Inspection on 16/03/06 for The Sycamores

This inspection was carried out on 16th March 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

The Sycamores 05/02/07

The Sycamores 27/10/05

The Sycamores 03/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Sycamores, The Johnson Street Wolverhampton West Midlands WV2 3BD Lead Inspector Rosalind Dennis Unannounced Inspection 16th March 2006 11:00 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sycamores, The Address Johnson Street Wolverhampton West Midlands WV2 3BD 01902 873750 01902 873751 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) Lakewood Limited Mrs Amanda Caroline Morgan Ellitts Care Home 84 Category(ies) of Learning disability over 65 years of age (10), registration, with number Old age, not falling within any other category of places (84), Physical disability (84) Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories except 10 (only) Elderly Learning Disability 27th October 2005 Date of last inspection Brief Description of the Service: The Sycamores is a care home that provides accommodation, personal and nursing care to 84 people. It is registered with CSCI to provide care for ten people over the age of 65 that have a learning disability, older persons and adults with a physical disability. The home is divided into four main areas, this enables individuals with a range of conditions to reside at the home and be cared for by specific staff groups that are appropriately skilled to meet their needs. The Sycamores is a purpose built care home and all bedrooms are single occupancy with en-suite facility. It is conveniently located on a main bus route to Wolverhampton city centre, local shops and amenities are close by. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 11.00am and the inspection lasted for just over 4 hours. During that time the inspector spoke with residents on the ground floor, observed records and spoke with the manager and staff. The focus of this inspection was to review the progress made by the home since the last inspection and to review outstanding “key standards”. What the service does well: 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. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6 is not applicable to this home EVIDENCE: The intended outcomes for Standard 3 were assessed and achieved at the previous inspection of this service and were not reviewed on this occasion. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 10 The home treats residents with respect and upholds their right to privacy. EVIDENCE: Seven residents that were spoken with during the inspection confirmed that staff respect their privacy and individuality. Observations made at this inspection confirm that staff are attentive and respond appropriately to resident’s needs. The CSCI pharmacist inspector is to inspect medication practices and procedures at the home. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 9 Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) 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 and 15. The home provides social and recreational activities that provide variation and interest for people living at the home. The home provides meals that offer variety and cater for different cultural and nutritional needs. EVIDENCE: The inspector arrived in the activities room at the end of a lively board game and spent some time discussing daily routines with two residents and the activities co-ordinator. All residents that were spoken with during the Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 11 inspection spoke positively regarding the activities co-ordinator, her enthusiastic approach and commitment to her role, this was also apparent during a discussion with the inspector. Residents confirmed that their choice to take part is always acknowledged. Residents are consulted on a daily basis about what they would like to do that day and comprehensive records are kept that show that a range of activities are offered such as arts and crafts, board games, reminiscence and outings to different community events. Activities are provided to residents residing on the different units within the home. Daily consultation with residents also provides a forum for residents to discuss any concerns/suggestions and these are communicated to the manager as appropriate. Observation of menu plans show that a good variety of choices are available at each mealtime, which also meet the nutritional and cultural needs of residents. Residents confirmed that the home offers a good choice of meals. The meal served during the inspection looked and smelled appetising and residents appeared to enjoy their meal. Staff were observed to be attentive in assisting residents to eat. Observation of the activity book showed that individuals visit the home regularly and residents confirmed that the home encourages and welcomes visitors. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: The intended outcomes for Standard 16 and 18 were assessed and achieved at the previous inspection of this service and were not reviewed on this occasion. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The standard of the environment in this home is good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home communicates effectively with CSCI and the local infection control team during outbreaks of infectious illness and observations made during the inspection confirmed that systems are in place to control the spread of infection and staff were observed utilising appropriate protective clothing when necessary. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 14 Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The home employs staff in sufficient numbers to meet the needs of residents. EVIDENCE: On the day of inspection staffing levels checked by the inspector appeared sufficient to meet the needs and dependency of the current residents. Residents on the ground floor and in The Bungalow that were spoken with commented that they felt the level and competence of staff was sufficient to meet their needs. Some residents from The Bungalow were attending day placements therefore outcomes for service users residing in The Bungalow regarding Standard 27 will be revisited at the next inspection. Staff overseeing each unit receive supernumerary time to enable them to ensure documents are kept up to date. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The manager has the skills and knowledge to lead the staff team and manage the home. The home monitors and reviews processes to ensure that residents receive a good range of quality services Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 17 EVIDENCE: The manager is a registered nurse with a good range of supporting qualifications, skills and experience and is currently studying for the Registered Managers Award. Observation of records demonstrates that resident’s financial interests are safeguarded and the home maintains accurate records of all financial transactions. It was discussed with the manager that it is good practice to have all financial transactions observed and signed by two people. The home operates a quality assurance system based on seeking the views of residents where capable and/or their representatives. Evidence was available to show that questionnaires have recently been distributed to residents and relatives and the results are to be collated. The manager has identified that some improvements to the format of the questionnaire may ncrease the amount of responses. Senior management conduct comprehensive monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. The manager holds regular staff meetings for all units and minutes are available for staff members that have not been able to attend. Residents meetings are currently conducted on an informal basis by the activities coordinator, the manager is looking at formalising this process. Maintenance and servicing of equipment was assessed at the last inspection, all parts of the home that were observed at this inspection appeared well maintained. The manager is in the process of investigating training programmes in the safe use of bed rails and a copy of a new bed rail risk assessment was observed during the inspection and deemed satisfactory. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 19 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 OP38 Regulation 13(4)(c) Requirement Staff who are responsible for selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be incorporated in a planned maintenance schedule. (In process of being achievedprevious timescale of 1/03/06) Timescale for action 01/05/06 2. OP38 13(4)(c) (In process of being achieved previous timescale of 1/03/06) Risk assessments to support the safe use of bed rails must be further developed and based on guidelines provided by HSE and the Medical Devices Agency (MHRA) and be regularly reviewed. 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 20 No. 1. Refer to Standard OP30 Good Practice Recommendations To assist the manager in reviewing staff training, it is recommended that a training matrix be devised (In progress). Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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. Sycamores, The DS0000017195.V286917.R01.S.doc Version 5.1 Page 22 - 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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