Inspection on 23/02/09 for Sycamore, The

This inspection was carried out on 23rd February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore, The 27/02/07

Sycamore, The 23/11/05

Sycamore, The 26/07/05

Sycamore, The 17/03/05

Sycamore, The 16/06/04

Sycamore, The 09/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Sycamore, The 34 Lancaster Avenue West Norwood London SE27 9DZ Lead Inspector Sonia McKay Unannounced Inspection 23rd February 2009 10:00 Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 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, The DS0000022767.V374549.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 Adults 18-65. 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, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore, The Address 34 Lancaster Avenue West Norwood London SE27 9DZ 020 8761 4909 020 8761 9064 corinne@mcdonald34.freeserve.co.uk www.larche.org.uk L`Arche Lambeth 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) Ineta Servaite Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 27th February 2007 Date of last inspection Brief Description of the Service: The Sycamore is a residential home for five adults with a learning disability. It is one of five residential care homes in the locality that form the L’Arche Lambeth community. The aim of the community is to create communities that welcome people with learning disabilities. Fundamental principles of the community are that each person has a right to friendship, a spiritual life and to live in an environment that fosters personal growth. It is a large Victorian house with front and back gardens. It is located on a residential street close to shops and transport links. The team of assistants live in the home and are managed by a house leader. LArche also provides access to college courses, therapeutic daytime activities and skills workshops, such as candle making, gardening, stonework, packing and weaving. Service users are encouraged to participate in all aspects of community life. A copy of the most recent inspection report is available in the home on request and weekly placement fees start from £797.00 and increase depending on the amount of staff support that an individual needs. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 5 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 inspection was carried out in one day. The methods used to assess the quality of service being provided were: • • • • • • • Talking with the newly appointed home manager Looking at the ‘Annual Quality Assurance Audit’ completed by the home manager (this document is sometimes called an ‘AQAA’ and it provides the Commission with information about the service) A tour of the communal areas of the premises Looking at records about the care provided to two of the residents Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled The Commission would like to thank all who kindly contributed their time, views and experiences to the inspection process. What the service does well: There is accessible information about the services provided. This is useful to prospective residents who may find text only documents difficult to understand. There is also ample opportunity for residents to experience life in the home before making a decision to move in for a trial period. Residents are supported to contribute their own goals and ideas to care plans. There is an experienced manager in post and the home is clean and comfortable. Residents are able to contribute their ideas to the running of the home and wider community. Systems are in place to monitor the safety of the home. Residents have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Residents are supported to maintain and develop relationships with family and friends and they are part of their local community. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is accessible information about the services provided. This is useful to prospective residents who may find text only documents difficult to understand. There is also ample opportunity for residents to experience life in the home before making a decision to move in for a trial period. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users’ Guide’. Emphasis is placed on making the guide accessible to people with a learning disability and the guide contains many colour photographs, symbols and plain English. During the last inspection a requirement was made as regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. The guide now contains some basic information about fees. It is Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 9 recommended that further work is done to ensure full compliance with this regulation. L’Arche offers long-term placements only and has a lengthy placement process, which is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This provides the referred person with an opportunity to experience life in the home before making a positive choice to move in for a trial period. There has been a detailed six-week and six month placement review involving the core member and his family, social services and staff from the home and the LArche workshops. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. Residents are supported to contribute their own goals and ideas to care plans. Staff would benefit from guidance in what areas of care and support should be considered when planning with people as some areas of support, for example, cultural needs are not presently documented. Systems are in place for staff to assess risk and staff understand the need for residents to take risks to develop their independence. EVIDENCE: Each resident has a set of written plans describing how they are to be supported and cared for. Two of the residents have helped develop their own plans and they are written in the first person. There is no set format for the areas of support and care to be looked at when planning care and some needs, for example, cultural needs are not documented. This must be addressed to ensure that residents get the support that they need. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 11 Planning involves each resident in setting goals and these goals are reviewed regularly. There are good plans for increasing daily living skills in place and this helps people to become more independent. Risks and independence are discussed and reviewed regularly. A general risk assessment process is in place. The document covers topics and activities that each person is likely to engage in and indicates the level of risk posed to the service user during each activity. In the event that an activity is deemed to present a higher degree of risk to their health and safety, a more detailed individual risk assessment is completed identifying the steps taken to minimise the risk. L’Arche uses a semi-independent advocacy system. This ensures that someone from outside the home who knows the resident and sees them often is involved. Fully independent advocates are in short supply but the home manager understands the need for advocates to be involved if major decisions are to be made and a resident lacks the capacity to fully understand an issue. Residents are encouraged to participate in the day-to-day running of the home and in community planning. They can take part in weekly house meetings, ‘talking group’ meetings with the community director six times a year and community council elections. Residents are also involved in the assessment of new staff during their probationary period and in discerning internal applications for house and community leaders. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Residents are supported to maintain and develop relationships with family and friends and they are part of their local community. EVIDENCE: L’Arche is a faith-based community and offers active support to each resident to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature instead. Each resident has a place in the L’Arche supported employment workshops (weaving, stone work, gardening and candle-making). Two residents also attend college. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 13 The close proximity of the other L’Arche homes provides an opportunity for residents visit each other and goes out for dinner. There is a strong community spirit and lots of parties and celebrations to attend or host. Residents are supported to maintain and develop relationships with family and friends. There is good information about family and friends that each person likes to keep in touch with. There are evening and weekend activities, such as daytrips and discos, in the community. There is a television, DVD player and stereo available in the communal lounge. The manager demonstrates an understanding of the need for people to have relationships and is careful to ensure that people get the right sort of information and support when considering closer relationships. L’Arche Lambeth has been operating for more than 30 years and has developed good relationships with local individuals and organisations. Some of the staff live at The Sycamore with the service users, with the intention of building a shared community and consistent engagement between the staff and the service users. Attention is paid to special celebration days and there are birthday parties and dinner parties with guests. All residents are offered a minimum three weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. One resident is helped to look after some pet goldfish. Records are kept of what each person eats. Records of the meals eaten show that a variety of meals are prepared. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive the right amount of support with their personal care and their physical and emotional health needs are addressed. Preventative healthcare could be improved with better planning. Medication is administered safely by staff. EVIDENCE: There are both male and female staff and residents receive same sex personal care support if necessary. Personal care routines are well documented. This ensures that residents receive the right amount of support to encourage them to develop greater independence. There is good information about the size of clothing that each person requires as all residents need assistance with purchases. There is a record of each person’s medical history. There is a record of the health professionals that each person sees and of the health appointments they attend. This includes recording what specialist advice has been given. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 15 Each person is registered with a local GP, dentist and optician. There is also input from a specialist team for adults with a learning disability on referral. They can provide advice about supporting emotional needs. There is evidence that residents see a health professional when the need arises but more can be done to ensure preventative healthcare and health action planning should be more robust. Staff help residents to take their medication. Medication is locked away in a cupboard and staff keep records of when it arrives in the home, when it is administered and when any unused medications are returned to the pharmacy. There are no controlled drugs in use at this time. During the last inspection it was noted that there were gaps in the recordings. Examination of medication administration records during this inspection indicate that this area of recording has improved. The home manager checks the medication stock and records regularly to make sure the medicines are being administered as prescribed. This is good practice. There is good information about why each medication is prescribed and what side effects there may be. Staff are not allowed to administer medication until they have been given training in how to do so safely. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The views of residents are listened to and acted upon and there are good systems in place to handle complaints. Residents are protected from abuse. EVIDENCE: There is a good complaints policy and information about how to make a complaint is produced in an accessible format with photographs and pictures to make it easier to understand. There are no recorded complaints since the last inspection. Residents and staff attend weekly house meetings where house issues are discussed and recorded by staff. This gives people the opportunity to raise concerns and staff always ask what is going well and what is going badly. There is a copy of the local authority safeguarding vulnerable adults’ procedures available and the manager talked about her understanding of the procedures. There is evidence that staff recognise safeguarding issues and get in touch with the right people when necessary. Staff receive training in abuse awareness during their induction training. All residents need help to manage their personal finances and good records are kept of cash and valuables held in the safekeeping of staff. These records are checked from a finance officer from the LArche head office on a regular basis. A spot check carried out during this inspection showed that records were Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 17 accurate and purchases were covered by receipts. This protects residents from financial abuse. There is a record of people who have visited the home. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 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 comfortable and clean. EVIDENCE: The large home is suitable for its purpose, comfortably furnished, homely and clean. The large rear garden and back veranda provide adequate outdoor space. A garden work shed has been built for one resident who enjoys woodwork. The homes location offers good access to local amenities, public transport and services. All bedrooms are single occupancy and attractively furnished to the preference of the person accommodated. There are two communal lounges that are comfortable and well furnished. Bathrooms and toilets are sufficient in number and well situated close to bedrooms and communal areas. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 19 The home is clean and pleasant smelling and hand-washing advice and facilities are readily available. There are regular ‘in house’ environmental safety checks, and a record is maintained. . Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are called assistants in the L’Arche community and they are provided with board and lodgings. Each has a job description and a contract of employment. Four staff live on premises and two live out. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. The community welcomes staff and residents from all faiths. Records are kept of all staff duty rosters. Between one and two members of staff are on duty in the home depending on the activities and needs of the residents. The current staff team have between one and five years in the community. As assistants usually only stay for between one and three years they do not normally have an NVQ (National Vocational Qualification). One option being Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 21 looked at to address this is the recruitment of more local people. This will help with staff retention and may also help the team to develop a qualified staff. Recruitment records are held at the L’Arche head office. They were made available during this inspection. L’Arche is in a challenging position in regards to recruitment checks, as staff are often recruited from overseas and cannot therefore complete an enhanced criminal records check until they arrive in the UK. As some staff are destined to ‘live-in’ this presents a risk to residents, as staff have not been fully checked before they arrive in the home. L’Arche is working to reduce this risk and has developed a range of polices, procedures and risk assessments to ensure that staff undertake the checks immediately on arrival to the UK. Additional reference checks, overseas police checks and translation of documents are completed before arrival. Clear responsibilities have been developed for the home manager and other staff to ensure that new staff are appropriately supervised during the period of time when only POVA first clearance is in place. This includes risk assessment and reduced responsibilities in providing care and support to service users, for example, not providing personal care or going out alone with any resident. During this inspection it is noted that a new member of the Sycamores staff team moved into the building that also accommodates another residential care home (also part of the L’Arche community of homes) one week before a satisfactory POVA First check was obtained. This is unsafe and new staff must be accommodated away from the homes of vulnerable adults until a satisfactory check is obtained. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’, mandatory training and training provided by the local specialist learning disability team. Each member of staff has an individual training record and certificates are retained as courses are attended. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along, medication administration, challenging behaviour as communication, Gentle Teaching and training around taking risks and making choices. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is an experienced manager in post. The manager must attain qualifications to achieve a good standard. Residents are able to contribute their ideas to the running of the home and wider community. Policies and procedures should be reviewed more often to ensure that the home is being run in accordance with changes in legislation and good practice guidance. Systems are in place to monitor the safety of the home. EVIDENCE: The new manager registered with the Commission in October 2008. She is experienced. The manager has yet to achieve a vocational qualification in care (NVQ at level 4 or above) or managers award (RMA). Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 23 As required in the previous inspection report, a representative of the registered provider visits the home each month to monitor the service being provided. They write a report of their findings and send a copy to the provider and to the manager. There was also an annual report of the service in November 2008. This reports sets out priorities for the coming year. The new manager has introduced a monthly ‘To Do’ list based on the need to conduct reviews within the home. There are also plans to survey the views of a wider group of stakeholders. There are already systems in place for residents to contribute their ideas and views to how the home and the wider L’Arche community are run. This happened by internal election and various meetings and consultations. The information supplied in the AQAA (Annual Quality Assurance Audit completed by the manager before the inspection) indicates that although policies and procedures are in place they have not been reviewed since 2007. It is recommended that there is ongoing review of policy and procedure to ensure changes in legislation and good practice are incorporated into the way the home runs. The manager is responsible for health and safety and she is assisted by a health and safety officer from within L’Arche. There are daily, weekly and monthly checks of the home and there are annual assessments of risks posed by fire and in the environment generally. Environmental health officers inspected the home recently and gave it a three star rating. Sycamore, The DS0000022767.V374549.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 Adults 18-65 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 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 2 X 3 X Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 25 No 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 YA6 Regulation 15 Requirement Timescale for action 31/08/09 2. YA34 19 The registered person must ensure that all areas of required care and support are documented in care plans. These plans must be reviewed regularly and amended when needs change in any way. The registered provider must 12/04/09 ensure that new staff are not accommodated with vulnerable adults before confirmation that the member of staff is not on the list of people prohibited from working with vulnerable adults. 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 3 Refer to Standard YA1 YA19 YA20 Good Practice Recommendations The service user’s guide should have more information about placement fees and how they are spent. Health action planning should be more robust to ensure good preventative healthcare. The list of over the counter remedies in use should be DS0000022767.V374549.R01.S.doc Version 5.2 Page 26 Sycamore, The 4. YA40 checked during medication reviews to make sure they are all safe to use with any newly prescribed medications. Policies and procedures should be reviewed on a regular basis to ensure that they are in line with current legislation and good practice guidance. Sycamore, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 27 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, The DS0000022767.V374549.R01.S.doc Version 5.2 Page 28 - 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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