Care Home: The Sycamores

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What the care home does well An impressive aspect of the Home, given the relatively large number of Residents, is the manner in which each of the four units retains its own identity whilst remaining an integral part of home. Changes to the menu have seen the introduction of freshly prepared, ethnically diverse meals, which specifically meet the preferences of Residents of AfroCaribbean and Asian origin. What has improved since the last inspection? What the care home could do better: Whilst it is recognised activities progress has been made in providing services aimed at meeting the specific care needs of Residents with dementia related conditions there remains room for further development. The Home should seek the views of Residents and their Supporters, in respect of service quality, on a more frequent basis. CARE HOMES FOR OLDER PEOPLE Sycamores, The Johnson Street Wolverhampton West Midlands WV2 3BD Lead Inspector Keith Salmon Key Unannounced Inspection 09:30 14th December 2007 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 Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sycamores, The Address Johnson Street Wolverhampton West Midlands WV2 3BD 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) 01902 873750 01902 873751 Lakewood Limited Mrs Amanda Caroline Morgan Ellitts Care Home 84 Category(ies) of Dementia (84), Learning disability over 65 years registration, with number of age (10), Old age, not falling within any other of places category (84), Physical disability (10) Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation to service users of both sexes whose primary care needs on admission to the home are within the following categories: Dementia (DE) 84 Older People (OP) 84 Physical Disability (PD) 10 Learning Disability over 65 (LD)(E) 10 The maximum number of service users to be accommodated is 84. 2. Date of last inspection 5th February 2007 Brief Description of the Service: The Sycamores is a care home registered with CSCI to provide accommodation, personal and nursing care for a maximum of 84 older persons, including up-to 10 adults with a physical disability, and up-to 10 persons over the age of 65 who have a learning disability. Situated on a main bus route into Wolverhampton city centre, with local shops and amenities close by the home offers accommodation on three floors, with all bedrooms being single occupancy with en-suite facilities. Functionally, the ground floor of the home (‘Elm’) provides ‘residential’ care for older people and, in an area known as ‘the bungalow’, care for ‘young disabled’ Residents. The two upper floors (‘Ash’ and ‘Oak’) provide nursing care. Fees for care are not available in the brochure or service user guide, and are determined following detailed assessment of care needs and within parameters set by local authority purchasers. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 9.30am, concluded at 4.30pm, and was conducted by Mr Keith Salmon. Present on behalf of the Home, throughout the inspection, was Mrs Amanda Ellitts (Registered Manager). In addition to an inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the most recent Unannounced ‘Key’ Inspection, held in February 2007. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff files, training files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. In addition, individual discussions were held with 9 Residents, 4 Visitors, Mrs Ellitts, and several members of staff. The inspection visit was further informed by data supplied by the Home’s Manager through our Annual Quality Assurance Assessment (AQAA) document. The AQAA is a self-assessment, which focuses on how outcomes are being met for people using the service, plus any plans the Home may have for future improvements. What the service does well: What has improved since the last inspection? All sixteen requirements cited at the previous inspection have been met, successfully addressing issues relating to • • • • Medicines administration, storage, and disposal The induction programme provided for newly appointed staff Formal staff supervision arrangements Risk assessment with regard to the use of bedrails and planned maintenance in respect of such equipment DS0000017195.V343289.R01.S.doc Version 5.2 Page 6 Sycamores, The What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. The findings are applied to ensure appropriate placement. EVIDENCE: Review of care plans, and related documentation, evidenced appropriate and thorough care needs assessment is undertaken by the Manager, or by appropriately experienced senior staff, prior to any admission. Information gathered is utilised in enabling an informed decision regarding the Home’s capability of meeting the individual care needs of each prospective resident, whilst also taking into account the likely effects his/her admission will have on the existing group of Residents. This is of particular importance with regard to ‘Elm Unit’ given the client ‘mix’, i.e. elderly residents with confusional disorder, together with elderly frail residents with more general care needs. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 9 Prospective Residents, and family members, may visit the home as often as they wish until making a final decision to accept a place at the Home. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The content, organisation and quality of entries within care plans, indicate Residents’ individual assessed care needs are fully met. Review of assessed care needs is undertaken on a regular basis. Storage, reception, disposal, and record keeping relating to medicines’ administration are now in accordance with accepted ‘good practice.’ Care provided is delivered considerately and effectively with residents’ privacy and dignity being respected. EVIDENCE: Review of care plans for ten residents, i.e. two from each unit, selected at random, plus the two most recent admissions to the home, demonstrated each resident has a plan of care based on comprehensive assessment of need and risk assessment. Care plans are individual and display commitment to team collaboration and a multi disciplinary approach. Where possible the relative, or Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 11 advocate/supporter is actively consulted and involved in their individual plan of care. Care plans are reviewed and evaluated on a regular basis, at least monthly. General Practitioners visit the home as required, plus twice weekly on Tuesdays and Fridays to assess Service Users health needs and provide medical services. Staff are pro-active in respect of ongoing care needs and comprehensive risk assessments are in place in respect of nutrition, tissue viability, moving and handling, transferring, use of bedrails and other equipment in addition to general risk management assessments. At the previous Key Inspection the Lead Inspector was accompanied by the Pharmacy Inspector, who issued a total of 12 Requirements relating to the management and administration of medicines. These Requirements encompassed three specific aspects within this Standard, as follows:Updating of the policy/procedure documentation Correct maintenance of medicine administration records (MAR sheets) Medicine storage, stock levels and rotation A review of the medicine policy/procedure evidenced this documentation has been revised and updated. MAR sheets are now maintained correctly and were found to be up-to-date. Records relating to the supply, storage, and disposal of medicines, together with storage arrangements including records of ambient and medicine refrigerator temperatures, evidenced they are now fully compliant with the Regulations and with the guidelines of the Royal Pharmaceutical Society. Therefore, all 12 Requirements have been met. From observations made during the Inspection, and comments made by Residents, there was no evidence to suggest Service Users’ privacy and dignity is not maintained. Staff were observed to address Residents and Visitors in an appropriate manner. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities provided are generally consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, wherever possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: The Home employs a full time activities coordinator who, in planning and implemented the Residents’ social/leisure programme is actively supported by other members of staff on a day-to-day basis, dependent on staff numbers and overall workload. Particular attention is given to ensuring Residents on each of the three floors enjoy leisure/social activities consistent with their individual preferences and capabilities. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 13 Examples of activities, reflected in the Home’s published programme, individual care plans, and comments made to us by Residents/Relatives included; traditional games (cards, dominoes, darts), bingo, an ‘art and craft’ club, a music club, incorporating a small percussion band, a book club which has regular book changes by the local library service, a DVD club, quizzes, and outings to Walsall Illuminations and the local pantomime. Residents commented to they were able to take part in whichever activities interested them, and were encouraged, though not pressurised, to do so. Residents who wish to continue following religious practices are encouraged and to do so – e.g. the local Rector conducts a Church of England Communion Service on the first Wednesday of each month, and one Resident is escorted to the local Temple each week. The home operates a four weekly menu, giving Service Users a choice of two meals each day for lunch, plus a wider choice if necessary. There is the opportunity for drinks and snacks throughout the day, and Residents commented to us how much they enjoyed the food, both the quality and quantity. A particular strength of meals provision is in seeking to provide food to the particular liking of Residents of Asian and Afro-Caribbean origins. Apart from adhoc choices this entails the provision of a hot meal at tea time, four days per week. Feedback on the success of this has been made through Residents’ meetings and Residents also commented to us that not only were the nature/range of this cuisine accurate, it was also cooked properly. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse and of taking appropriate action should it be necessary. EVIDENCE: The Home’s Complaints Procedure is displayed within the entrance to the Home, and up-to-date information advising on how to proceed in making a complaint can be found in the Service Users’ Guide. Policies and procedures are in place regarding ‘Protection of Vulnerable People, Restraint, Aggressive Behaviour, Whistle Blowing, Harassment, and Bullying.’ Discussion with staff, and review of training records, demonstrated the home has a rolling programme in respect of abuse awareness and adult protection training. Staff members informed us they feel they have been well prepared in respect of this area of care provision. Residents and Visitors consulted during the inspection confirmed they would have no hesitation in raising any matters of concern with the Manager, and were confident issues raised would be dealt with properly. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 15 A review of the Complaints Log evidenced a small number of complaints all of which appeared to be fully recorded and satisfactorily resolved. There were no complaints received by the Commission during this period, and a review of the accidents/incidents log demonstrated nothing to cause concern. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24, 25, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment with communal rooms and bedrooms, which are satisfactorily decorated with furnishings being in good order and presenting a ‘domestic’ ambience. Specialist equipment, consistent with meeting the assessed care needs of service users and the demands of tasks carried out by Care Staff, and is appropriately serviced and maintained. The home is clean and there are satisfactory standards of hygiene. EVIDENCE: The tour of the Home demonstrated it offers comfortable, clean, and homely accommodation. With each of the four units having its own separate lounge and dining provision, there is ample communal space. Bedrooms, which are all Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 17 en-suite, were pleasant, comfortable and evidenced Residents bring their own personal possessions’ into the Home. The grounds, which include a ‘secure garden area, are attractive, provide shaded areas, and are well maintained. At the previous inspection it was recommended that plug sockets be installed at the end of corridors to enable recharging of hoists in areas where they did not obstruct passing traffic. Work on this has now been completed and the desired effect achieved. A well-established maintenance, redecoration, and refurbishment programme, staffed by a Site Coordinator’ and a Maintenance Assistant (both full time), ensures a good standard of environment for Residents and staff. Individual bedrooms are redecorated as and when they become vacant and, in addition, the home engages professional decorators when necessary. A recent example of this was the refurbishment of Elm Unit, which has recently benefited from redecoration of the lounge and the dining area, together with refitting of the linked kitchenette, replacement of carpeting in the main corridor, and complete refurbishment of the assisted shower. Also within Elm Unit the Home has begun development of aspects of the environment aimed specifically at meeting the needs of Residents who have dementia, e.g. pictorial signs for toilets/bathrooms, tactile boards and memory boxes – some of the latter being small glass covered boxes, mounted on the wall outside a Resident’s bedroom containing personal items. The next phase of the environment improvement programme, due to commence in early 2008, is to be the refurbishment of the lounge, dining area, and kitchenette of Ash Unit, plus the refitting of the unassisted bathrooms in Elm and Oak Units so as to provide assisted bathrooms. Recommendations made by the Fire Safety Officer, e.g. the introduction of a Green Box over-ride system on fire doors have been responded to and satisfactorily completed. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are sufficient to ensure the provision of safe care to Residents. Recruitment procedures are sufficiently robust to ensure that Residents are not placed at risk. Staff receive training, which enables them to be competent to carry out their role in providing safe care to Residents. EVIDENCE: A review of duty rosters, and discussion with staff, confirmed that staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. Staff were observed to carry out their duties in an enthusiastic and professional manner. At the previous inspection a requirement cited was:“The registered person must ensure that an induction programme is introduced that meets the Skills for Care standards.” Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 19 Review of staff training records, and discussions with staff and the Manager, provided evidence this issue has been satisfactorily addressed. A new induction programme has been developed which is tailored to the particular learning and information needs of the individual staff member. During the completion of the programme the staff member is supernumerary and has the support of their nominated supervisor, e.g. the Registered Manager or Care Manager for the Unit to which they are initially recruited, and a mentor who is usually an experienced member of senior care staff. This requirement is met. The home has well-organised systems and detailed staff records. Records examined covered four staff members, two chosen at random, plus the two most recently appointed. Files evidenced all the necessary information demonstrating prospective staff are well screened before they are deemed suitable to start work at the home. Documentation evidence all staff had fully completed application forms; two satisfactory references; satisfactory protection of vulnerable adult and Criminal Records Bureau checks; satisfactory identification documentation, including a recent photograph. Records further demonstrated a very high proportion of care staff have attained NVQ Level 2, or higher. Support in undertaking NVQ Level 2 is also provided to staff other than care staff, e.g. food preparation, housekeeping, and caretaking. Two members of staff have successfully completed the Intermediate Food Hygiene qualification. Training records further evidenced care staff have attended courses on safe handling of medication, dementia care, moving and handling, risk assessment, ageism, fire prevention, dealing with challenging behaviour, first-aid and health and safety at work. Particularly noteworthy is the very low turnover seen for all grades of staff. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified, and experienced person manages the home. Whilst systems for consultation with Residents are generally satisfactory, there is need for an increase in the use of questionnaires. Health, safety, and welfare of service users, and staff, are promoted fully by safe working systems being in place. EVIDENCE: The home is very well managed by the Mrs Ellits, who is a first level nurse with considerable experience in nursing and residential homes. In addition to further qualifications, including NVQ Level 4 and the Registered Managers’ Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 21 Award, Mrs. Ellits has commenced an Institute of Leadership and Management Award and is undertaking a Diploma in Dementia Care. . There are clear lines of accountability within the home and the Manager is very supportive of staff and residents. Observations made, and discussions with residents and staff, indicated the Registered Manager is very approachable and operates an open door policy. This was confirmed to us by Residents, visitors and staff who stated they were happy to approach the Manager with any problems they might have. There is a good staff supervision system in place with each Unit Manager being responsible for staff working on ‘their’ Unit. Staff records confirmed staff receive supervision at least six times per year – more frequent if necessary. The home carries out an annual quality assurance assessment based on questionnaires to residents, their relatives/visitors and visiting clinical professionals. An analysis of findings reflected users of the service, and their relatives, to be happy with the quality of service provided. It is recommended that the frequency of such surveys be increased. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence (e.g. annual questionnaire and comments made to us) showing staff consult with residents, where possible, and their relatives, regarding the choice of meals and activities. Where requested by residents or relatives the home will hold a small sum of money to be used for items such as the weekly hairdresser or other incidentals. Examination of related records, and retained amounts of cash, evidenced arrangements to be robust and in order. Written reports were observed confirming a representative from the parent company undertakes monthly unannounced inspection visits. At the previous ‘key’ inspection two requirements were made in respect of the use of bed rails, i.e. “Staff who are responsible for selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be incorporated in a planned maintenance schedule.” “Risk assessments to support the safe use of bed rails must be further developed and based on guidelines provided by HSE and the Medical Devices Agency (MHRA) and be regularly reviewed.” Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 22 A review of staff training files, and monthly health and safety audit records, demonstrated action to meet these two requirements has now been completed. Therefore both requirements have been met. To assist in ensuring safety and the provision of a good quality service the home has a programme of monthly service audits including medicines administration, the kitchens, accidents/incidents, and ‘whole home’ e.g. décor, fabric/furnishings. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Review of relevant records provided evidence that Health and Safety Policies/Procedures/Practices are satisfactory, maintenance and servicing of equipment regularly undertaken, and appropriately documented, and all COSHH requirements met. Records are maintained for hot water supply to outlets accessible to Residents. Water temperatures tested during the Inspection were found to be satisfactory. However, it is recommended the risk to residents of scalding at unguarded hot water outlets be assessed and a programme to install temperature control valves is instigated. Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 OP25 Good Practice Recommendations It is recommended the risk to Residents of scalding, at unguarded hot water outlets, be assessed and a programme to install temperature control valves is instigated and implemented. It is recommended that the frequency of use of questionnaire based quality assurance assessment be increased. 2. OP33 Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sycamores, The DS0000017195.V343289.R01.S.doc Version 5.2 Page 26 - 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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