Care Home: Sycamore, The

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What the care home does well There is also ample opportunity for prospective residents to experience life in the home before making a decision to move in for a trial period. The home is comfortable and clean. The views of residents are listened to and acted upon and there are good systems in place to handle complaints. Residents are protected from abuse. Residents` health and personal care needs are well considered and met and staff administer their prescribed medications safely. Residents have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Residents are supported to maintain and develop relationships with family and friends and they are part of their local community. What has improved since the last inspection? Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 The manager is experienced and she is maintaining her professional development. She has good ideas and has an improvement and work plan in place for the coming year. There is better staff retention and this makes training and development more effective as well as providing residents with a more consistent service. Staff recruitment procedures have improved and staff are properly checked before they work alone with the residents. The service has improved from an adequate rating to a good rating. What the care home could do better: There is no formal quality assurance system in place and this must be done so that the home is able to better monitor the quality of care and improve. Medication storage facilities must be upgraded to ensure safe storage of controlled drugs, in case any are ever prescribed. There should be better evidence of how residents were consulted about their written plans for care and whether they have agreed the plans. There should be a standard format for care planning so that staff are fully aware of the areas of care and support that need to be reviewed and so that all areas of care and support required are properly recorded. There should be plans for how goals set by each resident are to be supported and achieved There should be proper assessment of mould growing on a first floor bathroom ceiling as the ventilation may be inadequate as the mould grows back frequently. This room should be properly ventilated and redecorated. Key inspection report CARE HOME ADULTS 18-65 Sycamore, The 34 Lancaster Avenue West Norwood London SE27 9DZ Lead Inspector Sonia McKay Key Unannounced Inspection 10th December 2009 09:00 Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 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 home adults 18-65 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, The DS0000022767.V378532.R01.S.doc Version 5.3 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, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Sycamore, The Address 34 Lancaster Avenue West Norwood London SE27 9DZ 020 8761 4909 020 8761 9064 corinne@mcdonald34.freeserve.co.uk www.larche.org.uk L`Arche Lambeth 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) Ineta Servaite Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 23rd February 2009 Date of last inspection Brief Description of the Service: The Sycamore is a residential home for five adults with a learning disability. It is one of five residential care homes in the locality that form the L’Arche Lambeth community. The aim of the community is to create communities that welcome people with learning disabilities. Fundamental principles of the community are that each person has a right to friendship, a spiritual life and to live in an environment that fosters personal growth. It is a large Victorian house with front and back gardens. It is located on a residential street close to shops and transport links. The team of assistants live in the home and are managed by a house leader. LArche also provides access to college courses, therapeutic daytime activities and skills workshops, such as candle making, gardening, stonework, packing and weaving. Service users are encouraged to participate in all aspects of community life. A copy of the most recent inspection report is available in the home on request and weekly placement fees start from £797.00 and increase depending on the amount of staff support that an individual needs. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience Good quality outcomes. This inspection was carried out in one day. The methods used to assess the quality of service being provided were: • • • • • • • Talking with the registered home manager Looking at the ‘Annual Quality Assurance Audit’ completed by the home manager (this document is sometimes called an ‘AQAA’ and it provides the Commission with information about the service) A tour of the communal areas of the premises Looking at records about the care provided to two of the residents Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled The Commission would like to thank all who kindly contributed their time, views and experiences to the inspection process. What the service does well: What has improved since the last inspection? Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 6 The manager is experienced and she is maintaining her professional development. She has good ideas and has an improvement and work plan in place for the coming year. There is better staff retention and this makes training and development more effective as well as providing residents with a more consistent service. Staff recruitment procedures have improved and staff are properly checked before they work alone with the residents. The service has improved from an adequate rating to a good rating. What they could do better: 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, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 4. 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 is also ample opportunity for prospective residents to experience life in the home before making a decision to move in for a trial period. EVIDENCE: L’Arche offers long-term placements only and has a lengthy placement process, which is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This provides the referred person with an opportunity to experience life in the home before making a positive choice to move in for a trial period. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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): 6, 7 & 9. 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. Care planning records are better kept and cover a wider range of areas. The information is meaningful and person centred. However there should be better evidence of how plans have been agreed with the resident themselves. Risk assessment is used to increase peoples opportunity for self development within a risk management framework that helps to staff to keep people safe. EVIDENCE: Each resident has a set of written plans describing how they are to be supported and cared for. The manager has worked hard to organise this information so that staff have ready access and the files are well organised. I looked at records for two of the residents. Staff have written very detailed and thoughtful information about some of the residents needs. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 10 Both of the residents have helped develop their own plans to some extent and some plans are written in the first person. At the last inspection we noted that there is no set format for the areas of support and care to be looked at when planning care and some needs, for example, cultural needs were not documented. This has been addressed and there is more information about meeting the cultural needs of the current residents. This is important because staff do not have the same cultural background as the residents. There is still no set format for planning care and this remains a recommendation so that staff know what areas of support and care should be reviewed and when. This will address the issue of important information being missed out at review, which the files show still happens at times. There are still documents that are not fully developed into formal plans, for example the support planned for each person to safely manage their finances. Care plans do not currently record how the resident was consulted or whether they agree with the plan. None are signed by the resident themselves. There should be better evidence of how they have been consulted and whether they are in agreement of the plan. Planning involves each resident in setting goals and these goals are reviewed regularly. The meetings are creative and residents choose the venue and chair the meeting where possible. There are no specific plans as to how goals are to be achieved in some cases and this is recommended to ensure that goals are achieved. There are good plans for increasing daily living skills in place and this helps people to become more independent. Risks and independence are discussed and reviewed regularly. A general risk assessment process is in place. The document covers topics and activities that each person is likely to engage in and indicates the level of risk posed to the service user during each activity. In the event that an activity is deemed to present a higher degree of risk to their health and safety, a more detailed individual risk assessment is completed identifying the steps taken to minimise the risk. L’Arche uses a semi-independent advocacy system. This ensures that someone from outside the home who knows the resident and sees them often is involved. Fully independent advocates are in short supply but the home manager understands the need for advocates to be involved if major decisions are to be made and a resident lacks the capacity to fully understand an issue. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 11 Residents are encouraged to participate in the day-to-day running of the home and in community planning. They can take part in weekly house meetings, ‘talking group’ meetings with the community director six times a year and community council elections. Residents are also involved in the assessment of new staff during their probationary period and in discerning internal applications for house and community leaders. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11, 12, 13, 15, 16 & 17. 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. Residents have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Residents are supported to maintain and develop relationships with family and friends and they are part of their local community. EVIDENCE: L’Arche is a faith-based community and offers active support to each resident to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature instead. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 13 Each resident has a place in the L’Arche supported employment workshops (weaving, stone work, gardening and candle-making). Some also attend college classes and groups as well. One resident is getting older and prefers to spend her time doing more relaxing things instead. She attends a relaxation group and enjoys art classes. She has been supported to display her work at an art exhibition and her now on the walls of her home. Three of the residents attend church services on a regular basis. Services attended are from a wide range. One resident has recently started to attend a Greek Orthodox Church after being inspired by attending his sisters wedding. The close proximity of the other L’Arche homes provides an opportunity for residents to visit each other and go out for dinner. There is a strong community spirit and lots of parties and celebrations to attend or host. The manager said that residents and staff are currently preparing for a Christmas play with other members of the LArche community. There is a good relationship with neighbours, some of whom have known the residents for many years and there has recently been a festive party with friends and neighbours coming to the house for a mince pie. Residents are supported to maintain and develop relationships with family and friends. There is good information about family and friends that each person likes to keep in touch with and how. There are evening and weekend activities, such as daytrips and discos, in the community. There is a television, DVD player and stereo available in the communal lounge. The manager demonstrates an understanding of the need for people to have relationships and is careful to ensure that people get the right sort of information and support when considering closer relationships. L’Arche Lambeth has been operating for more than 30 years and has developed good relationships with local individuals and organisations. Some of the staff live at the home with the residents with the intention of building a shared community and consistent engagement. Attention is paid to special celebration days and there are birthday parties and dinner parties with guests. All residents are usually offered a minimum three weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. There are lots of daytrips and outings. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 14 One resident is helped to look after some pet goldfish. Records are kept of what each person eats. Records of the meals eaten show that a variety of meals are prepared. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Residents are supported to help with household chores and shopping and to choose and help to prepare the meals. There has been better support and research into cultural needs and this extends to the choice of meals and ingredients served. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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. Residents health and personal care needs are well considered and met and staff administer their prescribed medications safely. Medication storage facilities must be upgraded to ensure safe storage of controlled drugs, in case any are ever prescribed. EVIDENCE: There are both male and female staff and residents receive same sex personal care support as necessary. Personal care routines are well documented and monitored to ensure that residents are encouraged to be as independent as possible. This ensures that residents receive the right amount of support to encourage them to develop greater independence. There is good information about the size of clothing that each person requires as all residents need assistance with purchases. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 16 One of the people whose care I looked at is African-Caribbean. Staff have improved written plans about her personal care routines to ensure correct choice of hair and skin care products and application. They have also supported her to visit new hairdressers and make a new friend, her new stylist. This residents health care is good. She has a health action plan in place and there is a clear record of the appointments attended and the outcome of these appointments. There has also been consideration of routine health screening. There is a record of each person’s medical history. There is a record of the health professionals that each person sees and of the health appointments they attend. This includes recording what specialist advice has been given. Each person is registered with a local GP, dentist and optician. There is also input from a specialist team for adults with a learning disability on referral. They can provide advice about supporting emotional needs. There is evidence that residents see a health professional when the need arises and more has been done to ensure preventative healthcare and health action planning is more robust. I looked at healthcare records for another resident. He had been given a general anaesthetic for dental treatment. There are records that multidisciplinary meetings were held to help him with decision making as he lacks capacity. The treatment was successful and the manager said that he seems happier indicating he may have had some pain before the treatment. Staff help residents to take their medication. Medication is locked away in a cupboard and staff keep records of when it arrives in the home, when it is administered and when any unused medications are returned to the pharmacy. There are no controlled drugs in use at this time. Examination of medication administration records during this inspection shows that staff maintain the records well. There is a photograph of each resident with their administration record. An assistant checks the medication stock and records regularly to make sure the medicines are being administered as prescribed. This is good practice. Staff are not allowed to administer medication until they have been given training in how to do so safely. The secure storage of controlled drugs is specified in the Misuse of Drugs (Safe Custody) Regulations of 1973. In the 2007 an amendment was made. The impact is that every care home must store controlled drugs in a CD cupboard, including care homes registered for personal care. We have made a requirement about this. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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. The views of residents are listened to and acted upon and there are good systems in place to handle complaints. Residents are protected from abuse. EVIDENCE: There is a good complaints policy and information about how to make a complaint is produced in an accessible format with photographs and pictures to make it easier to understand. There are no recorded complaints since the last inspection. Residents and staff attend weekly house meetings where house issues are discussed and recorded by staff. This gives people the opportunity to raise concerns and staff always ask what is going well and what is going badly. The manager plans to focus more on how to make a complaint at future meetings. There is a copy of the local authority safeguarding vulnerable adults’ procedures available and the manager talked about her understanding of the procedures. There is evidence that staff recognise safeguarding issues and get in touch with the right people when necessary. Staff receive training in abuse awareness during their induction training. There is a record of people who have visited the home. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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): 24 & 30. 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. The home is comfortable and clean. EVIDENCE: The large home is suitable for its purpose, comfortably furnished, homely and clean. The large rear garden and back veranda provide adequate outdoor space. A garden work shed has been built for one resident who enjoys woodwork. The homes location offers good access to local amenities, public transport and services. All bedrooms are single occupancy and attractively furnished to the preference of the person accommodated. There are two communal lounges that are comfortable and well furnished. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 19 Bathrooms and toilets are sufficient in number and well situated close to bedrooms and communal areas. There is mould on a first floor bathroom ceiling. The manager said it had been redecorated since the last inspection but had come through again. This should be rectified and an assessment made of the ventilation of the bathroom as it may be inadequate. The home is clean and pleasant smelling and hand-washing advice and facilities are readily available. There are regular ‘in house’ environmental safety checks, and a record is maintained. . Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): 32, 34 & 35. 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 is better staff retention and this makes training and development more effective as well as providing residents with a more consistent service. Staff recruitment procedures have improved and staff are properly checked before they work alone with the residents. EVIDENCE: Staff are called assistants in the L’Arche community and they are provided with board and lodgings. Each has a job description and a contract of employment. Four staff live on premises and two live out. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. The community welcomes staff and residents from all faiths. Records are kept of all staff duty rosters. Between one and two members of staff are on duty in the home depending on the activities and needs of the residents. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 21 Staff retention has improved since the last inspection. There is only one new assistant and four of the staff have worked in the home or Larche community for over a year. Two of the staff live at the home and two live in residents accommodation elsewhere. Recruitment records are held at the L’Arche head office. They were made available during this inspection. L’Arche is in a challenging position in regards to recruitment checks, as staff are often recruited from overseas and cannot therefore complete an enhanced criminal records check until they arrive in the UK. Staff are not accommodated in the home until they have had a POVA check and an overseas criminal records check in place. The manager understands the restrictions in place for staff without an enhanced UK criminal records check and they are supervised and do not work alone with the residents until full checks are in place. Recruitment records for two members of staff were examined and these show that appropriate checks had been made. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’, mandatory training and training provided by the local specialist learning disability team. Each member of staff has an individual training record and certificates are retained as courses are attended. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along, medication administration, challenging behaviour as communication, Autism, Gentle Teaching and training around taking risks and making choices. Two assistants will start the NVQ 3 in January 2009 and the manager is looking at minimum standards for care in team meetings. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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. The manager is experienced and she is maintaining her professional development. She has good ideas and has an improvement and work plan in place for the coming year. There is no formal quality assurance system in place and this must be done so that the home is able to better monitor the quality of care and improve. EVIDENCE: The new manager registered with the Commission in October 2008. She is experienced. There is an experienced manager in post and she is studying for her NVQ 4. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 23 The manager facilitated the inspection well and she has many creative ideas for improving the service. She is well organised and has a plan for managerial and team tasks for each month of the next year. Information she provided in the AQAA was detailed and shows us that she knows what to do to improve the service. A representative of the registered provider visits the home each month to monitor the service being provided. They write a report of their findings and send a copy to the provider and to the manager. There is no defined quality assurance system in place and this must be done so that the home is better monitored and working towards improvement. We have made a requirement about this. The manager is responsible for health and safety and she is assisted by a health and safety officer from within L’Arche. There are daily, weekly and monthly checks of the home and there are annual assessments of risks posed by fire and in the environment generally. Environmental health officers inspected the home and gave it a three star rating. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000022767.V378532.R01.S.doc 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sycamore, The Score 3 3 1 X X 3 X Version 5.3 Page 25 3 3 2 X No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement Timescale for action 31/03/10 2. YA39 24 There must be an appropriate medication storage cabinet. The cabinet must meet the legislation in regards to the storage of controlled drugs. The registered provider must 31/03/10 ensure that there are effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 YA6 Good Practice Recommendations There should be better evidence of how residents were consulted about their written plans for care and whether they have agreed the plans. There should be a standard format for care planning so that staff are fully aware of the areas of care and support DS0000022767.V378532.R01.S.doc Version 5.3 Page 26 Sycamore, The 3. 4. YA6 YA24 that need to be reviewed and so that all areas of care and support required are properly recorded. There should be plans for how goals set by each resident are to be supported and achieved. There should be proper assessment of mould growing on a first floor bathroom ceiling as the ventilation may be inadequate as the mould grows back frequently. This room should be properly ventilated and redecorated. Sycamore, The DS0000022767.V378532.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission 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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