Inspection on 05/02/07 for The Sycamores

This inspection was carried out on 5th February 2007.

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 16/03/06

The Sycamores 27/10/05

The Sycamores 03/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Sycamores, The Johnson Street Wolverhampton West Midlands WV2 3BD Lead Inspector Mr Ian Harris Key Unannounced Inspection 5th February 2007 08:00 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 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.V329849.R01.S.doc Version 5.2 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.V329849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories except 10 (only) Elderly Learning Disability 16th March 2006 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.V329849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 2 days in the presence of the Care Manager, two regulation inspectors and a specialist inspector. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked 4 members of staff 10 residents and 1 relative were consulted. What the service does well: What has improved since the last inspection? The home has a good programme of maintenance and refurbishment and since the last inspection it was noted that 12 residents’ bedrooms the corridors, Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 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.V329849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 and 6 the Quality in these outcome area is Good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide provides service users and prospective users with details of the services the home provides, enabling an informed decision about admission to the home. Assessment of need is conducted in a respectful and plain speaking way so that service users understand their needs will be met during their stay. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. EVIDENCE: Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 9 The home has a good Statement of purpose and a Service Users Guide. All the residents are referred by the P.C.T. and undergo a full multi-disciplinary assessment prior to admission. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six residents files and care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Observations and discussions with the Care Manager and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home in a satisfactory and sensitive manner. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 the Quality in these outcome areas is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has an individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. EVIDENCE: Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 11 The home provides a Care Plan for each individual resident based on the initial assessment. Where possible the Care Plans are drawn up by the Care Staff in consultation with the resident and their family. It was noted that some of the daily records lack a detail on daily activities. However there was evidence on the files to show the Care Plans are being carried out and reviewed on a monthly basis. It was evident during the inspection, from looking at records, inspecting the facilities, observation of care given and chatting to staff and residents that individual health, and personal needs were being met. Residents were being treated with respect, and staff were working sensitively in meeting individual needs. All the residents looked comfortable and well cared for. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The residents’ health is closely monitored and appropriate medical care services are sought as and when required. The Inspector spoke to several service users, but was unable to have meaningful conversation. The residents appeared to be content, comfortable and happy and it was obvious that their needs were being met. The Pharmacist Inspector (Ian Henderson) visited on the 9th February 2007 to assess what progress the home had made in meeting the requirements made following the pharmacy inspection carried out on the 13th September 2006. The policy and procedures document for the handling of medicines was again reviewed and it was seen that in the first instance a copy of the document had been located in the medication room so that all nurses had access to it. It had also, by the way it had been organised in the A4 file, been made more user friendly. However, upon examining the content it was found that the document was much better but still was not a comprehensive description of how medicines were to be handled within the home. A copy of the policy and procedures document for the safe handling of medicines was supplied to the inspector for his comments on how to improve the contents. Following the last pharmacy inspection the home had decided not to use homely remedies and as a consequence had not obtained written authorisation from each resident’s GP. If the home wanted to pursue the use of homely remedies in the future the policy and procedures document for the safe handling of medicines did set out very well the procedures for gaining authorisation from the GP, purchasing the medicines, administration and recording the administration. The Manager had recently introduced a fantastic monthly medication audit, which resulted in a score for the handling of medication, being awarded. The most recent audit of the receipt, storage, administration, recording and disposal of medicines had resulted in a score of around 50 . This audit will be a good tool for driving up standards in the home. It was suggested that the monthly audit should incorporate an audit of whether the records could show whether a sample of residents had received their medication as prescribed. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 12 The current MAR charts were examined and a number of issues were again found. These issues were found in great abundance on the Oak and bungalow floor. The Ash and Elm floors had significantly improved and these issues were found only on one or two occasions: • The MAR charts were being used to record the receipt of medication each month but it was seen that not all quantities received were being recorded and therefore audits to check whether all medication had been administered as prescribed were impossible. Hand written additions to the MAR charts were not being transcribed properly from the pharmacy label nor were they being countersigned to confirm the accuracy. The name, strength, form of the drug and the directions must mirror what appears on the pharmacy label. A number of the MAR charts examined had gaps where a signature to confirm administration or an abbreviation for non-administration should have been. Without the initials of the member of staff who administered the medication or an abbreviation giving the reason for the non-administration the outcome of the medication was unknown. When generic abbreviations were being used to identify non-administration it was observed that they were not being defined. The integrity of some of the MAR charts could not be guaranteed because there were examples of where medication had not been given yet the MAR charts had been signed to confirm that they had. A number of the MAR charts showed that the home was not administering some of the medication according to the directions displayed on the dispensing labels. No written evidence from the prescriber could be found to take account of the difference. The home must ensure that the prescriber’s directions are adhered to without fail. If it appears that the directions are not appropriate for the circumstances of the resident then the GP must be consulted and written confirmation sought. Some medication had been prescribed with variable doses and it was seen that the home had no record of what circumstances would result in the higher doses being given and visa versa. The home was also not recording which particular dose was given on the MAR charts. • • • • • • Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 13 There were still a number of medicines with dispensing labels attached that were showing the directions “As directed”. The home was instructed to obtain written confirmation from the prescribers’ of what the precise directions should be and adhere to them accordingly. If it was discovered that the home had not been administering medication as the prescriber had intended, then reviews of the affected residents must be organised. The home was also asked to ensure that any medication received into the home with “As directed” labels were returned immediately to the pharmacy for alteration to the precise prescribed instructions. There did not appear to be any direction for nursing staff on the administration of rectal diazepam prescribed for one resident for the prevention of status epilepticus. In order to ensure that the resident receives the rectal diazepam at the appropriate time the home must develop, with the residents’ GP, a written protocol for when the rectal diazepam should be administered. It appeared that the administration of Warfarin and Alendronic acid were being administered as prescribed and in the manner specified by the manufacturers. At the time of the inspection none of the residents were self administering their medication. If the home wanted to risk assess a resident for selfadministration the policy and procedures document for the safe handling of medicines did set out very well the process for doing this. The home had also introduced a very good and very detailed risk assessment questionnaire for the nursing staff to use. An audit of the Controlled Drugs register identified that one resident had received only one dose of a twice daily treatment of Morphine Sulphate 10mg capsules. The manager agreed to investigate and report her findings. The nursing staff were also asked to take care when dating entries in the register because on a number of occasions the wrong date gave the appearance that the residents had been overdosed on one day and under dosed on the other day. An examination of the medication room found that there had been significant improvements in the storage and safekeeping of the residents’ medication. The stock levels had been significantly reduced so that the home was only keeping approximately one months supply of medicines for each resident. The residents’ medication had been reorganised so that each unit’s medication was kept together and separate from the other units’ medication. The home was waiting for a further cabinet to be delivered so that the medication could be organised further into separating out the residents’ medication. No out of date medication was found, all medication appeared to have a dispensing label attached and the internal and external medicines were being kept separate. The three trolleys appeared to be reasonably well organised with the home attempting to organise the non MDS medication by resident, keeping each residents medication together but separate from other residents medication. A Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 14 vial of insulin was found in one of the trolleys, which had not been dated when it had been removed from the fridge. The home was therefore unable to identify when the expiry date of this product would have lapsed. A tube of Daktacort cream, which must be stored in the fridge, was found being stored in one of the trolleys. The management of the fridge had again improved because the home was using a maximum and minimum thermometer to ensure that the fridge temperature was maintained at between 2 and 8°C through daily monitoring. It was disappointing to find that there were some medicines in the fridge that did not require cold storage conditions and that a number of eye drops had not been dated upon opening. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15 the Quality in these outcome areas is adequate This judgement has been made using available evidence including a visit to this service. The home provides a good programme of social activities within the home and outside the home, which are designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety, also catering for special dietary and ethnic needs. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 16 EVIDENCE: The Home works hard to involve residents in a range of leisure opportunities, consistent with each resident’s capabilities. The role of the activity organiser ensures there are a variety of things for residents to do as a group or on their own. It was noted that the people who currently live at the home have enjoyed numerous outings throughout the summer All residents that were spoken with during the inspection spoke positively regarding the activities co-ordinator, her enthusiastic approach and commitment to her role, this was also apparent during a discussion with the inspector. Residents confirmed that their choice to take part is always acknowledged. Residents are consulted on a daily basis about what they would like to do that day and comprehensive records are kept that show that a range of activities are offered such as arts and crafts, board games, reminiscence and outings to different community events. All residents’ were very complimentary about the standard and choice of food provided. It was apparent that the menu is changed on a regular basis. Several residents’ told the Inspector that the food was good, tasty and well prepared. It was also noted Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 the Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home has a good complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, which a is issued on admission to the home. A copy is also placed in the reception hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the home opened in December 2006 all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in internal and N.V.Q. training, which all care Staff undergo. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 the quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home and the garden is good providing the residents with a very attractive, comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home has been established for a number of years and is maintained to a good standard, as are the gardens and grounds and provides a very comfortable homely and safe environment. The home is furnished to a high standard throughout. All the bedrooms are well furnished, however it was noted that none of the en-suites in the residents’ bedrooms are fitted with a cabinet for toiletries. It was noted that the electric hoists are being stored and charged up in the corridors causing an obstruction. Plug sockets should be fitted at the ends of the corridors in order to store them and charge them up out of the residents’ way. The bathrooms throughout the home appear clinical and would benefit from the provision of some pictures plants tile transfers in order to make bathing a more pleasurable experience. The home was found to be clean tidy and free from odour. The home has good hygiene and infection control policies and all the care and catering staff have undergone Food Hygiene and infection control training. All the staff are conscious of the risks of cross infection and use appropriate protective clothing. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29, and 30 the quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home is staffed with good numbers and skill mix of staff. The staff have a very good understanding of the residents support needs. The home has good policies and procedures regarding the recruitment of staff. The manager has introduced a good staff-training programme however the staff induction needs to be updated. EVIDENCE: The inspection of staff rotas and discussions with staff and residents indicated that the home is adequately staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that there have been minimal staff changes since the last inspection. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 21 The home operates an efficient recruitment procedure. On inspecting 6 staff files, there was evidence within them that all C.R.B. checks are being carried out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training that has exceeded the minimum standard. Also the care staff have attended courses on Safe handling of medication, Dementia care, Moving and handling, Risk assessment, Ageism, Fire Prevention, Dealing with Challenging Behaviour, First- Aid and Health and safety at work. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a competent registered manager, where service users interests and welfare is promoted. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 23 The home has good policies and procedures regarding Health and safety and meets the requirements of the Fire Officer and Environmental Health Officer, promoting EVIDENCE: The home is well managed by the Care Manager who is qualified in both practice and management and has considerable experience in people in nursing and residential homes There are clear lines of accountability within the home and the manager is very supportive of both staff and residents. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is a good staff supervision system in place however there is no evidence that the staff have regular supervision meetings. The care manage stated that she had not yet met the required standard of staff supervision. It was also noted that the home has a Quality Assurance system in place, which includes questionnaires to residents, visitors and relatives to obtain feedback on the quality of service. However consultation only takes place annually. Consultation should take place at least twice a year. The feedback from the last issue of questionnaires was very positive with all feedback stating they are satisfied with the care they are receiving. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents where possible and relatives regarding the choice of meals and activities. All the records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 24 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 3 2 X 3 X 4 X 5 X 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13(4)(c) Requirement Staff who are responsible for selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be incorporated in a planned maintenance schedule. (In process of being achievedprevious timescale of 1/03/06) 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. (In process of being achieved previous timescale of 1/03/06) The policy and procedures document must be updated and amended to include the issues identified by the Pharmacist Inspector Previous timescale not met The quantities of all medication received by the home must be recorded and confirmed with a DS0000017195.V329849.R01.S.doc Timescale for action 05/04/07 2. OP38 13(4)(c) 05/04/07 3. OP9 13(2) 05/04/07 4. OP9 13(2) 05/04/07 Sycamores, The Version 5.2 Page 26 signature of the member of staff receiving the medication. Previous timescale not met 5. OP9 13(2) All medicines administered/non 05/04/07 administered must be recorded immediately after the transaction with either a signature or a defined abbreviation so that gaps in the administration record do not occur. Previous timescale not met Any hand written additions to the Medicine Administration Record (MAR) charts must be transcribed from the prescription or pharmacy label and countersigned for accuracy. Previous timescale not met 05/04/07 6. OP9 13(2) 7. OP9 13(2) All generic abbreviations used to 05/04/07 identify the reason for nonadministration on the MAR charts must be defined properly. Previous timescale not met Evidence must be available to show that all hand written entries on the MAR charts have been prescribed for a particular service user. Previous timescale not met The prescriber’s directions must be adhered to without fail. If it appears that the directions are not appropriate for the circumstances of the resident then the GP must be consulted. Previous timescale not met For all variable doses the home must seek information from the residents’ GP as to when it is appropriate to give the higher dose. The home must also start DS0000017195.V329849.R01.S.doc 8. OP9 13(2) 05/04/07 9. OP9 13(2) 05/04/07 10. OP9 13(2) 05/04/07 Sycamores, The Version 5.2 Page 27 recording which particular dose was administered to the resident on the MAR charts. Previous timescale not met 11. OP9 13(2) All as directed doses must be confirmed in writing by the prescriber and the MAR sheets must be amended accordingly. Previous timescale not met A written criterion for the administration of rectal diazepam must be available and based on documented medical advice. It must be ensured that all medication is stored in accordance with the manufacturers storage requirements. Previous timescale not met Products that have a short shelf life when opened must be dated upon opening and discarded at the appropriate time. Previous timescale not met The registered person must ensure that an induction programme is introduced that meets the Skills for Care standards. The registered person must ensure the all staff receive formal supervision at least six times a year and that records are kept. 05/04/07 12. OP9 13(2) 05/04/07 13. OP9 13(2) 05/04/07 14. OP9 13(2) 05/04/07 15. OP30 18 05/04/07 16. OP36 18 (C) (ii) 05/04/07 Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 28 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 OP30 Good Practice Recommendations To assist the manager in reviewing staff training, it is recommended that a training matrix be devised (In progress). To provide cabinets in en-suite bathrooms Provide pictures plants, tile transfers in bathrooms. To fit plug sockets at end of corridors for recharging hoist. 2 3 4 OP19 OP19 OP19 Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Sycamores, The DS0000017195.V329849.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!