Inspection on 24/05/05 for The Sycamores

This inspection was carried out on 24th May 2005.

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 20/02/09

The Sycamores 23/01/08

The Sycamores 31/05/06

The Sycamores 17/11/05

The Sycamores 04/11/04

The Sycamores 04/06/04

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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Sycamores Jacobs Well Lane Wakefield West Yorks WF1 3PB Lead Inspector Tony Brindle Unannounced 24 & 31 May 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 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 J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Sycamores Address Jacobs Well Lane Wakefield WF1 3PB 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) 01924 379994 sycamores@tri-care.co.uk Tri Care Limited Mrs E Parr Care Home 40 Category(ies) of Older People 40 registration, with number of places The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 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 J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced 5-hour inspection began after lunch and ended after tea. 8 residents and 4 members of staff were spoken with. The inspector would like to take the opportunity to thank the residents, the manager and support workers for their hospitality and patient cooperation throughout the inspection. During the inspection, the following documents were inspected: 6 care plans, the daily records, staff personnel files, health and safety records, the complaints log and the residents financial records. A service user’s invitation to see their bedroom was welcomed and accepted, and the building and gardens were seen. The unannounced inspection took place after CSCI were alerted to the fact that a fire had occurred at the home in April. There have been no additional or complaints visit to this home since the last inspection in November 2004. What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that all pre-employment checks are satisfactorily completed before new staff start work. Record keeping must be kept up to for the protection of the residents and to ensure that all legal requirements are complied with. The manager was informed via an Immediate Requirement Notice of the need to comply with the law, and measures were immediately put in place to make that the staff without the relevant checks did not continue work. A fresh look at the staffing levels and their deployment would be a positive move, freeing up time for the manager to undertake The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 6 management tasks, and giving greater opportunity for the residents to benefit from better staff ratios based on their assessed needs. 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 J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 standard(s) 3 and 6 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: Before coming to living at the home, the needs of new residents are assessed by way of a Community Care Assessment undertaken by a professional such as a social worker and the homes manager. For new residents who are self funded, the registered manager and staff team carry out an assessment of need. The needs of new residents are recorded, and used to put together a plan of care for daily living. Each resident has their own file where records are kept. The manager explained that residents and their families (where appropriate) can have a look at their files. Intermediate care is not provided at the Sycamores. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 standard(s) 7,8,9 and 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 make 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 staff showed that they have a good understanding of the support and care needs of the residents. The systems for supporting residents with their medication is satisfactory and makes sure that each resident gets their own medication at the right times. The registered manager explained that a member of staff who has been trained in medication issues works on each shift. One resident said that she liked the staff and that they are very caring, another said that the staff are always ready to help. When asked about what happens if a resident needs to see the doctor, one resident explained that the staff make a telephone call and when the doctor comes, she see him in her room. One resident confirmed that he always wears his own clothes, has access to a telephone, and if he gets The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 10 any, receives his mail unopened. Residents were seen to supported discreetly and with respect during dinner and when needing to use the toilet. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 standard(s) 12, 13, 14, 15 The work of the staff and the systems operated at the Sycamores make sure that appropriate activities are provided for residents to get involved with. Residents maintain contact with family/representatives and the local community as they wish. Residents benefit from a wholesome, appealing and balanced menu. EVIDENCE: One staff member explained she has noticed that many of the people who live at the Sycamores have differing outlooks and preferences as to their everyday life within the home. One resident said that she likes to take part in a new of activities in the home such as bingo, quizzes, raffles and physical exercise classes. Another said that she just likes to watch the others take part, and joins in only now and again. Another resident explained that she really enjoys it when her relatives visit, and the manager explained that relatives are welcome to visit as they please. A number of visitors were seen but the opportunity did not arise to speak with any of them. One resident explained that she enjoys taking a walk around the grounds, and sometimes with staff help, goes down to the local shops where she buys sweets and biscuits. Residents said that the food they receive is very good, and one said that it was really important to get good quality food at her time of life, as she believed it helped in maintaining her health and wellbeing. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 12 Residents and their relatives are informed of how to contact external agencies. (e.g. advocates), who will act in their interests by way of a leaflet on the notice board. The home supports residents with the handling of their finances, holding small amounts of pocket money for them to access as and when they need it. The manager explained that she has systems in place for referring the names of residents who are vulnerable around finances, to the appropriate body that would support them, and their families if appropriate. These arrangements were found to be satisfactory, allowing for referral to the adult protection team and Court of Protection officer. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 13 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 standard(s) 16 and 18 The work of the staff and systems operated by the Sycamores make sure that residents and their relatives can raise complaints with the confidence that they will be listened to and taken seriously. There are suitable arrangements in place for responding to and reporting suspected or alleged abuse. EVIDENCE: There is a simple and clear complaints procedure. When asked about how to complain, one service user said that she could speak to any of the staff about problems or issue, and she felt certain that her problems would be looked into and dealt with properly. The record of all complaints made shows that no complaints have been received since the last inspection in November. Information about advocacy services is provided in leaflet form, and the Sycamores have systems in place for responding to suspicion of abuse. One staff member said that she knew that she could approach CSCI anonymously with concerns if she had concerns about bad practice in the home. She also explained that the company has a whistle blowing policy. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 14 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 standard(s) 19 and 26 The systems and procedures operated by the home, and the work of the staff ensure that the service users live in a homely, comfortable and clean environment. The home is clean, pleasant and hygienic. EVIDENCE: The facilities within the home are as home-like as possible while being fit for the purpose of the home and for the people who live there. One resident said that the staff put a lot of hard work in keeping the home clean, and another said that she thought the décor was very pleasant. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Pre-employment checks are not completed prior to new staff starting work at the Sycamores which potentially puts residents at risk. The Sycamores operate a minimum staffing complement which does not always meet residents needs. EVIDENCE: The manager explained that the number of staff employed at the home allow for the needs of the residents to be met. Two residents said “there are always staff around to help, but they are always very busy”. The staff rota shows that the total number of care staff and the total number of hours they work in a week, is lower than the that recommended by CSCI when the Department of Health guidance on staffing is used. The manager’s time is spent both supporting and caring for the residents, and undertaking her management tasks. She did say that having some extra management hours would allow her to do more work with the staff, up date the records and keep on top of the office tasks. The personal records of two staff members showed that they had started work with the correct employment checks taking place. One staff member explained that she had received a lot of good training since starting work at the Sycamores. The training list showed that the staff had had up to date and relevant essential training. The manager explained that she has now been given back the responsibility for advertising staff vacancies, and recruiting and selecting new staff. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 Safeguards are not in place for the protection of all the residents by way of effective record keeping, and effective health and safety checks. EVIDENCE: The manager explained that Tri-Care sends out yearly questionnaires to relatives and others seeking their views of the services provided at the home. She added that she has never seen the outcomes of these questionnaires. Residents monies are keep securely in the home’s safe, with each resident having their own wallet and set of records relating to any financial transactions made. When one resident’s records were checked, some receipts were found to missing, although the balance was correct. The fire alarm records showed that the alarm had not been tested for 3 months. The manager said that the system had been tested but the records had not been filled in. This oversight was made, despite the fact that a fire had occurred at the home in April 2005. The records relating to this fire were checked, and showed that the manager had failed to notify the CSCI of the incident. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 17 The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 2 x x 1 The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 19 NONE 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 as far as reasonable practicable, all areas of the home are free from hazards. Fire Tests must be tested as required. The registered person must ensure that all notifiable incidents relating to the service users and the operation of the home as passed onto the CSCI without delay. Timescale for action Immediate 2. OP38 13(4) Immediate 3. OP38 37 Immediate 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 OP27 Good Practice Recommendations The ratios of care staff to service users must be determined according to the assessed needs of residents, and a system operated for calculating staff numbers J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 20 The Sycamores 2. OP35 required, in accordance with guidance recommended by the Department of Health. The money of individual service users should be is handled appropriately with appropriate records and receipts kept. The Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © 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 Sycamores J51J01_s35670_the sycamores_v219649_2405052.doc Version 1.30 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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