CARE HOMES FOR OLDER PEOPLE
The Sycamores Norton Road Wakefield WF1 3PB Lead Inspector
Mr Tony Brindle Unannounced Inspection 17th November 2005 09:30 X10015.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 The Sycamores DS0000035670.V267288.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Sycamores Address Norton Road Wakefield WF1 3PB 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) 01924 379994 sycamores@tri-care.co.uk Tri-Care Limited Mrs Elizabeth Parr Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: The Sycamores is a purpose built care home, which can accommodate up to 40 older people 65 years and over. It was registered in January 2003. The home is built on two levels with all single en-suite rooms. It is sited in an urban area close to the centre of Wakefield at a convenient site for all forms of transport. There is a large car park to the front of the building. The home is easily accessible to local shops, church and public houses. The grounds and gardens to the home are well-presented and accessible to service users. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was a positive and enjoyable one, undertaken by 1 inspector, who spent 3.5 hours taking to service users and staff, looking at care plans, daily records, health and safety records, the complaints log, the menus and the staff recruitment and training files. The inspector would like to take the opportunity to thank the service users, the deputy manager and support workers for their hospitality and patient cooperation throughout the inspection. Since the last inspection in May 2005, the management of the home was asked to investigate an anonymous complaint that was received by CSCI in July 2005. The complaint centred on suspected poor care practice and staff management. The conclusion of the complaints investigation was that more attention would be paid to the assessed needs of individual service users, and that staff would be discouraged from taking smoking breaks together. Staff now take breaks in turn to ensure that the residents are not left unattended. There have been no changes to the Registered Persons registered with CSCI. What the service does well: What has improved since the last inspection?
The deputy manager explained that the staffing levels had recently been increased following a review and a requirement made by CSCI at the last inspection. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 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 Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The work of the staff and the systems operated at the home make sure that residents only move into the home once assurances have been given that their assessed needs can be appropriately met. EVIDENCE: Care plan files included details of pre-admission assessments completed both by the home and, where relevant by the placing authority and any other professionals involved. These assessments were detailed and considered all areas of the potential residents needs. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The resident’s health, personal and social care needs are set out in individual plans of care. The work of the staff and the systems operated at the Sycamores makes sure that resident’s health care and medication needs are met, and that residents are treated with respect and dignity. EVIDENCE: Resident care plans contain detailed information about support and healthcare needs. The plans have a straightforward approach, concentrating on aspects of daily living. Restrictions are only placed on the residents following an appropriate risk assessment. Discussions with the deputy manager showed that she has a good understanding of the support and care needs of the residents, which is shared by the staff. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards within this section were assessed at the last inspection. EVIDENCE: The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The systems and procedures operated by the staff at the home make sure that service users and their carers are made aware of how to raise issues and complain, giving them confidence that they will be listened to and their views acted on. There are satisfactory systems on place that protection service users from abuse and harm. EVIDENCE: Policies and procedures for dealing with suspicion or evidence of abuse are in place. Complainants are informed that they may make complaints directly to the CSCI. Complaints are recorded within the complaints book and actioned as appropriate. CSCI recently received an anonymous complaint relating to suspected poor care practice and staff management. The details of the complaint were passed onto the management of the home, who investigated the issues raised. The investigation found that some improvements were needed and these have been made. There are systems in place such as staff training and reporting systems, which are used to safeguard service users from abuse and neglect. The deputy manager said that there is an open atmosphere within the home which allows for issues to be raised by staff and visitors. One resident said that she feels confident in raising issues with the staff about the care and support she receives. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The communal areas of the home were found to be clean, comfortable and furnishings are suitable for the needs and lifestyles of the residents. Bedrooms are nicely furnished, personalised and include equipment as needed by the individual resident. All areas of the home appeared clean and hygienic. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Service users needs are met by the numbers and skill mix of staff. Service users are not supported and protected by the home’s recruitment policy and practices. The systems and procedures operated at the Sycamores make sure that the assessed needs of the people living there are met by appropriately trained and experienced staff. EVIDENCE: The rota showed that there is a satisfactory mix staff working at the home, appropriate to the assessed needs of the service users, the size, layout and purpose of the home. The deputy manager explained that the staffing levels had recently been increased following a review and a requirement made by CSCI at the last inspection. The deputy manager explained that a number of staff had attended training in dementia and the training records show that the staff training and development programme based on the assessed needs of the service user group. The deputy manager had come to work without the main office keys, and once she had gone back home and returned with the keys, the personnel records of the sample of the staff team were found to be in good order. However, the records of a bank team member were found not to contain all the necessary documents, such as CRB checks and references. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The health and safety of service users and staff is put at risk when systems and procedures that are in place are not followed. EVIDENCE: The records relating to fire alarm testing were not up to date with the last fire alarm test entry being October 2005. Fire alarms must be tested weekly. The deputy manager tested the alarm on the morning of the inspection, and it was found to be in good working order. The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 15 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 1 The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 16 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 OP29 Regulation 19 Requirement New employees must not start work in the home until full and satisfactory information relating to them has been obtained via a POVA/POCA check, and a CRB check. The registered person must ensure that all records required by regulation are at all times available for inspection by any person authorised by the Commission to enter and inspect the care home. The registered person must ensure that as far as reasonable practicable, all areas of the home are free from hazards. Fire Tests must be tested as required. Timescale for action 02/12/05 2. OP29 17 (3) (b) 17/11/05 3. OP38 13(4) 17/11/05 The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Sycamores DS0000035670.V267288.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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