Inspection on 13/03/06 for WCS - Sycamores, The

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 01/09/05

WCS - Sycamores, The 08/02/05

WCS - Sycamores, The 16/08/04

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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 Deborah Shelton Unannounced Inspection 13th March 2006 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 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 Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager achieves the Registered Manager’s Award (Adults) by April 2006. 1st September 2005 Date of last inspection Brief Description of the Service: The home is situated 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 Spa’s main shopping centre is within 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.V286044.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 10.00am and 6.00pm on Monday 13 March 2006. During this inspection the Manager was on duty along with eight care staff. Thirty-five people were living at The Sycamores, eight of whom were spoken to about their experiences of life at the Home. The inspection process also involved looking at paperwork and discussions with the manager. Some of the documentation was looked at in the lounge, this enabled the inspector to see residents in their usual surroundings and see the relationship between staff and residents. What the service does well: What has improved since the last inspection? The new manager has made changes to the way in which anticoagulant medication details are recorded and signed by staffs The new system in place clearly demonstrates the dosage of medication taken on a daily basis. A new system of staff supervision has commenced. Staff receive individual and/or group supervision at least once per month. Corporate policies have been reviewed and a new policy manual sent to the Home. The manager reported that the “staff handbook” is also under review and the new version should be sent to the Home shortly. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 6 Seven staff have undertaken training regarding diabetes, further training is planned for the remaining staff. 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. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected. EVIDENCE: None of the standards in this section were inspected on this occasion. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 The actions required to meet the needs of residents are not consistently described in individual plans of care. This may cause an oversight of care. Systems and practices regarding storage and administration of medicine are good. The Home’s policies and procedures for dealing with medicines protect residents from risk of harm. EVIDENCE: Each resident has a plan of care based on information obtained during the preadmission assessment and information provided by the social worker in the form of a care plan (where applicable). Three care files were reviewed, each contained standardised documentation, which if completed correctly would give staff sufficient information to be able to meet the care needs of resident. One of the care files had been completed in a satisfactory manner with a wealth of information recorded such as risk assessments, likes and dislikes, personal and physical care details and hobbies and interests. Fluid intake charts were available, staff had not been completing these documents on a regular basis. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 10 The other two care files had a lot of blank sheets. Some information had not been dated or signed and it was difficult to tell whether resident’s needs had changed recently. Each month aspects of care are reviewed, any changes should result in new information being recorded in the care plan. This was not always the case. These care plans did not contain sufficient information about the actions required to meet the needs of residents. Not all of the care files contained evidence that care needs are discussed and reviewed with the resident or their representative. Daily records were brief on some occasions and did not demonstrate any actions taken by staff to meet care needs. “No concerns” or “eat well, no concerns” was sometimes recorded. The daily records in one file highlighted a health issue, the GP had been called in and various tests undertaken. There was no short-term care plan regarding this detailing how staff are to meet the resident’s needs until the issue is addressed. Medication administration records had been completed in a satisfactory manner. Controlled medications in use where being stored appropriately and records were kept according to legislation. A fridge is available to store any medication that requires refrigeration. The requirement made at the last inspection to change the way in which anticoagulant medication was recorded has been addressed. The manager has also changed duty rotas to ensure that two staff are responsible for administering medication per shift. This was also changed as the result of a requirement made at the last inspection. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 Social/leisure activities do not meet the expectations of all residents. The systems for resident consultation require improvement, there is limited evidence to demonstrate that resident’s views are sought or acted upon. EVIDENCE: Details regarding activities provided by external entertainers are on display throughout the Home. Each care file contains information regarding hobbies and pastimes, some had not been fully completed. Residents spoken to said that there is not a lot to do in the day. Two residents said that they used to play bingo, which they really enjoyed, but they haven’t played for a long time. Another resident said that they liked to read and would like the mobile library to visit the Home. In general residents were not satisfied with the activities provided. The manager was aware that residents required further mental stimulation and said that she is in the process of arranging time each day when staff will initiate activities with residents on an individual or group basis. Care files recorded preferred times for rising and retiring and routine upon waking etc. A choice of two meals is available at lunch each day. Residents WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 12 also have a choice of evening meal, this was seen during the inspection, and residents were eating either toast, egg on toast or sandwiches. Residents spoke about the choices that they make, the responses received varied. Some residents said that you are able to maintain a level of independence and make some choices, others said that you make choices but that you are reliant upon staff to assist you, which can prove difficult sometimes, and other residents were unaware that they had a choice. The manager started her employment on the 9 February 2006. No resident meetings have been held since she started at the Home. A meeting has been arranged for March. Details of the time and date are available in each unit. Families/representatives are also invited to attend. Currently none of the residents handle their own financial affairs. Pocket monies are kept on behalf of residents, receipts are kept for all items of expenditure, records are up to date and in good order. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Adult protection arrangements in place need further development. EVIDENCE: Records demonstrated that criminal records bureau (CRB) checks have been completed on all staff prior to employed. The records for one staff member demonstrated that a standard disclosure had been applied for, all staff responsible for personal care of a resident must have an enhanced CRB check undertaken. The manager was unable to locate the whistle blowing procedure. New policy and procedure manuals were issued in January 2006, this policy was not included in the file. The adult protection policy was comprehensive and contained sufficient guidance for staff. Protection of vulnerable adults (POVA) training has been completed by ten staff. Training is also planned each week during April and June. The manager reported that all staff will undertake this training. There has been one allegation of abuse since the last inspection. The manager demonstrated that a full investigation was completed and a training need identified. Appropriate actions have been taken to address issues. The manager must ensure that the training need identified is met immediately. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected EVIDENCE: None of the standards in this section were inspected on this occasion. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Staffing levels offer a good consistency of care within the home. In order to ensure that the workforce has the skills to meet the needs of service users mandatory and service user focussed training must take place. Recruitment practices are not carried out thoroughly for all staff. EVIDENCE: A duty rota is kept which details staff available for each shift, these documents do not record the hours that the manager and care manager work. The manager was aware that these hours must be recorded on rotas in order to demonstrate that sufficient management time is provided. There are no vacancies for care staff currently, the manager reported that the high usage of agency staff has now stopped. Three shifts are worked during the day between the hours of 8.00am – 3.00pm, 3.00pm – 10.00pm and 10.00pm – 8.00am. Rotas are also available to demonstrate the hours that domestic staff work. Throughout the inspection staff were friendly, relaxed and professional and were readily available to assist residents. Residents spoken to stated: “staff are kind and friendly” WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 16 “there is always someone there to help if you need it” “the staff are polite and friendly” Residents were seen to have a good relationship with staff and were at ease in their company. Three staff files were seen. One file did not contain a copy of the birth certificate and there was no photograph on another. Two of the files had been signed to record that the member of staff had been issued with the General Social Care Council Code of Conduct, and the other had not. As mentioned under standard 18 one member of staff has not had a CRB check undertaken at the appropriate level. All staff that are involved in any form of personal day-to-day contact with residents must have an enhanced CRB check undertaken. All new staff that have been employed since the new manager commenced her employment have been issued with an induction package. This package meets the national training organisation’s requirements. There was limited evidence that other staff employed have undertaken appropriate induction training. Discussions with the manager and documentation seen demonstrated that a range of training is planned for the coming months including health and safety, fire, infection control and POVA. The manager has yet to organise manual handling training. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 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): 31, 33, 35, 36 and 38 The newly appointed manager has a clear vision for the home and a good understanding of the areas in which the home needs to improve The quality management systems in place ensure that the home is run in the best interests of the residents. Procedures are in place to manage residents’ monies and valuables so their interests are safeguarded. Staff are supervised to ensure that they have the support, skills, practises and knowledge to met all of the residents needs. Staff training in health and safety issues is necessary to promote and protect the health, safety and welfare of residents. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 18 EVIDENCE: The newly employed manager has worked at The Sycamores since 9 February 2006. During discussions the manager demonstrated that she has at least two years experience in a senior managerial position. The manager has obtained NVQ level 4 and the Registered Manager’s Award and is currently undertaking an NVQ level 5 in management. The manager is in the process of applying for approval with the Commission for Social Care Inspection as the registered manager. There have been no changes to the quality assurance systems in place since the last inspection, the manager reported that the systems are robust and that she has set procedures to follow. This standard was not fully audited on this inspection. The issue identified during the previous inspection was reviewed and found to be met. Corporate policies and procedures are currently being reviewed. A majority have been reviewed and re-issued to the Home in January 2006. The Registered Provider is required to undertake monthly unannounced inspections of the Home and provide a written report of this visit. A copy of this report is to bed forwarded to the Commission for Social Care Inspection. No reports have been received recently. The Home’s secretary is responsible for handling all finances and records regarding resident’s pocket monies. The Home’s policy requires two signatures for each withdrawal or receipt of funds. Records demonstrated that only one staff signature is available. The manager audits the spending money records of two residents to ensure details are correct. Records were in good order and up to date and receipts are available regarding any expenditure. A system of group and one to one supervisions as well as appraisal meetings are in place. Unit meetings are held on a monthly basis. These meetings are used to discuss practice issues, to reinforce the philosophy of care at the Home and to discuss resident’s individual needs and any changes to their care. One to one meetings are held three times per year. These meetings are held to discuss training needs amongst other things. Observed practice also takes place twice per year and an appraisal meeting once per year. The schedule for these meetings was reviewed, the manager has met all targets and meetings have been held as required. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 19 Records show issues discussed and a copy of unit meeting notes is kept on the staff file of those who attended. The manager reported that this is a new system that was introduced in January. All staff are supervised as part of this system. The standard relating to health and safety was only audited to identify whether the issue raised at the last inspection had been addressed. This issue related to the need for staff to undertake mandatory training such as moving and handling, fire, first aid, and basic food hygiene. A training matrix is available which started in January 2006. This records the training undertaken to date. The manager discussed training booked. No date has been booked for moving and handling and fire training. WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X x 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 3 X 3 X 2 3 x 2 WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 21 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. (Outstanding since 1 September 2005) 2 OP7 15 Evidence must be available to demonstrate that residents or their representatives are involved in the care planning process. Daily records should be linked to care plans and demonstrate the actions that staff are taking to deliver the prescribed care. 17/04/06 Timescale for action 17/04/06 3 OP7 15 17/04/06 WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 22 4 OP12 12 (3) 16(2)(m) (n) Evidence must be available to demonstrate that activities take place which are suited to the wants and needs of residents. The registered manager must ensure that evidence is available to demonstrate that residents have a choice regarding daily routines and all aspects of life at the Home. 17/04/06 5 OP14 12(2)(3) 17/04/06 6 OP18OP29 7 9 19 29 Sch 2 The registered person and 17/04/06 manager must ensure that a file of information is available for all employees of the Home, these files must contain all details as per Schedule 2 of the Care Home Regulations. This must include criminal records bureau checks which have been undertaken at the appropriate level. The hours that the Manager works at the Sycamores must be documented on duty rotas. The registered person must ensure that at least fifty percent of care staff achieve NVQ level 2 or above. (Outstanding since 1 September 2005) 17/04/06 7 OP27 12(4)(a) 12(5)(b) 18 8 OP28 17/04/06 9 OP30 14 18 The registered person shall 17/04/06 ensure that persons employed by the registered person to work at the care home receive induction and other training appropriate to the work they are to perform; and suitable assistance, including time off for the purpose of obtaining further qualifications appropriate to such work. (Outstanding since 1 September WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 23 2005) 10 OP37 26 The registered provider must ensure that a representative of the organisation visits on a monthly basis and prepares a written report. (Outstanding since 28 February 2004) 11 OP38 13 16 23 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 Commission for Social Care Inspection. (Outstanding since 1 September 2005) 17/04/06 17/04/06 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 OP18 Good Practice Recommendations A whistle blowing procedure should be available to enable staff to report poor practice WCS - Sycamores, The DS0000004269.V286044.R01.S.doc Version 5.1 Page 24 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.V286044.R01.S.doc Version 5.1 Page 25 - 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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