protection training. Several staff have also now completed training in Dementia care, they were able to discuss and demonstrate knowledge. All staff are in process of receiving their criminal records bureau checks and new staff have undergone the protection of vulnerable adult checks. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 standard(s) 19,26 Service users live in a safe and satisfactorily maintained environment, however areas are looking tired and in need of redecoration. Whilst the home is clean and hygienic there are several odour problems that require attention. EVIDENCE: Both units were clean and tidy, however on first entering the sycamore unit malodour was evident; on returning at a later time in the day this had been eradicated. On the tour of the home at this later stage two service users rooms were noted to have a malodour, again in the sycamore unit. All other areas were clean pleasant and hygienic. It was noted throughout the tour that there is an ongoing redecoration programme in place, however the top corridor in the sycamore unit requires attention as the wallpaper is torn in several areas. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Service users can be assured the number and skill mix of staff will meet their needs. EVIDENCE: Staffing rotas demonstrated there are sufficient staff employed in both units. Skill and mix of staff is taken into account when planning the rota and there was evidence of this occurring. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,36,38 Service users personal finances are safeguarded, however further consideration may be given to this procedure to fully protect service users. Service users can be assured staff are appropriately supervised. Whilst health, safety and welfare of service users is promoted this may be compromised due to the maintenance man continuing to carry out portable appliance testing. EVIDENCE: The administrator attends to service users personal allowances, each service user has a separate account, which demonstrates all transactions, and two members of staff sign these; however money is kept within one central pooling system, which is reconciliated every month. The administrator also deposits and withdraws money for some service users. Supervision sessions take place every two to three months and cover the requirements of the standard, staff were able to substantiate that these do take place.
Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 16 All maintenance checks and certification were in place and staff are currently working towards the recommendations of the environmental health officer. Staff training is at a good standard, which is underpinned by policies and procedure in place. The maintenance man continues to check service users portable appliances when they are brought into the home despite having no qualification in this speciality. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x x x x x 1 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 3 x 1 Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? 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 15 (1) Requirement The registered person is required to ensure service users undergo an assessment to determine needs and a plan of care based upon this in place. The registered person is required to enure the safe administration of medication. The registered person is required to ensure a safe and well maintained environement therefore the idenfied trip hazard is to be repaired. Erradicate malodour in the sycamore unit. This is an outstanding requirement and action must be taken to avoid enforcement action. The registered person is required to ensure all electrical checks are carried out by a qualified electrician. This is an outstanding requirement and action must be taken to avoid enforcement action. Timescale for action 30th August 2005 2. 3. OP9 OP19 13 (2) 13 (4a) 30th August 2005 Immediate 4. OP26 16 (2k) Immediate 5. OP38 13(4a) Immediate Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 19 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 OP19 OP35 Good Practice Recommendations Further consideration to be given to the redecoration of the upper corridor in the sycsmore unit. Further consideration be given to the handling and banking of service users personal allowances to increase the protection of service users and staff. Sycamores and Poplars Care Centre C03 C53 S24656 Sycamores and Poplarsl V240818 260705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Edgeley House 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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