Inspection on 27/10/05 for The Sycamores

This inspection was carried out on 27th October 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 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 05/02/07

The Sycamores 16/03/06

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 27th October 2005 12:30 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.V264514.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 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.V264514.R01.S.doc Version 5.0 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.V264514.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories except 10 (only) Elderly Learning Disability 4th March 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.V264514.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 conducted by one inspector over a period of five hours and included observing activity within the home, speaking with residents and staff, observing documents such as residents care files and staff training records. The manager was present on the day of inspection and the inspector found the home functioning well, the atmosphere calm and residents appeared content and well cared for. Staff were observed to be attentive to resident’s needs throughout the inspection. Residents and staff were welcoming and helpful at all stages of the inspection. A full tour of the premises was not undertaken at this inspection and the inspector did not have opportunity to meet with individuals residing in The Bungalow area of the home, this will be followed up at the next inspection. What the service does well: What has improved since the last inspection? The last full inspection of the home was in August 2004 and the home has met or partially met requirements made at that inspection. The CSCI pharmacist inspector visited in March 2005 and conducted a full audit of medication practices within the home, which resulted in 24 requirements being made. Compliance was not assessed at this inspection and the pharmacist inspector is to return to the home to check that the home has achieved the requirements. Sycamores, The DS0000017195.V264514.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. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 7 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.V264514.R01.S.doc Version 5.0 Page 8 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): 3 and 4. The home has a satisfactory admissions procedure that provides for an effective needs assessment for each resident. Staff individually and collectively have the skills and experience to deliver the care required by residents. EVIDENCE: Observation of a random selection of care files demonstrates that resident’s care needs are appropriately assessed prior to and on admission to the home. Case tracking these files showed that the needs identified during the assessment process form the basis of care plans and were found to be individually relevant to each resident. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 9 The home provides care to individuals with a range of conditions. Through discussions with residents and staff, observation of staff training records and residents care plans the home demonstrates that it can meet the needs of the current residents. The Sycamores continues to offer “step down/interim care” nursing and residential beds on a contractual basis. This service does not incorporate intensive rehabilitation and is generally for individuals transferred from hospital that are waiting for a care package to be arranged before returning to their own home or sheltered accommodation. Residents admitted for interim care spoke positively about their experience and about the staff group caring for them. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 10 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): 7 and 8. There is a clear and consistent care planning system in place that provides staff with the information they require to meet resident’s needs. EVIDENCE: A sample of care files were inspected on each of the four units within the home. All files contained an extensive range of care plans relevant for each individual case tracked during the inspection. For example a care plan that had been drawn up for a resident with diabetes contained detailed information to provide staff with the information they need to ensure that the residents Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 11 diabetic needs are met. A care plan for a resident requiring PEG feeding included comprehensive information regarding their specific “feed regime”. A range of risk assessments were available on all files seen that identify residents needs and the interventions required to reduce risks. Residents identified at risk of developing pressure sores had good preventative measures in place and the home was observed to have a range of pressure relieving equipment available. Moving and handling risk assessments and plans were comprehensive, reviewed regularly and contained information on types of moving and handling equipment required to move the resident safely. Two “moving plans” had not been signed or dated by staff and the manager was advised to ensure that staff sign and date all documents. Care staff maintain additional charts that document pressure relief/turn charts and fluid intake. The manager conducts audits of care documentation to ensure that staff adhere to policy and staff overseeing each unit receive supernumerary time so as they can ensure documents are kept up to date. Evidence was available to demonstrate that the home seeks prompt advice from other healthcare professionals such as dieticians and GPs as and when appropriate. Six residents that were spoken with during the inspection were extremely positive about the care they receive; one resident described the care as “ten out of ten”. A resident on the residential floor spoke of how all the staff had worked hard to enhance her mobility. In March 2005 the CSCI pharmacist inspector conducted a full audit of medication practices within the home, which resulted in 24 requirements being made. This standard was not covered at this inspection and the pharmacist inspector is to return to the home to assess compliance. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed at this inspection. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 13 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): 16 and 18 The home has a complaints system that ensures that concerns are listened to and acted upon. The arrangements for the protection of residents from abuse is satisfactory. EVIDENCE: The home has a complaints procedure that it is clear and easy to read and a copy is available on the notice board and in the service user guide. It was discussed with the manager that a slight amendment to the procedure is needed to clarify the timescale to investigate the complaint. A pictorial guide is also available to assist individuals with communication difficulties. The manager reports that four complaints have been made to the home since August 2004. A record is kept of complaints and observations of these records show that the manager responds appropriately to any concerns raised. Residents that were spoken with felt that the staff and manager would respond quickly should they have any concerns. The manager has a sound knowledge of local adult protection procedures; this competence was demonstrated earlier this year when a complaint raised by a Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 14 resident was referred appropriately and promptly by the manager for investigation under the local adult protection process. Two members of staff have attended training to equip them with the skills to teach adult protection/abuse awareness and the manager reports that approximately 60 of staff have now received training in this area. Discussion with two members of care staff confirmed that this training had taken place and these individuals were able to respond competently to questions regarding adult protection. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 15 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): 19 The standard of the environment is good providing residents with an attractive and clean place to live. EVIDENCE: A full environmental inspection was not undertaken at this visit, however the parts of the home that were observed were found to be clean and decorated to a good standard. Residents seen during the inspection spoke of their satisfaction with their rooms and the cleanliness of the home. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 16 The local fire officer visited in September 2005 and made a number of that observations requiring attention. The manager provided evidence to confirm that work is due to commence within the home in order to comply with the fire officer’s report. Residents that dislike having their bedroom doors closed were observed to have risk assessments in place and “door guards” fitted to their bedroom doors. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 17 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): 28, 29 and 30 The home has a robust recruitment procedure in place that protects residents from the employment of inappropriate staff. The home employs appropriately skilled staff to meet the needs of residents. EVIDENCE: Three staff files that were observed showed that the home operates a robust recruitment procedure. The staff files were well organised and contained the required pre-employment checks for staff. Training certificates contained within files demonstrate that staff have attended a variety of different study days and courses to ensure they are sufficiently skilled to meet the needs of the current residents. The home provides an induction programme that meets the required level and a staff member recently employed by the home spoke positively of her induction. The manager confirmed that 28 staff have now attained NVQ Level 2 or above and a further 11 staff recently commenced studying for their NVQ Level 2. Staff spoke positively regarding training opportunities provided by the home. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 18 To assist the manager in reviewing staff training it is recommended that a training matrix is devised. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 19 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): 32 and 38 The manager leads the staff team with confidence from which residents and their families benefit. The home is well maintained and the staff group appropriately skilled to ensure that the health, safety and welfare of residents is promoted Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 20 EVIDENCE: Discussions with residents during the inspection were highly complementary regarding the service provided, level of care, staff and the manager. Two visitors to the home were satisfied with the level of care provided to their relative. Staff confirmed that they feel well supported by the manager and that good training opportunities exist within the home. All records pertaining to the maintenance and servicing of equipment were observed to be up to date and well organised. Records of checks made on the temperatures of water temperatures show that temperatures are maintained within the required limits. Discussion with staff and observation of their files confirms that training in safe working practice topics is provided. Bed rails that were observed in use were fitted correctly however the home is strongly advised to incorporate the general maintenance of bed rails into a planned preventative maintenance programme. The manager confirmed that the maintenance person and/or clinical staff are responsible for the fitting of bed rails, as it could not be established what training had been undertaken to deem these people competent to perform this procedure the manager must ensure that staff responsible for the fitting of bed rails receive appropriate training. The use of bed rails can pose significant risks and although some risk assessments had been undertaken to support the safe use of bed rails, the assessments required further development based on guidelines provided by the Health and Safety Executive and the Medical Devices Agency 2001 guidance. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 21 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 3 4 3 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X 37 X 38 2 Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 22 No 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. 2 Standard OP22 Regulation 23(2) Requirement Storage areas must be provided for aids and equipment, including wheelchairs and hoists. (Not assessed at this inspectionprevious timescale of 12/11/04). 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. 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. Timescale for action 01/03/06 3 OP38 13(4)(c) 01/03/06 4 OP38 13(4)(c) 01/03/06 Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 23 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 2 Refer to Standard OP8 OP30 Good Practice Recommendations The registered person is strongly recommended to ensure that staff sign and date all documents To assist the manager in reviewing staff training, it is recommended that a training matrix be devised. Sycamores, The DS0000017195.V264514.R01.S.doc Version 5.0 Page 24 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. 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