Inspection on 23/11/05 for Sycamore, The

This inspection was carried out on 23rd November 2005.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sycamore, The 23/02/09

Sycamore, The 27/02/07

Sycamore, The 26/07/05

Sycamore, The 17/03/05

Sycamore, The 16/06/04

Sycamore, The 09/02/04

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

CARE HOME ADULTS 18-65 Sycamore, The 34 Lancaster Avenue West Norwood London SE27 9DZ Lead Inspector Sonia McKay Unannounced Inspection 23rd November 2005 08:30 Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 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.V266214.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 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.V266214.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sycamore, The Address 34 Lancaster Avenue West Norwood London SE27 9DZ 0208-761-6237 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) L`Arche Lambeth Ms Corinne McDonald Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: The Sycamore is a residential home for five adults with a learning disability. It is one of six 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 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. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of The Sycamores was conducted in four hours. Staff recruitment and training records were examined on 16 November 2005 at the L’Arche head office. The inspection involved observing meal arrangements (breakfast), talking with four service users, staff and the home manager. Records of care were examined and the premises were partially toured. What the service does well: What has improved since the last inspection? What they could do better: Recruitment must provide service users with a higher degree of protection, by ensuring that adequate checks are taken up for all staff. The home must administer medication in a more methodical and diligent manner. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 6 Risks associated with access to hazardous cleaning products must be examined. The registered provider must visit the home more often to monitor the quality of service being provided and check essential records. LArche staff training must be to National Vocational Standards. The shower room must be refurbished and the hallway floor covering replaced. 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, The DS0000022767.V266214.R01.S.doc Version 5.0 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.V266214.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Prospective service users have adequate information to make an informed decision to move into The Sycamore. There is an extensive opportunity to ‘test drive’ the home. Individual needs and aspirations are assessed and met and each service user has a written contract stating the terms and conditions of occupancy. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users’ Guide’ to the home. Emphasis has been placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. 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 allows the referred person the opportunity to experience life in the home before making a positive choice to move in for a trial period. The most recently admitted service user to The Sycamores had visited the home on a number of occasions before making a decision to move in. A community care assessment compiled by the placing authority has been obtained, as required in the previous inspection report. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 9 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. The views of existing core members are also taken into account during the placement process and trial period. L’Arche places emphasis on providing staff with communication support skills and provides staff with ‘sign-a-long ‘ training, and specialist training for communicating with adults with a learning disability. A database of photographs of all community members (core members and staff), significant locations and other useful objects is available to assist with this. Each service user has a contract of service and occupancy that has been explained to them if they are unable to understand the document themselves. Copies are available in individual care files. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Service users know that their assessed needs and goals are reflected in their individual plan. They are consulted on and participate in all aspects of home and community life and are able to maximise their independence through a framework of risk management. Information about service users is handled appropriately and confidentially. EVIDENCE: Individual care plans are reviewed annually and every six months new goals are reviewed/set with the service user, home staff and staff from the workshops. L’Arche are developing service user accessible plans. Care plans are appropriate and detailed. Placing authorities have reviewed the care provided to all four service users this year. The service user invites people of their choosing to the in-house annual review, this may be family members, home/workshop and senior staff and a LArche advocate. Home staff work creatively with service users before the annual review to enable them to understand and contribute as much as possible to the process in ways of their individual choosing (video, photographs, spoken word, objects, Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 11 music and drawings). The actual review meeting is held in a place that is comfortable to the service user (either at home or in a formal meeting room). The meeting aims to review goals from previous planning meetings and explore how new goals can be supported. Risks and independence are discussed and reviewed regularly. The home manager said that initial steps are being taken towards independent travel for one service user, by travel training, although these are long-term plans. Each service user has a general risk assessment to identify high and low risk activities. Individual risk assessments and risk management plans are developed as a result. L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a key worker. This is in place at The Sycamore. L’Arche uses a semi-independent advocacy system. This ensures that someone from outside the home who knows the service user and sees them often is involved. The services of fully independent advocates are obtained if major decisions need to be made. Service users 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 director six times a year and community council elections. Service users are also involved in the assessment of new staff during their probationary period. A general risk assessment process is in place. The document covers topics and activities that each service user 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. Confidential written information about each service user is stored securely in lockable filing cabinets in the home managers office. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Service users have opportunities for personal development. They are able to take part in a wide range of leisure activities, and therapeutic employment. Appropriate relationships with family and friends are encouraged and supported. Service users are encouraged to be responsible in their daily lives. Meals are healthy and attractively presented and mealtimes are relaxed. Staff interact well with service users. EVIDENCE: L’Arche is a faith-based community and offers active support to each service user to develop their faith and spiritual lives. Service users who choose not to attend religious activities of any particular denomination are offered alternative activities. All service users are offered opportunities to engage in art, music and nature. Each service user has a place in the L’Arche workshops (weaving, stone work, gardening and candle making). Two service users also visit the LArche retirement group. Some service users attend local college classes specifically Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 13 for service users with a learning disability, developing skills for daily living, drama, music, art and sailing. One service user is attending mainstream classes. Service users said that they enjoyed their daytime work and activities. The proximity of the other L’Arche homes provides a close community. L’Arche Lambeth has been operating for more than 25 years and has developed good relationships with local individuals and organisations. 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. All service users are offered a minimum two weeks holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interests. Holidays have included trips to France, America, Canterbury and Ireland. One service user is interested in visiting India, and although the home manager acknowledged that it would involve extensive planning, this is a long-term goal. The home manager said that home staff supported the cultural needs of one service user by making Caribbean Gospel music available, exploring Caribbean recipes and visiting culturally appropriate hair salons, markets and restaurants in the area. Personal information held in individual care files contained detailed information about family and friends, their birthdays and family history. This enables staff to support service users to maintain and develop family relationships. One service user is able to use a front door and bedroom door key. Observed interactions between the staff and the service users were respectful, natural and caring. The service users and assistants ate at a large dining table together in the communal kitchen. Breakfast was being served as the inspection began. Service users and staff interacted very well. The mealtime was relaxed and only paced with a view to getting everybody to his or her activity or workshop on time. Each service user was having the breakfast menu of their choice, and the food prepared was fresh and appetising. Records of meals eaten examined indicated that a range of meals had been served. Food stocks were stored appropriately and contained plenty of fresh fruit and vegetables. Each service user chooses and helps to prepare an evening meal each week to the best of their ability. One service user said that he liked the meals. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users receive personal support in the way they prefer and require. Service users physical and emotional needs are met and the home manager is liaising effectively to improve pro-active healthcare and understanding of the individual treatment needs of individual service users. Staff must ensure that prescribed medication is administered as prescribed. EVIDENCE: Service users are well dressed in clothes that are weather appropriate, in styles that reflect their personal choice, personality and the day ahead (for example, sensible clothing for gardening work). A staff team comprised of both men and women provides same gender personal care support. Female staff occasionally provide personal care support to one male service user. This has been discussed and agreed with the service user and professionals involved in his care. Personal care routines are clearly laid out in individual plans, detailing the level of support required with each task. Service user accessible ‘Health Action Plans’ are being developed with each service user. Local health teams have developed an accessible template. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 15 The home manager is working with the local group practice and a hospital trust to improve healthcare for adults with a learning disability and communication needs. The potential outcomes for this work are: increased understanding of the healthcare needs of individual service users, better access to health services and developing tools to assess levels of distress that can be automatically communicated to nurses, doctors and consultants (for example, signs of anxiety or pain an individuals inability to wait patiently in hospital or surgery waiting rooms). Records of the health appointments attended by the service users indicate that the home has maintained adequate records of healthcare, and provides support for each service user to attend a range of appropriate healthcare appointments. Healthcare provided includes regular visits to the dentist, doctor, optician, audiologist and neurologist. There is also input from specialists from the community team for adults with a learning disability on referral. Staff support service users to take their medication. • • • • • • • • • There are clear MAR charts with a photograph of each service user to aid identification There is clear and detailed information about each prescribed medication, why it is being used and any potential side effects There are clear medication procedures that are reviewed regularly There is a letter from the GP about what over the counter medicines each service user can have (to avoid contra-indications) There are clear guidelines for when staff should administer as required medication (PRN) There is detailed information about what symptoms to look out for and how individual service users may express pain or discomfort There is a system of stock checking that justifies stock available with stock administered or disposed of There is a staff signature list to identify who has administered a dose of medication There is a register of medication collected from the pharmacy and disposed of A medication stock check showed that one service user had missed three doses of morning medication in the last month. Although medical advice has been taken about the implications of missed doses, it is essential that medication be administered as prescribed at all times (the medication missed is for epilepsy). (See requirement 1) Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed and fully met during the July 2005 inspection. There have been no complaints made since then. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 & 28 Although the home is comfortable, the missing carpets and poor quality shower room facilities are not in keeping with the modern expectations of service users. 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 and are maintained. The homes location also offers good access to local amenities, public transport and services. All bedrooms are single occupancy. 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. The first floor shower room floor is uneven and the shower suite and toilet bowl are badly scaled. There are signs of mould on the walls and ceiling. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 18 Ventilation in this room may be inadequate. The uneven floor has caused water to run out into the first floor hallway and soak through the ceiling. The hall and stair carpet has been removed throughout the building as it was old and water damaged. The home manager is not able to replace the carpet until the shower room floor is replaced by the housing association. The floorboards are exposed. (See requirements 2 & 3) One bedroom occupied by a member of staff is adjacent to a toilet. The ventilation system in the toilet is noisy and this causes disturbance for the member of staff. This should be resolved to reduce noise disturbance to the occupant of the bedroom. (See recommendation 1) Fire authorities inspected the premises on the 9th March 2005 and confirmed that fire safety arrangements are satisfactory. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, & 36 Staff have clearly defined roles. Steps are being taken to ensure that staff are equipped with the specialist training required to meet the needs of the service users although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures must be further developed to ensure that service users are adequately supported and protected. Staff are well supported and supervised. EVIDENCE: The training co-ordinator has made progress with compiling a team training and development needs assessment for each of the L’Arche homes and records of training undertaken by individual staff. As new assistants arrive on a regular basis this training is ongoing. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. Staff are paid a small wage/expenses for a 40-hour a week commitment to the home and L’Arche community. 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 disabilities team. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 20 NVQ training is provided for staff that are able to commit to more than two years. Working visa constraints prevent some staff from staying for more than a year, so few have achieved this. The status of the assistants means that they normally do not have NVQ qualifications when they arrive and the director of L’Arche has conceded that it will be hard for the organisation to meet this standard. (See requirement 4) The home manager has introduced a detailed record of which assistants have worked on each day. Staffing levels are adequate. There is always a minimum of two assistants on duty. Agency staff are not used. Assistants from other LArche homes can provide sickness cover if necessary. Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and is currently revising the LArche recruitment procedures. The recruitment records are still incomplete in some cases. References taken up by telephone have not all been authenticated in writing. Twelve members of the LArche community staff do not have UK CRB checks in place or confirmation of a satisfactory POVA First check. Overseas police checks are in place for these staff and all have applied for an enhanced UK CRB check. (See requirement 5) The home manager is trained in supervision and supervises each member of staff on a regular basis. New staff are supervised frequently until they are established and familiar with the home and the service users. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 The home is well run, although monthly monitoring by the registered provider is inadequate. Policies and procedures are reviewed regularly and protect service users (although recruitment procedures must be improved). The health, safety and welfare of service users is promoted and protected by environmental checks. EVIDENCE: The registered home manager has been in post for almost four years and has commenced an NVQ level 4 in Care and Registered Managers Award. The manager has an in depth knowledge of the Sycamore service users and displays good leadership and commitment to her role. She is taking a positive approach to improving and developing the service provided. The L’Arche community has an annual development plan for quality assurance in place and consults with service users on a regular basis. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 22 The home has not been visited on a monthly basis by a representative of the responsible individual as required by Regulation 26 of The Care Homes Regulations 2001. (See requirement 6). The L’Arche policies and procedures are reviewed periodically and a number have been reviewed or developed in 2005. L’Arche has demonstrated that policy and procedure are reviewed in light of changing circumstances. COSHH (Control of Substances Hazardous to Health) information is available. Dishwasher products are stored under the sink. This must be risk assessed and steps taken to minimise the danger of accidental poisoning. (See requirement 7) The Gas Boiler annual safety certificate is available and is dated 23/10/05. Mains electrical circuitry had been safety tested on 04/04/03. The test certificate was noted to cover a five-year period from that date. Small electrical appliances had been safety tested on 09/10/05. The range cooker was serviced on 09/04/05. Fire authorities inspected the premises on 31/01/05. Regular checks are conducted on fire detection and emergency equipment. Fire evacuation drills are conducted with the required frequency. Environmental risk assessments are conducted annually. Accidents and incidents are recorded and reported appropriately. ‘In house’ Health and safety responsibilities are nominated to a member of the team and a record of the environmental checks undertaken maintained. A fire risk assessment and building floor plan are available. Fridge and freezer temperatures are checked daily. A record is kept of visitors to the home. Environmental health inspectors inspected the food handling arrangements on 18/07/05. The report of the inspection confirmed that food hygiene standards are being maintained. There is a photographic guide to good hand washing that service users can refer to when washing their hands at the kitchen hand-wash basin. Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore, The Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 3 X DS0000022767.V266214.R01.S.doc Version 5.0 Page 24 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 YA20 Regulation 13(2) 12(1) Requirement Timescale for action 31/12/05 2 3 YA24 YA24YA27 4 YA32 5 YA34 The registered persons must ensure that service users do not miss doses of prescribed medication. 16(2) The registered person must replace the hallway floor covering. 23(2) The registered persons must supply the CSCI Southwark office with a refurbishment plan for the first floor shower room. The plan must address: • Mould on the ceiling and walls • Uneven floor causing hallway water damage • Inadequate ventilation • Stained shower base and toilet bowl 18(1)(a) The registered person must ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. 19(1)(b)(i) The registered persons must Sch 2 ensure that evidence of all DS0000022767.V266214.R01.S.doc 17/02/06 31/12/05 31/01/06 31/12/05 Sycamore, The Version 5.0 Page 25 6 YA39 26 7 YA42 13(4) 12(1) information and documentation required by Schedule 2 of the Care Homes Regulations 2001 (revised in July 2004) is obtained for staff before they commence work in the care home. The registered person must 31/12/05 ensure that monitoring visits conducted on behalf of the registered provider, as required by Regulation 26, occur at least on a monthly basis, are unannounced and result in a written report that is supplied to the home manager and the CSCI Southwark office. Previous timescale of 16/09/05 not met. The registered persons must risk 31/12/05 assess the suitability of keeping COSHH materials under the kitchen sink. 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 YA24 Good Practice Recommendations The registered persons should reduce the noise disturbance experienced in one staff bedroom (caused by a noisy ventilation system in an adjacent toilet). Sycamore, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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, The DS0000022767.V266214.R01.S.doc Version 5.0 Page 27 - 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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