Inspection on 20/02/06 for The Sycamores

This inspection was carried out on 20th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Sycamores 04/12/06

The Sycamores 05/10/05

The Sycamores 15/03/05

The Sycamores 14/10/04

The Sycamores 27/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Sycamores Victoria Street Newton Hyde Tameside SK14 4DH Lead Inspector Janet Ranson Unannounced Inspection 20th February 2006 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 DS0000005584.V278276.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. 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 DS0000005584.V278276.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Sycamores Address Victoria Street Newton Hyde Tameside SK14 4DH 0161 368 4297 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) Tameside Care Limited Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (45) The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 60 (OP); up to 60 (DE) (E) and up to 45 (PD) (E). 5th October 2005 Date of last inspection Brief Description of the Service: The Sycamores is a large, two storeys, purpose built home registered to provide care for 60 older people, some of whom may have dementia or a physical disability. Accommodation is provided on each of the two floors. Originally commissioned by the local authority, the home is now managed by Tameside Care Limited. There are 58 single rooms, 12 of which have en-suite facilities. The one shared room also has an en-suite facility. The home is divided into self-contained units, each one having its own small kitchen and laundry. There are aids and adaptations to meet the assessed needs of the service users. Paved sitting areas have been created to the front of the home and also to the rear, the latter being secured by fencing. The grounds are fully accessible to the service users, with garden furniture to be used in the better weather. The home is located in a residential area of Newton with associated community resources and transport links to Ashton and Hyde. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over five and a half hours in the presence of a senior carer. Since the last inspection (October 2005) there has been a change of manager who was on leave at the time of this inspection. The Sycamores is registered by the Commission for Social Care Inspection (CSCI) to provide personal care for up to 60 people over 65 years of age. It is owned and managed by Tameside Care Limited, a not for profit organisation. In addition to teams of carers, the organisation employs domestic, catering and maintenance personnel. The inspection process involved discussions with 3 residents all of whom have lived in the home for a short period. The discussions were carried out in the privacy of their bedrooms. Two visitors also assisted the inspector with their observations. The content and quality of the main meal was assessed and an observation of staff practice concerning the administration of medications was carried out. A visiting Community Psychiatric Nurse was also spoken with. Comment cards were made available to the residents and left for visitors to complete. A written comment from a visitor received after the last inspection stated: “ I don’t remember seeing inspection reports, but I’m sure if I asked to see them I could. The staff are all really approachable about anything and everything. I feel sure the shortage of staff is just the same in other homes.” The inspector undertook a limited tour of the building and spoke with the senior team. Compliance with the requirement made at the previous inspection was also ascertained. What the service does well: The Sycamores in general, provides a good service for vulnerable residents in a pleasant and secure environment. The residents feel safe and secure. The home cares for the residents’ families and encourages them to remain involved in the care. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 6 The residents have an opportunity to influence their daily routine through regular meetings. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 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 DS0000005584.V278276.R01.S.doc Version 5.1 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): Standard 3 was assessed at the previous unannounced inspection (October 2005) when it was judged to meet fully with the intended outcomes. Intermediate care (standard 6) is not provided at The Sycamores. EVIDENCE: The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 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&9 A failure to document the risks associated with daily living did not reflect the homes good care practices. Standards 8 and 10 were assessed at the previous unannounced inspection (October 2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: In the case of a newly admitted resident the documented risk assessment was too generalised and did not reflect the risks associated with the resident’s ability to make hot drinks and snacks. The same resident was also considered able to manage their own medications. The Medical Administration Record (MAR) showed this to be the case but again there was no documented risk assessment. A policy concerning the assessment of risk was accessible but had not been carried out. In both of these cases the risk assessments were carried out, once this situation had been brought to the attention of the person in charge. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 10 It was further noted that medication had not been administered in one instance due to it being missing from the monitored dosage system. This detail was noted on the MAR sheet but any further investigation and the procedure in the event of missing medication had not been carried out. No explanation could be given to the inspector regarding this incident, which occurred on the 16th February 2006. It was confirmed the individual cassettes containing the medications are checked on receipt against the prescription and any anomalies rectified with the contracting pharmacist at this time. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 11 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): Standards 12,13,14 and 15 were assessed at the previous unannounced inspection (October 2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 12 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 The residents and their representatives were confident that their complaints would be addressed by the service. Standard 18 was assessed at the previous inspection (October 2005) when it was judged to meet fully with the intended outcome. EVIDENCE: Nine (out of ten) comment cards received from the residents on the day of the inspection confirmed they knew who to speak to if they were unhappy with their care. Those who spoke directly with the inspector were also aware they could make a complaint and although they were unsure of the written complaints system named either a member of the family or staff. They also said they expected the complaint would be dealt with to their satisfaction. A detailed complaints record was examined. It consisted of pro forma sheets retained as a document. Details within the record show the outcome of investigations and comments from the complainants noting their satisfaction. A written complaints system is available to the residents within the service users guide located in the bedrooms. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 13 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 The Sycamores provides a warm, clean, and secure environment. The building both externally and internally is to be upgraded to the corporate standard. Standards 24 and 26 were assessed during the unannounced inspection (October2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: The Sycamores is well maintained internally, however the exterior of the building is beginning to look shabby, as are the furnishings and fittings. It is understood the home is to undergo a total refurbishment in the near future. There are also plans to improve the building in general. Work has commenced on the expanse of flat roof after several areas of ceilings in the laundry area had given way under the weight of rainwater. At the time of the inspection some bedrooms were in the process of having new carpet fitted. It is understood this is the beginning of a total refurbishment to include The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 14 two conservatories and a reorganisation of laundry areas. It was unclear as to when the major work was to commence. Two visitors also commented on the generally shabby state of the building but were aware of the plans to improve it. The residents are being kept up to date with the plans during the regular residents meetings. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 15 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): 29 In general the organisations recruitment policy and procedure is robust serving to safely support the residents. EVIDENCE: It is the organisations policy to obtain two references in addition to satisfactory criminal records clearance prior to offering them a post. The contents of a recently employed staff’s file were examined. It was noted that only one reference had been received and this was for a period of work that totalled six months. The second one had been applied for but not received. It is acknowledged that the carer who had no previous experience was working under close supervision. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 16 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): 35 & 38 The lack of appropriate protective clothing could place the health and safety of the resident’s, staff and visitors at risk. Standards 31, 33 and 36 were assessed at the previous unannounced inspection (October 2005) when they were judged to meet fully with the intended outcomes. EVIDENCE: Systems are in place to safely handle small amounts of resident’s personal allowances. The system is considered to be unnecessarily complicated and there are plans to rationalise it to benefit the resident’s concerned. Records of expenditure are retained along with receipts and the resident’s have immediate access to small amounts of cash should they require it. The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 17 Comments written on the daily observation notes concerned the absence of appropriate protective clothing. In the absence of suitable disposable gloves the staff had been issued with gloves that are not recommended for infection control purposes. It is understood some staff had been purchasing their own gloves to ensure their protection. Whilst the inspector agrees with the written comments the carers must be reminded that the daily observation sheets are not the place to bring this to the attention of senior staff. This is indicative of a lack of supervision in addition to poor ordering and is not conducive to good infection control practices. The Sycamores DS0000005584.V278276.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 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 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13 (4) (b)(c) 12(4) (c) Requirement The registered person must ensure that the risk assessments accurately reflect the risks associated with daily living. The registered person must ensure risk assessments concerning self-administration are carried out, documented and reviewed. The registered person must ensure that the staff adhere to the procedure concerning the administration of medication. The registered person must ensure the organisations recruitment and selection process is satisfactorily completed out before offering employment. The registered person must ensure stocks of appropriate protective clothing are maintained and provided to the staff. Timescale for action 01/04/06 2. OP9 01/04/06 3. OP9 13 (2) 01/04/06 4. OP29 12(1) (a) 01/04/06 5. OP38 13(3) 01/04/06 The Sycamores DS0000005584.V278276.R01.S.doc Version 5.1 Page 20 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 DS0000005584.V278276.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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