Inspection on 26/07/05 for Sycamore, The

This inspection was carried out on 26th July 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 16 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 23/11/05

Sycamore, The 17/03/05

Sycamore, The 16/06/04

Sycamore, The 09/02/04

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Chatsworth Care - Tudor Lodge

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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 The Sycamore 34 Lancaster Avenue West Norwood London SE27 9DZ Lead Inspector Sonia McKay Unannounced 26th July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Sycamore Address 34 Lancaster Avenue, West Norwood, London SE27 9DZ 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) 0208 761 9064 & 0208 764 4909 sycamore34btopenworld.com LArche Lambeth Ms Corinne McDonald CRH Care Home 5 Category(ies) of PC Care home only registration, with number of places The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2005 Brief Description of the Service: The Sycamore is home to four adults with learning disabilities (although it is currently registered for five), who live with four house assistants. It is one of six residential care homes in the locality which form part of the L’Arche Lambeth community. The aim is to create communities which welcome people with learning disabilities. Fundamental principles of the community are that each person has a right to friendship, to a spiritual life and to live in an environment that fosters personal growth. The home is a large Victorian house with a large rear garden on a residential street, and is comfortably furnished. A team of assistants, some of whom livein, are managed by a house leader, who registered as the care manager of the home in March 2002. The service users attend L’Arche workshops and college classes during the week and are encouraged to participate in all aspects of the L’Arche community life as well as the local and wider community in which they live. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of The Sycamores was conducted over one day. It commenced at 8am and was completed by 1pm. Staff recruitment and training records were examined on 4 July 2005 at the L’Arche head office. The inspection involved observing meal arrangements (breakfast), talking with service users and staff, inspecting home records and records of the care required and provided to each person. A tour of the premises, including all of the bedrooms occupied by service users also took place. Comments were also received from a health professional involved in the care of some of the service users. What the service does well: What has improved since the last inspection? A staff training needs assessment has been conducted to identify training that staff should attend to equip them to meet the needs of the service users living in The Sycamore. A ceiling in a communal lounge, damaged by a water leak, has been repaired. There has been further development of a person-centred approach to planning the lives and care provided to service users. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 6 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 Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5. Prospective service users have adequate information to make an informed decision to move into The Sycamores, after extensive opportunities 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. The staffing information in the Statement of Purpose is out of date and requires revision. (See requirement 1). 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 was not in The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 9 place. This had been the subject of a requirement in the previous inspection report. The home manager said that she had requested the assessment during a recent placement suitability review. (See requirement 2). There had 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. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9 & 10. The changing needs and personal goals of each service user are reflected in their individual care plan. Service users are able to make decisions about their lives with assistance as needed. However, the assistance in place is not fully independent of the service and this could be improved. Emphasis is placed on service user consultation and participation. Confidential information is handled appropriately. 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. Two individual care plans examined were appropriate and detailed. Care records showed that steps are taken to meet the individual goals and care needs identified. Placing authorities had recently reviewed the care provided to the two service users whose files were examined. The service user, along with family members (if the service user wishes) and home staff attend the annual review. Home staff work creatively with the service user before an annual review to enable them to understand and contribute as much as possible to the process The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 11 in ways of their individual choosing (video, photographs, spoken word, objects, 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. A new format for care planning is being introduced using a format suggested by the local community team for adults with a learning disability. The format is accessible to service users with a learning disability and includes many symbols so that service users have greater ownership and understanding of the document. The home manager said that these plans are being developed in the home for each service user able to use them. For service users unable to use these plans an alternative document, written as if the service user has written it themselves, is being developed by the home manager. One plan is already in place and provides staff with essential information about the service user and how they like to be supported. The home has close links to the Lambeth community team for adults with a learning disability, who provide behaviour support and speech and language therapy as the need arises. A professional from the team spoke positively about the way home staff worked with the service users. L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a keyworker. This is in place at The Sycamore. Fully independent advocates are in short supply in the borough. L’Arche uses a semi-independent advocacy system with assistants from other homes or workshops who know the service user well. This is not ideal, but does ensure that someone from outside the home who knows the service user and sees them often is involved. A recommendation is made for L’Arche to pursue the services of fully independent advocates. (See recommendation 1). Service users are encouraged to participate in the day to 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. One service user demonstrated how the symbols based agenda form, used for the weekly house meetings, assisted her with understanding the topics to be discussed at each meeting. 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 The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 12 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. The overall risk assessment examined had not been reviewed in over a year. It is important to review these potential risks on a regular basis to ensure safety and also to reflect any changes in need or skills development. (See requirement 3). Confidential written information about each service user is stored securely in lockable filing cabinets in the home managers office. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 11, 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 of the service users 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 for service users with a learning disability, developing skills for daily living, The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 14 drama, music ,art and sailing. 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. The Sycamore service users and staff recently celebrated the home’s twenty first year of operation by holding a garden party and inviting friends and neighbours. 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. Forthcoming holidays included trips to France, America, Canterbury and other U.K destinations. 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. A requirement made in the previous inspection report to ensure that service users are offered a key for their bedroom door and the front door of the home is being progressed by the home manager is not yet fully met. (See requirement 4). 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 and staff were observed to manage interactions between service users with tact and diplomacy. There was a very real sense of shared living and close community spirit. The mealtime was relaxed and only paced with a view to getting everybody to their 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. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18 & 19. Service users receive personal care in the way they prefer and require. Physical health needs are addressed but are inadequately recorded. Emotional health needs are being met with professional input as needed. EVIDENCE: Service users were well dressed in clothes that were weather appropriate, in styles that reflected their personal choice, personality and the day ahead (for example, sensible clothing for gardening work). Same gender personal care support is provided by a staff team comprised of both men and women. Personal care routines are clearly layed 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. An accessible template had been developed by local health teams. Records of the health appointments attended by the service users indicated that the home had maintained adequate records of healthcare, and provided support for each service user to attend a range of appropriate healthcare The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 16 appointments. Healthcare provided included regular visits to the dentist, doctor, optician and audiologist. The Sycamore refers people with emotional needs to the local community team for adults with a learning disability when necessary. A member of the behaviour support team spoke positively about the relationship between home staff and the service users. One service user had developed pneumonia, as a result of aspirating particles of food. The pneumonia has been succesfully treated. A speech and language therapist has conducted an assessment and the home has taken the required action to ensure that meals are suitably moist to prevent this from happening again. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 22 & 23. Service users feel their views are listened to and acted upon. Service users are protected from abuse, neglect and self harm. EVIDENCE: The home has a good complaints policy. There is text version and a more accessible version for service users who may not be able to understand a text only document. A complaints poster is displayed on the notice board in the communal kitchen and has colour photographs of people who can assist with a complaint, including the CSCI. Regular house meetings provide service users with an opportunity to raise their concerns. The weekly meetings have a complaints or concerns agenda item. One complaint has been recorded in the home’s record of complaints made since the last inspection visit. A service user had complained about the length of time that the repair of the lounge ceiling was taking. The ceiling has been repaired and records kept of the timescales and actions taken as a result of the complaint. A record of visitors was available and was being used appropriately. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. Staff were observed to manage instances of minor challenging behaviour calmly and appropriately. The relationships and interactions between service users are also closely monitored by the home manager. A spot check of service user finances held in safe keeping by staff indicated that adequate systems are in place to protect service users from financial abuse. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30. Service users live in a comfortable and homely environment. Bedrooms and bathrooms meet their individual needs and are sufficient in number. Service users have the equipment they need to maximise their independence. Environmental hazards had been identified but were in need of review to ensure that service users are safe. 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. The homes location also offers good access to local amenities, public transport and services. All bedrooms are single occupancy, personalised and suitable to the needs of each service user. Wall planners are in use, using photographs and symbols to plan the weeks activities for service users who require this type of visual display. Communal areas are comfortable and well furnished. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 19 Bathrooms and toilets are sufficient in number and well situated close to bedrooms and communal areas. Toilets and a shower base require descaling. (See requirement 5). The front and rear gardens are overgrown and require maintainance. (See requirement 6). A recently re-plastered ceiling in a communal lounge was yet to be repainted. (See requirement 7). Hallway and stair carpets are threadbare in areas. This presents a significant trip hazard. (See requirement 8). One bedroom occupied by a member of staff is adjacent to a toilet. The ventilation sytem in the toilet is noisy and this causes disturbance for the member of staff. This must be resolved to prevent the noise distubance to the occupant of the bedroom. (See requirement 9). The kitchen waste bin is of a type operated by hand. It must be replaced by one that is foot pedal operated to reduce the risk of cross contamination. (See requirement 10). Dry goods packages (food) stored in kitchen cupboards were not adequately sealed. They should be stored in air tight containers once opened. (See requirement 11). Fire authorities had inspected the premises on the 9th March 2005 and confirmed that fire safety arrangements are satisfactory. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 & 35. Staff roles and responsibilities are clear. Recruitment procedures have improved and now provide service users with adequate protection. Staff training has improved, although high staff turnover has reduced the effectiveness of the training plan. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Staff at The Sycamores live on the premises and take turns to do duty. 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 week commitment to the home and L’Arche community. L’Arche assistants are volunteers, usually from abroad, who work in the homes for one or two years. A L’Arche framework of policies and procedures, provides staff with guidance. There had also been ongoing staff support and training from the home manager, the homes co-ordinator and other long standing community staff. The status of the assistants means that they normally do not have NVQ qualifications and the director of L’Arche has The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 21 conceded that it will be hard for the organisation to meet this standard by 2005. (See requirement 12). L’Arche is currently looking at ways in which staff retention can be improved. Staff duty rotas are in place. Full names had not been used and as the staff changed frequently this is particularly inadequate. This is the subject of a requirement in this report. (See requirement 13). Recruitment records are held at the L’Arche head office. They were examined on 4 July 2005. Individual audit sheets for members of staff working at the Sycamores were examined during the inspection of the home. The recruitment co-ordinator has made progress in auditing staff recruitment records. The recruitment records are complete for employees at the Sycamores. Training records are held at the L’Arche head office. They were examined on 4 July 2005. A 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. 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’ and training provided by the local specialist learning disability team. NVQ training is provided for staff who 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 Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41 & 42. Service users benefit from a well run home. The manager is registered and competent but must undertake appropriate training to fully develop her skills. Service users are involved in the review of the services provided by the home. Service users rights and best interests are protected by the homes policies and procedures. Areas of health and safety in the environment must be improved. EVIDENCE: The registered home manager has been in post for three and a half years and has undertaken to begin an NVQ level 4 in Care and Registered Managers Award this year. (See requirement 14). Staff members on duty on the day of the inspection spoke positively about the managers support, skill, approachability and inclusive management style. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 23 The L’Arche community has an annual development plan for quality assurance in place. 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 15). The L’Arche policies and procedures are reviewed periodically and a number have been reviewed or developed in 2004, including physical restraint, challenging behaviour, risk assessment, internal incident reporting, internal financial controls, confidentiality, medication and transport. 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 and COSHH risk assesments are in place and are reviewed regularly. The Gas Boiler annual safety certificate was available and was dated 29/09/04. 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 by one of the house assistants. A record had been made of the items tested by an assistant on 13/06/04. The annual test is therefore overdue. (See requirement 16). Fire authorities had inspected the premises on 31/01/05. Recommendations made in the report of the inspection had been addressed. Regular checks have been conducted on fire detection and emergency equipment both in house and professionally. Fire evacuation drills have been conducted with the required frequency and the outcome of the evacuation drills recorded. Environmental risk assessments have been conducted annually. Accidents and incidents have been recorded 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. Environmental health inspectors had inspected the food handling arrangements on 18/07/05. The report of the inspection confirmed that food hygiene standards are being maintained. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 2 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Sycamore Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 2 x G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 25 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 YA1 Regulation 4(1)(c) & Sch 1 Requirement The registered persons must ensure that the staffing information in the Statement of Purpose is reviewed and revised to include current staffing. The registered persons must obtain copies of the single Care Management ‘assessment of need’ and ‘care plan’ for all new service users. Copies of which must be maintained in individual records. Previous requirement of 24/06/05 unmet. The registered persons must ensure that risk assessments are reviewed on a regular basis and to reflect any changes in need. The registered persons must ensure that all service users who are able to use keys are offered a front door and a bedroom door key. Where the provision of keys is deemed to be inappropriate or not desired by individuals accommodated, a record must be kept of this decision and the rationale for making it in the care planning documentation for that individual. Timescale for action 18 November 2005 30 September 2005 2. YA2 14 3. YA9 12(1)(a) &13(4)(a) 12.4(a), 12(5)(a) (b) & 23 30 September 2005 30 September 2005 4. YA16 The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 26 5. 6. 7. 8. 9. YA27 YA24 YA24 YA24 YA24 23(2)(d) 23(2)(o) 23(2)(d) 23(2)(b) 23(1)(a) 23(3)(b) 10. 11. YA30 YA30 13(3) 13(3) 12. YA32 18 13. 14. YA33 YA37 17(2) & Sch 4(7) 9,18(1) (c) 15. YA39 26 Previous requirement of 01/07/05 not met. The registered persons must ensure that the toilets and the shower base are descaled. The registered persons must ensure that front and rear gardens are maintained. The registered persons must ensure that the communal lounge ceiling is repainted. The registered persons must repair or replace the hallway carpet. The registered persons must reduce the noise disturbance experienced in one staff bedroom (caused by a noisy ventilation system in an adjacent toilet). The registered persons must provide a foot operated kitchen waste bin. The registered persons must ensure that dry goods (food) are stored in air tight containers once opened. The registered persons must ensure care staff hold an NVQ 2 or 3; are working to obtain one by an agreed date; or the registered manager can demonstrate that through past work experience staff meet that standard. The registered persons must maintain an accurate and full record of staff duty rotas. The registered persons must ensure that the registered care manager is supported to achieve the required NVQ Care and management qualification. The registered person must ensure that monitoring visits conducted on behalf of the registered provider, as required by Regulation 26, occur at least 30 September 2005 30 November 2005 30 September 2005 28 October 2005 30 November 2005 30 September 2005 30 September 2005 31 December 2005 9 September 2005 31 December 2005 16 September 2005 The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 27 16. YA42 13(4) 23(2)(c) on a monthly basis, are unannounced and result in a written report that is supplied to the home manager and the CSCI Southwark office. The registered persons must ensure that small electrical appliances are safety tested annually. 30 September 2005 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 YA7 Good Practice Recommendations The registered persons should pursue independant advocacy services for LArche service users. The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor, 46 Lomand Street Southwark London 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 The Sycamore G52-G02 S22767 Sycamore V241113 260705 Stage 4.doc Version 1.40 Page 29 - 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. 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