Care Home: Sycamore Cottage Private Residential Home

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What the care home does well People who use the service and a relative said that staff were friendly and attentive in general and welcomed visitors. People/their relatives are involved in what care they need from staff. There are now more activities on offer to interest people and so improve their quality of life. Food supplied to people has healthier and tastier choices. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 What has improved since the last inspection? There are now more activities on offer to interest people and so improve their quality of life. Food supplied to people has healthier and tastier choices. What the care home could do better: Peoples welfare could be more effectively met by ensuring that: Assessments are detailed and contain all aspects of individual needs to make sure staff can meet those needs from day one of a persons admission. All aspects of care e.g. proper toileting programmes, stated dates of health checks, a full record of daily living wishes etc are detailed in Care Plans to assist staff to meet all residents needs, that proper moving and handling procedures are used to protect people from injury, medication recording is always done after issuing it to residents and that this respects infection control procedures. Management need to ensure that staff respect residents at all times. The Complaints Procedure needs to be clearer for residents and their representatives so that complainants can go to the Lead Agency to reach a proper resolution. Staff need to know the full abuse procedure to protect residents effectively. An environmental audit is recommended to make facilities better signed for residents with dementia etc. Staffing levels at weekends need to be increased to meet the assessed needs of people. The staff training programme needs to become more comprehensive through ensuring all staff receive thorough training to increase their skills in delivering good quality care for people who use the service. Yearly Quality assurance systems need to be in place to ensure the service fully meets peoples needs.Sycamore Cottage Private Residential HomeDS0000062462.V377355.R01.S.doc Version 5.2 People who use the service must have a safe environment through management effectively ensuring that they are protected from scalding water, that effective fire safety is observed, and that there are Risk Assessments for all safe working practices in place to eliminate risks for people who use the service. Key inspection report CARE HOMES FOR OLDER PEOPLE Sycamore Cottage Private Residential Home 14 Harborough Road Oadby Leicestershire LE2 4LA Lead Inspector Keith Charlton Key Unannounced Inspection 8th October 2009 04:40 DS0000062462.V377355.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamore Cottage Private Residential Home Address 14 Harborough Road Oadby Leicestershire LE2 4LA 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) 0116 2711720 0116 2711880 harwinderjagpal@yahoo.co.uk Sycamore Cottage Limited Vacant Care Home 14 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (14) of places Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - code OP Dementia, over 65 years of age - Code DE(E) (5) The maximum number of service users who can be accommodated is 14 31st October 2008 2. Date of last inspection Brief Description of the Service: Sycamore Cottage is a residential care home for a maximum of 14 older people. The home is situated off the Harborough Road in Oadby, and is close to local shops and supermarkets. The home is a converted detached house with a ground floor extension. There are 10 single and two shared bedrooms. The first floor comprises of five bedrooms and a bathroom that are accessed by a stair lift. The communal areas include a lounge and dining room. There is a courtyard and garden to the rear of the property. The range of fees for the service is between £350 and £415 per week. The Manager provided this information on the day of the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, etc. There is a displayed copy of the last Inspection Report in the hallway or can be accessed via the CQC website: www.cqc.org.uk. Further information about the home can be obtained from the Manager. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 5 Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is One Star. This means the people who use this service experience adequate quality outcomes. ‘We,’ as it appears throughout the Inspection Report, refers to ‘The Care Quality Commission. The inspection process consisted of pre-planning the inspection, which included reviewing the last inspection report and other information we have received about the service. We have sent surveys to people who use the service along with staff and their comments are reflected in this Report. The unannounced site visit commenced on the 8th September 2009 and was carried out by Keith Charlton. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Sycamore cottage. Two residents were selected. Discussions were held with five people who use the service, one relative, the Manager, and two members of staff. Surveys have been received and comments from these can be found in this Report. What the service does well: People who use the service and a relative said that staff were friendly and attentive in general and welcomed visitors. People/their relatives are involved in what care they need from staff. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Peoples welfare could be more effectively met by ensuring that: Assessments are detailed and contain all aspects of individual needs to make sure staff can meet those needs from day one of a persons admission. All aspects of care e.g. proper toileting programmes, stated dates of health checks, a full record of daily living wishes etc are detailed in Care Plans to assist staff to meet all residents needs, that proper moving and handling procedures are used to protect people from injury, medication recording is always done after issuing it to residents and that this respects infection control procedures. Management need to ensure that staff respect residents at all times. The Complaints Procedure needs to be clearer for residents and their representatives so that complainants can go to the Lead Agency to reach a proper resolution. Staff need to know the full abuse procedure to protect residents effectively. An environmental audit is recommended to make facilities better signed for residents with dementia etc. Staffing levels at weekends need to be increased to meet the assessed needs of people. The staff training programme needs to become more comprehensive through ensuring all staff receive thorough training to increase their skills in delivering good quality care for people who use the service. Yearly Quality assurance systems need to be in place to ensure the service fully meets peoples needs. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 8 People who use the service must have a safe environment through management effectively ensuring that they are protected from scalding water, that effective fire safety is observed, and that there are Risk Assessments for all safe working practices in place to eliminate risks for people who use the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 9 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 Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Sycamore Cottage have their needs assessed before moving into the home, though this needs to be more detailed to ensure their needs are fully met. EVIDENCE: A relative confirmed that relevant information had been provided about the homes services and an assessment are carried out by the Manager. Yes, the previous Manager assessed what care I needed before I came here, one resident said. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 11 Residents were not able to confirm that they had been provided with sufficient written information about the home but a relative spoken with said they had enough information at the time of the admission to make up their minds about the home. We case tracked a person living in the home who had moved into Sycamore cottage in the past. We also checked that this person had his needs properly assessed prior to moving in, to ensure that the staff at the home could meet their needs and we found that the assessment system had information regarding residents needs though some sections had not been properly completed - e.g. past health checks had not been included, which is useful to prompt these checks and improve the health and daily quality of life for people, and there was no information regarding hobbies and social needs and relationships. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at Sycamore Cottage receive adequate health and social care practice. EVIDENCE: My mum has a care plan and the Manager involved me in doing this, one relative said. Some people who use the service spoken with recalled having a care plan and being invited to reviews. We checked the care plans of two people living at the home who were case tracked. Plans showed detail regarding the support required by staff to ensure the physical health of people living at the home, though there was little information to inform staff of some of the people who use services personal history or preferred daily living routines, which ensures their social and Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 13 emotional well being is fully supported. The Manager said that she had identified that this needed to be done. Staff said they had read the Care Plans - this is needed so that they can fully understand people who use the service needs. Accident records were checked and appropriate action taken be staff to protect people who use the service. The Manager may wish to consider putting an audit in place to review why accidents happened so that preventative steps could be put in place, thus the health of protecting the health people who use the service. We checked the medication records, and found that there was generally good recording of the administration of the medicines in the home, though there were some gaps that the Manager said she would follow up and put a system in place so these could be checked on a daily basis. There was a picture of residents on medication sheets to ensure the medication is given to the right residents and the Manager said that there will be information on medication sheets regarding other important information - allergies etc so that people’s health is fully protected. Controlled medicines storage is not currently needed though the Manager was aware it needs to be in a secured cabinet and conform to the latest legal requirements. We saw medication being issued but staff signed the record before issuing and supplied to people without gloves being used, which did not follow infection control prevention - the Manager agreed this was contrary to policy. Staff were observed as being gentle and kind to people living in the home except when they were trying to coax a person to go to the toilet - two care staff were seen with their arms under a persons shoulders just about to do a drag lift. The Manager said she would follow up. We saw people who use the service were treated with respect in the way they were spoken apart from one comment which said that some staff speak curtly with some people who use the service who tell them to sit down. The Manager said she would follow this up. There was also a comment in a survey from a relative that staff ‘sometimes’ provide the proper care and support, ‘sometimes’ are there when people need them, and ‘sometimes’ listen to people and act on what they say. The relative on the day confirmed that staff were very caring. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are opportunities for people at Sycamore Cottage to take part in activities and have a relaxed lifestyle. EVIDENCE: People who use the service said that in general the activities provided suited them. Yes, staff do things and Im satisfied with that, one person said. One person requested having more outings, and one person wanted to have a visit from the mobile library, which the Manager said would be followed up. Staff said that there is a flexible routine, with individual and group activities. We saw a list of activities and we saw staff providing activities to residents. The Manager said that memory boxes were going to be provided for residents which will be useful for reminiscence one to one sessions with residents with Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 15 dementia and we saw that laminated sheets with articles and adverts from papers in the 1950s were used for one to one sessions to stimulate conversation with people who use the service. Staff said there were activities - playing ball, playing games, music and movement, watching TV, listening to music and staff said they took people out to the garden in good weather, which we saw the Manager doing. The relations between staff and people who use the service were observed to be relaxed. Staff said there were no rules. People can get up when they like, and choose their clothes and food. The home supports residents with dementia though not all the staff had received training on this. There was no displayed information for day, weather, and menu etc on a notice board, though the Manager said that she had identified these issues and they would be installed in the near future. Staff said visitors were always welcome and the relative spoken with on this visit confirmed that staff are welcoming and thought the care the staff supplied was of a high standard. Residents said that food was good though there is no choice of food, though people who use the service can request an alternative if they wish. We saw staff assisting some people to eat. On the day of inspection the meal was chicken with two vegetables and mashed potato, followed by dessert. All the food was well cooked and tasty. The cook showed us good supplies of fresh vegetables, fruit and salad so that food can always be fresh and tasty for people who use the service. There was also a comment in a survey from a relative that the home ‘sometimes’ provides relevant activities and ‘sometimes’ the food is good. This goes on to say that there should be more activities and stimulation for people. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are taken seriously and there is a system in place to protect people who use the service from abuse at Sycamore Cottage. EVIDENCE: I am sure Elaine would follow things up properly but there is nothing to complain about, one person who used the service said. The Manager stated that staff have been trained in protecting residents from abuse. There have been no complaints since the last inspection. Spoke with staff and asked what they would do if it was reported that a member of staff had been seen abusing a resident. They were clear that this was unacceptable and needed to be reported to the Manager though one staff did not know how to contact the right outside agencies, although the Manager pointed to a procedure displayed in the office for staff to follow. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 17 The Complaint procedure was seen but found not to be in line with the need to refer such matters to the Lead Agency - the Adult Care Department. The Manager said this would be followed up. Staff were found to have proper checks to protect staff from unsuitable staff. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Sycamore Cottage live in a homely environment. EVIDENCE: All residents spoken with said they liked their bedrooms: Yes, my bedroom is nice and I have it the way I want’, one person said. We saw people at Sycamore Cottage living in a well maintained environment. We discussed the need to sign the environment to further help residents with dementia, e.g. pictures on residents doors to orientate them to their bedrooms, colour coding toilet doors, pictures of residents favourite scenes on Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 19 bedroom doors etc to make facilities clearer, e.g. orientate residents to go to their own bedrooms etc, and the Manager said she had already identified the need for this and would shortly be putting it in place. There were no odours to any parts of the home and some people said that the domestic worker was very good and thorough. There was also a comment in a survey from a relative that ‘sometimes’ the home was fresh and clean. This could relate to the lack of a domestic worker at weekends. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are not fully met as staffing levels are not adequate to deal with them at weekend periods and some training for staff has not been provided. EVIDENCE: Speaking to residents and a relative we found that there were a lot of positive comments about the staff: Staff are really nice and friendly, one person said. However there was one remark that some staff are curt with people with dementia and tell them to sit down when they want to wander, which the Manager is to follow up. There were comments that staffing was short at weekends as it reduces to two care staff doing all duties - care, domestic and catering, especially with the addition of three more residents since the last inspection. The Manager said she had identified this issue as well and is to request the Provider to increase the staffing level so that peoples needs are fully met. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 21 A staff member said that although she had only been working at the home for only just over a year, she had been encouraged by management to do the NVQ 2 course and had already completed a number of training courses and a thorough induction. We found that staff have been on a number of training events to help update their practice on areas such as Moving and Handling, Fire Safety, Infection Control though not all staff had Dementia training and no staff had Challenging Behavior training and training regarding residents health conditions were missing - e.g. Sight and Hearing Impairment, Stroke, Parkinsons Disease, Diabetes, etc. The Manager said that these would be added to the training programme. Staff records showed that proper checks had been carried out to protect residents from unsuitable staff. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complete management systems are not in place to protect the health and safety of residents. EVIDENCE: Elaine Piles is now the Manager of the home and confirmed she will be applying for registration once she had gone through the probationary period. Elaine has completed the RMA Award in management skills. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 23 Elaine has knowledge of the Mental Capacity act so knows that there would need to be a referral to the relevant Agency if it was proposed that people were deprived of their liberty if this was seen to be in their best interests. We saw in records that satisfaction questionnaires were sent around the home last in 2007 so there has not been the opportunity since then for people who use the service, relatives etc to comment on the running of the service. Written records regarding finances for people who use the service are properly in place, and monies were checked for two residents and totals were found to be correct. There was evidence of a people who use the service/relatives meeting discussing relevant issues - activities, food etc, which shows involvement in the running of the home. Staff informed us that they were able to tell management of the problems they were facing and there was regular supervision to support them. Safe working practice Risk assessments were in place though did not fully cover all issues - e.g. need for radiator covers or window restrictors, working with the lift, use of ladders etc. Fire records were in place with regular fire drills tough there was a gap of weekly testing for fire bell testing - the Manager said this would be more frequently done. There was an unlocked store cupboard which was a fire door. The Manager said that would be followed up. Staff were asked about the fire drill procedure though one staff did not know the full procedure. The Manager said that these issues would be followed up to ensure people who use the service are fully protected from fire. Hot water is regularly tested though the hot water in the staff WC was over 10c more than the National Standard and was accessible to people who use the service so was a scalding risk to them. The Manager then locked this facility with a sign displayed for staff to lock after their use to protect people who use the service from this scalding risk. The Manager had a system in place and recorded when hot water temperatures were too high, though there was no action column to indicate what had been done to protect people who use the service. Sycamore Cottage Private Residential Home DS0000062462.V377355.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 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 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP8 Regulation 13 Requirement Management must ensure that proper Moving and Handling practices are followed at all times by staff. Staffing levels need to be reviewed and increased in line with the management assessment to meet peoples needs. Effective quality assurance systems, based on seeking the views of people who use the service need to be in place to measure success in meeting the aims, objectives and the statement of purpose of the service. The Registered Provider must ensure that all health and safety systems are in place to protect residents - e.g. that hot water temperatures do not scald residents and that fire systems are fully in place. This will ensure residents health and safety is fully promoted. DS0000062462.V377355.R01.S.doc Timescale for action 08/10/09 2. OP27 18 08/10/09 3. OP33 24 08/11/09 .4. OP38 13 08/10/09 Sycamore Cottage Private Residential Home Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations A detailed assessment is needed to ensure that all residents needs are met by the home. Care plans should contain comprehensive information regarding resident’s needs. Medication needs to be given safely, without the risk of cross infection and records should be with out blanks so it is the case that medication has always been supplied to people. Management must ensure that people who use the service are always talked to in a respectful manner to ensure their dignity. A Complaints Procedure needs to be in place giving the complainant the choice to go to the Lead Agency first if they do not want to go to the Manager or Registered Provider, and the details of the Lead Agency - Social Service Department(s). Management need to ensure all staff understand the full safeguarding procedure to protect people from abuse. The Registered Provider needs to carry out an environmental audit to sign facilities to provide orientation for residents with dementia. Staff training needs to include training on residents conditions and challenging behaviour etc to fully meet peoples needs. The Provider needs to ensure that the risk assessments for DS0000062462.V377355.R01.S.doc Version 5.2 Page 27 4. OP10 5. OP16 6. 7. OP18 OP19 8. OP30 9. OP38 Sycamore Cottage Private Residential Home safe working practices cover all issues. Sycamore Cottage Private Residential Home DS0000062462.V377355.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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