Inspection on 01/09/05 for WCS - Sycamores, The

This inspection was carried out on 1st September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

WCS - Sycamores, The 25/07/06

WCS - Sycamores, The 13/03/06

WCS - Sycamores, The 08/02/05

WCS - Sycamores, The 16/08/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE WCS - Sycamores, The Sydenham Drive Leamington Spa Warwickshire CV31 1PB Lead Inspector Louise Thompson Unannounced Inspection 1st September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address WCS - Sycamores, The DS0000004269.V311367.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. 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. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCS - Sycamores, The Address Sydenham Drive Leamington Spa Warwickshire CV31 1PB 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) 01926 420964 01926 833591 Warwickshire Care Services Limited Mrs Karen J Doherty Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager achieves the Registered Manager’s Award (Adults) by April 2006. 8th February 2005 Date of last inspection Brief Description of the Service: The home is situated on the outskirts of Leamington Spa, within a housing estate and adjacent to an industrial estate. Close by is a small parade of shops, including a post office. The Sycamores care home is managed by Warwickshire Care Services. The Sycamores is registered as a care home providing personal care to 36 older people. On the ground floor of the premises there is accommodation for ten service users. The first and second floors can be accessed by means of a shaft lift or stairs and can accommodate a further 26 service users. Each floor has a lounge/diner, which have been extended and fitted with kitchenettes. On each floor there is also one bathroom and one shower room. Leamington Spas main shopping centre is within a five-minute bus journey; the bus stop is directly outside the home. There is limited parking space for staff and visitors to the rear and side of the home. WCS - Sycamores, The DS0000004269.V311367.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 inspection and took place over one day between the hours of 10.00 am and 5pm. This was the first visit for this inspection year and two inspectors were present. Staff co operated fully with the inspection. The manager was present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents and staff. What the service does well: What has improved since the last inspection? What they could do better: There are a number of things that the manager and staff need to do to make sure that the residents get the care that they need from staff that are well trained. Staff training needs to be planned and staff need to receive regular supervision. This includes training on health and safety matters. Assessment and care planning must improve so that the staff are able to know what to do for each resident. The recording of some medicines needs review to ensure that medicines are given correctly. Recruitment to lead carer and catering vacancies is necessary to ensure consistency of care/service by suitably skilled staff to people living in the home. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 6 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. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users have their needs assessed before admission to the home. Consideration is given to health, personal and social needs to ensure that their needs could be met by the home. EVIDENCE: The organisation has recently implemented a new care planning documentation, which includes a detailed assessment process. The assessment includes the identification of risks with regard to mobility, falls, nutrition and tissue viability. Four-service user files were examined and contained completed assessments identifying the needs of the individual. Copies of Social Services’ care plans were available on the files of service users referred to the home through social services. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The actions required to meet the needs of service users are not consistently described in individual plans of care. This may cause an oversight of care. Systems for the administration of medication are not organised in a way that maintains safe administration. Service User’s dignity is respected which will result in increased self-esteem and well-being. EVIDENCE: The home has recently introduced a new care planning and quality management system. The files of four service users were examined. Care plans for 3 of the service users did not contain sufficient information about the actions required to meet the needs of service users. Care plans were not consistently evaluated and reviewed monthly which may result in the changing needs of service users being overlooked. The inspector visited one service user who was very physically frail and was cared for in bed. The service user was comfortable and pain free and staff were WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 10 able to describe care needs and the actions they were taking to meet these needs. There was evidence of liaison with other health and social care professionals including optician, chiropodist and dentist. The community nursing service visits several residents in the home. Systems for receiving and storing medication are robust. Staff who administer medication receive training in the safe administration of medicines. However, staff spoken to told the inspector that there may be only one staff member on duty who has received the training and who is responsible for the administration of medicines for all 36 service users in the home for that shift. Documentation for the safe administration and recording of anticoagulant therapy was inadequate. Five service users spoken to made positive comments about the home, the staff and the service they receive; ‘I feel safe here’, ‘I trust them’, although one service user commented, ‘I might ring the bell and ask them for something, they say they’ll do it and forget’. Staff were observed to knock before entering rooms and addressed service users appropriately using preferred names, or some more formally ‘Mr’ or ‘Mrs’. Assistance was observed being offered to service users at appropriate levels to their needs and was given with discretion in public areas. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 People living in this home are supported to maintain family links and friendships and continue to be part of the local community in which they live. Dietary needs of residents are catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: There are no restrictions placed on visiting unless requested by residents. Four of the residents said that visitors are welcome at any time. Local churches visit the home and provide regular services and communion for those residents who may be unable to visit the church. The inspectors ate lunch with the residents. The meal was tasty and well presented. Residents said that choices were available at meal times and one resident who had lived in the home for a number of years said “you couldn’t wish for anything better.” The meal was served in homely relaxed surroundings and staff were available to assist should residents need this. Menus had been reviewed in June and appeared satisfactory. Results of a recent resident survey conducted by the home demonstrate high levels of satisfaction by respondents with the meals provided. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. EVIDENCE: Residents told the inspector that if they had any concerns about any aspect of the service they would discuss these with the manager. The complaints procedure is located on a notice board in reception and on each floor of the home. The inspector observed the complaints records, which included details of investigations and any action taken as a result. The CSCI has not received any complaints since the last inspection visit. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of décor and furnishings is satisfactory with evidence of ongoing planned improvement and maintenance. The home presents as comfortable and homely for residents. EVIDENCE: The Sycamores is registered as a care home providing personal care to 36 older people. On the ground floor of the premises there is accommodation for ten residents. The first and second floors can be accessed by means of a shaft lift or stairs and can accommodate a further 26 service users. Each floor has a lounge/diner, which have been extended and fitted with kitchenettes. The décor, furniture and furnishings are homely and suited to residents needs. Evidence of ongoing redecoration and refurbishment were seen. Quotes for replacement windows were being sought at the time of this inspection. Since the last inspection the garden areas have been improved and are easily accessible to residents. Residents said that they enjoyed the gardens and took the opportunity regularly to walk/sit in the garden areas. The home was observed to be clean and tidy and free from odours at the time of the WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 14 inspection. A tour of the laundry at the time of the inspection found this to be satisfactory. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The home is experiencing a period of instability with staffing and ongoing difficulties in recruitment of local staff. Problems with recruitment of staff have led to a reduction in staff attending training. This has the potential to lead to inconsistency of care within the home. The procedures for the recruitment of staff are satisfactory and protect the residents. EVIDENCE: The inspector observed the duty rotas for the period of a month. These demonstrated that although care staffing numbers were being maintained this was achieved by the use of agency and the manager and staff doing additional shifts to cover. Two staff said that weekends were difficult to maintain cover with lead carers and occasional problems were being experienced with ensuring sufficient and suitability qualified staff for the administration of medications. Where possible the manager uses the same agency carers to provide a greater consistency of care. The manager is currently arranging further training in medications for staff. Two residents said that the staff were very good and helpful but sometimes they were short of staff. In addition to the care staff vacancies the home is experiencing difficulties in recruiting to a cooks position. The manager and one other staff member are assisting in covering vacant shifts until a new cook is appointed. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 16 The inspector examined the records of three recently appointed staff members. Each file contained evidence of suitable CRB checks, references and all other information as required by this standard. A management checklist on the front of each file evidenced that staff had been given copies of the General Social Care Council Code of Conduct. Training records observed during the inspection demonstrated that staff have accessed less training in 2005 and that several staff required training/refresher training in fire, manual handling and first aid. The manager said that due to the ongoing problems with recruitment it was difficult to maintain suitable staff numbers to meet residents care needs and release staff to attend training. One staff member said that she had achieved NVQ level 2 and 3 and had commenced NVQ level 4 which she was enjoying. The manager has recently introduced a mentor system for lead carers to work with new staff members on their induction programmes. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38 The quality management systems in this home are developing, with evidence that residents’ views are sought and acted upon. The manager needs to progress the implementation of a suitable system for formal staff supervision to ensure consistencies in care practice. Staff training in health and safety issues is necessary to promote and protect the health, safety and welfare of residents. EVIDENCE: A comprehensive quality management system linked to resident assessment and care planning is partially implemented. A management matrix is completed monthly, which enables the homes manager and senior managers to monitor aspects of care and staffing throughout the home. This includes dependency levels and staffing, accident/incidents and complaints. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 18 Residents are asked one quality question each month and the responses are recorded. Throughout the year this will give an overall indication on residents views of the home. The manager has recently completed an annual resident survey with results available at inspection. The majority of responses to the areas included in the survey were very positive. Areas identified for review and development include laundry services and activities. The manager is taking action to address these. Policies are produced corporately and are currently subject to review. A system for formal staff supervision has been partially implemented with evidence seen of some completed supervisions on staff records observed during the inspection. The manager said that the current staffing problems and the implementation of the new care planning systems had affected the number of supervisions completed. Certificates were seen during the inspection for the maintenance and service of major systems. Copies of the last Fire Officers report and Environmental Health Officers report were seen. During this inspection work in the kitchen was in progress to meet requirements made by the EHO. Training records available during the inspection indicate that some staff are still to attend training in fire, manual handling and other health and safety issues. Accident records were observed, occasional records lacked sufficient recorded detail with regards to the accident/incident. These are reviewed regularly by the manager and reported to the head office as part of the quality management system. WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 2 WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered manager must ensure that each resident has a care plan. Care plans must set out in detail the action needed to be carried out to ensure that all aspects of the health, personal and social care needs of each resident is met. Care plans must be up to date and reflect the current needs of individual residents. These must be reviewed monthly as a minimum. The registered person must ensure that at all times a sufficient number of staff trained in the Safe Administration of Medicines are on duty on each shift. Staff responsible for administering medications must receive training from an appropriately qualified person. The registered person must ensure that directions for the administration of anticoagulant therapy (Warfarin) are documented on the medicine administration record (MAR) in a manner that gives clear DS0000004269.V311367.R01.S.doc Timescale for action 30/11/05 2. OP9 13, 18 30/11/05 3. OP9 13 30/11/05 WCS - Sycamores, The Version 5.2 Page 21 4. OP27 5. OP28 6. OP30 7. OP37 8. OP38 9. OP38 instructions for the dosage to be given. 18 The registered manager must ensure that staffing levels and skill mix are maintained within previously agreed levels.These should be based on resident dependency and assessed care needs. 18 The registered person must provide an action plan to ensure fifty percent of care staff have achieved NVQ level 2 or above by 2005. 18, 14 The registered person shall ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform; and suitable assistance , including time off for purpose of obtaining further qualifications appropraite to such work.(old timescale of 28/02/05 part met) 26 The registered provider must ensure that a representative of the organisation visits on a monthly basis and prepares a written report.(old timescale of 28/02/04 and 31/03/05 remains unmet) 16, 13 The registered provider must confirm that requirements made by the environmental health officer have been met. A copy of the visit is to be forwarded to the commission. 13, 23, 16 The registered manager must ensure that staff receive training in moving and handling, fire and infection control. A copy of the training plan should be forwarded to the CSCI. 30/10/05 31/12/05 31/12/05 31/10/05 31/10/05 30/11/05 WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 22 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 OP8 Good Practice Recommendations The inspector recommends that the manager liaise with the district nursing services for advice/training on the monitoring of diabetics and procedures to be followed in the event of hypoglycaemia. The inspector recommends that the organisation provide a timetable for the review and provision of new corporate policies. The inspector recommends that the manager continues to implement the system for staff supervision. Care staff should receive six supervisions each year. 2. 3. OP33 OP36 WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCS - Sycamores, The DS0000004269.V311367.R01.S.doc Version 5.2 Page 24 - 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. 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