Inspection on 20/09/06 for New Swinford Hall

This inspection was carried out on 20th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

New Swinford Hall 04/09/07

New Swinford Hall 31/01/06

New Swinford Hall 06/09/05

New Swinford Hall 25/01/05

New Swinford Hall 21/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE New Swinford Hall Martley Drive Stourbridge West Midlands DY9 7PE Lead Inspector Mrs Cathy Moore Unannounced Inspection 20th September 2006 07:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Swinford Hall DS0000038656.V309457.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. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Swinford Hall Address Martley Drive Stourbridge West Midlands DY9 7PE 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) 01384 815975 01384 815978 N/K Dudley Metropolitan Borough Council Mrs Helen Janet Green Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 25 and 26 November 2003 are met within the timescales contained within the action plan agreed between Dudley Metroplitan Borough Council and the National Care Standards Commission. Service users to include up to 18 OP ((PD(E) or MD(E) or both PD(E) and MD(E)), 2 MD and up to 2 PD, of which must be 50 years of age and over. By the 30 September 2003 water available from bedroom/bathroom taps together with any exposed pipeworks shall not exceed 43 degrees celsius. In the interim, following risk assessments, strategies are implemented to safeguard service users. 31/01/06 2. 3. Date of last inspection Brief Description of the Service: New Swinford Hall is a Local Authority owned and managed home. It is fairly unique as the care that it provides is short term rehabilitation and re-ablement. Up to 18 residents at any one time can receive care from this service, the ultimate aim for them is to enhance or relearn skills lost by accident or illness, or to acquire new skills to enhance their independence in respect of daily living. The maximum length of stay at this home for each resident is five weeks. The home is a traditional style property. It is located between Lye and Stourbridge in the Borough of Dudley. The home is sited on a residential estate. Unfortunately few shops or facilities are available within the vicinity. The home has adequate outdoor space. There is limited car parking space at the front and side of the home.The home is divided into three units, these are known as Romsley, Clent and Malvern units. Each unit has its own living, dining and kitchen facilities. An assisted bath is situated on all units. All of the bedrooms are single occupancy, each having en-suite facilities to include a walk in shower, hand wash basin and toilet. A physiotherapist and two Occupational Therapists work within the home producing rehabilitation and reablement programmes. Staff are trained to continue with these programmes during all hours. Placements up to five weeks in duration (which is generally the norm) are not charged for. Charges are made for some services which include hairdressing and private chiropody. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.30 and 16.30 hours. The inspection process assessed all of the key National Minimum Standards for older people. To aid the inspection process a number of questionnaires were forwarded to the home for completion before the inspection. A proportion of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection three residents’ files to include assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounge/dining rooms on both floors, two bedrooms, the laundry, garden, bathrooms and toilets. Medication systems and the safe keeping of resident money were assessed. The main meal of the day was partly observed. Six residents, three staff and one relative were spoken to during the inspection. Senior staff and the manager were on site during the inspection process. What the service does well: The home is unique as it offers a short term rehabilitation and re-ablement service. Staff within the unit are trained to work with each resident to enhance or relearn skills needed for every day living and independence. Physiotherapists and Occupational therapists are available to give professional input. The home in general is maintained to a good standard. It is clean, comfortable and fit for purpose. The home is divided into three units internally which creates a ‘homely atmosphere’. All bedrooms are single occupancy and are appointed to a good standard. All have en-suite facilities provided which include a walk in shower, hand washbasin and toilet. The home offers a range of aids and adaptations to enhance mobility, independence and potential such as; a passenger lift, grab rails, assisted bathing facilities and training kitchen and laundry. Records and care plans produced are of a good standard. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 6 The home belongs to Dudley Council and is therefore able to access a wide range of services and advice. The manager, senior and staff team continue to be motivated and committed to providing a good standard of service to the people in their care. The manager gives a clear sense of direction and leadership to the staff team. Relationships and interactions between staff and service users were seen to be very positive. As with past inspections the majority of requirements previously made have been met. 66 of the staff team have attained N.V.Q level 2 or above which is very good. A number of positive comments were received from service users which included; “ I can not praise the home and staff enough excellent in all respects”. “ I enjoyed my stay and found everything exceptionally good”. “ Commend the staff”. “ This is the nearest thing to home you can get with the care and attention to hand”. “ I think that the staff and the service they provide are excellent”. “I stayed at another home for same service, this place is a total palace in comparison. The staff are friendly and the place fresh smelling and clean”. Positive comments were also received from staff about the home and included; “ I think the home is very good, compared to the one I worked in before it is excellent”. “ I enjoy working here”. “ It is lovely to see people returning home, very rewarding”. “ The staff receive a lot of support”. A relative said; “ It’s the best home around here. Happy she is here”. What has improved since the last inspection? The manager has returned from maternity leave. The manager has commenced an N.V.Q level 4 management course. Progress and improvement has been achieved in the areas of need assessment and care planning. A number of requirements concerning medications made following the last inspection have been met. Accredited medication training has been secured. A number of staff including seniors have received abuse awareness training. Satisfaction surveys for residents have been used with the results displayed in the front entrance hall. The majority of staff have received health and safety training. Electrical appliances have now all been tested as required. The home has established and implemented a monthly accident analysis. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 7 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. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 8 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 New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,6. The overall outcome for this group of standards is judged to be good. Service users are issued with a contract/ terms and conditions document. No service user moves into the home without having their needs assessed and assurance given that these needs will be met. Service users assessed and referred for this service for either rehabilitation or re-ablement are helped to maximise their independence and return home. EVIDENCE: It is positive that information about the home was readily available within the front entrance hall examples being; the last inspection report and the service user guide. Ten of the eleven completed resident questionnaires received confirmed that they had all been given enough information prior to them being admitted to enable them to make the decision that the home would be suitable for them. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 10 One resident said; “ I have been here for treatment before. This time the hospital sent me to another home for rehabilitation. I was so depressed there. They were not doing anything for me so I insisted I was either transferred to New Swinford Hall or I was going home. I got transferred here and have improved quickly. Another resident said; “ I heard it was very good and had no qualms about coming here”. Eight of the eleven completed resident questionnaires received confirmed that they had been issued with a contract/terms and conditions. Three of the eleven did not answer this question. A contract/ terms and conditions document was included on resident files seen. It was noted however, that one resident who had been admitted for the average stay of five weeks in April 2006 is still resident and is being charged for the service. The contract did not reflect this or detail the weekly fee applicable. Written evidence was available to demonstrate that each resident had been visited by a staff member before admission and a documented assessment of need had been produced covering main core areas. The home is fairly unique as it offers a short term rehabilitation and reablement service. Staff within the unit are trained to work with each resident to enhance or relearn skills needed for every day living and independence. Physiotherapists and Occupational therapists are available to give professional input. The main aim is for each resident to return back home after their stay at New Swinford Hall evidence was available to demonstrate that the majority of residents do return home after their stay. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The overall outcome for this group of standards is judged to be good. Service Service Further safe. Service users health and personal care needs are set out in an individual plan. users health care needs are fully met. development is needed to ensure that medication systems are fully users feel that they are treated with respect. EVIDENCE: A detailed care plan was in place for each resident whose file was examined. Care plans are typed which makes them easier to read. The care plan style was very good in that it was divided into sections examples being; ‘ Identified needs’ and ‘Goals’. Care plans seen had been reviewed and had been signed by the resident it belonged to. As stated in previous sections the home has access to a range of health care professionals every weekday at least. It has Occupational and Physio Therapy New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 12 input. The local doctor who takes residents from the home onto his list on a short term basis is responsive. The district nurse from the practice visits the home each day and assesses and gives advice and treatment where needed. The nurse said; “ There are no communication problems between the practice and the home. The staff always follow instructions given by the nurses”. It must be remembered that the home only provides short term care however, it was positive that where needed other health care services examples being; the chiropodist and optician are secured for residents. There was evidence of this. One shortfall identified was that one resident had been at the home since April 2006 (this length of stay is unusual) it would have aided the audit of healthcare services for this resident if a health care professional recording system had been used instead of having to track back through numerous pages of daily notes. Eight of the eleven completed resident questionnaires received confirmed that they always receive the care and support they need, three answered usually to this question. Ten of the eleven confirmed that they always receive the medical support they need. One answered usually to this question. One resident commented; “ Staff are very quick to follow up medical problems”. Another resident commented; “ The staff are excellent and responsive to my needs”. The home has a good medication policy which was updated last year by the manager and has been approved by the homes pharmacist. The manager has secured further, accredited medication training for the staff which is due to commence soon. A contract is in place between the home and their pharmacist. The pharmacist carries out regular monitoring of the homes medication systems. Medication administration was indirectly observed and good practice was seen. The senior ensured that residents had taken their medication and where for example; pain killers were prescribed as ‘when needed’ she asked each resident if they needed their painkillers. The home has a dedicated medication fridge and a controlled drug cupboard. Controlled drugs were counted and found to be correct against balances. The home has a robust assessment system and good documentation concerning those residents who self medicate. A few shortfalls were identified which need to be rectified and include; medications returned to relatives must be counted and receipted. Two staff must verify that the transfer of information from medication bottles and packets to medication records is correct and short life medications creams for example must be date labelled when opened. All bedrooms are single occupancy and are provided with en-suite facilities this enhancing privacy and dignity. On all files viewed there was documentary evidence to show that residents on admission had been offered a key to their bedroom door. A pay phone is available for residents to make private phone calls. The preferred form of address is determined for each resident and this is the name used for them. Staff observed during the inspection were very polite and respectful to the residents in their care. One resident said; “ The staff treat you very well”. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 13 Eleven of the eleven resident questionnaires confirmed that; ‘ Staff always listen and act on what I say” which is very positive. New Swinford Hall DS0000038656.V309457.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be good. Activity provision may need some fine tuning and development. The home has an open visiting policy and encourages service users to maintain contact with family and friends. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet, in pleasing surroundings. EVIDENCE: Activities are predominantly geared to the goal setting of each resident based on their needs and include home life assessment and exercise programmes. The manager said; “ soon the home will be able to offer more in the way of Occupational and Physio programmes to improve the service further”. Six of the eleven completed resident questionnaires received confirmed that there were always activities arranged that they could take part in. Four answered usually to the same question. One resident commented;” Not a great deal but I join in them all”. Another said; “ There is exercise to music each morning”. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 15 Daily routines revolve around the needs of the residents. All are encouraged to get up and go to bed themselves with support and supervision given where needed by staff. The home has an open visiting policy which encourages visitors just to avoid meal times. One visitor said; “ I feel welcome. Visitors can make themselves a drink when they want to”. A resident said; I have visitors nearly every day”. The home only offers short term care but residents are welcome to bring into the home small personal possessions if they want to. Information about external advocacy services was seen displayed in the front entrance hall. Each of the three units has its own dining area this makes the home feel homely. Each kitchen area is well equipped. Residents encouraged to do their own drinks and cereals/ toast in the mornings to relearn/retain their skills in this area. The home also has a training kitchen where residents can also relearn kitchen skills with adapted equipment where needed. The home has a set menu which details four meals per day. It is extremely positive that the home has just been approved for the silver healthy eating award by Environmental Health. The main meal on the day of the inspection was chicken or belly draft, carrots, cauliflower potatoes and gravy followed by lemon curd tart or stewed apple and custard. The meal smelt appetising and was well presented. One resident said; “ The meals are very enjoyable. It does not matter what meat we have you don’t need a knife it just melts in your mouth. The cook is marvellous”. Another resident said; “ The meals are good there are choices every day”. New Swinford Hall DS0000038656.V309457.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The overall outcome for this group of standards is judged to be adequate. Service users must all be fully informed of complaints processes in order that any complaints will be listed to and acted upon. Improvements are needed to ensure that service users are fully protected from abuse. EVIDENCE: No complaints have been received by the Commission about New Swinford Hall. One complaint has been received by the home in August of this year which was dealt with within 28 days by the manager. The only improvement to the complaints system would be for future complainants to be encouraged to put in writing that they are satisfied with outcomes/ actions taken. Seven of the eleven completed resident questionnaires confirmed that they always know who to speak to if they are unhappy. Four answered ‘usually’ to this question. Five of the eleven completed questionnaires confirmed that they know how to make a complaint. Four answered ‘usually’ to this question. Ongoing processes to advertise the home’s complaints procedure should continue. It is positive that most seniors have received the one day abuse awareness training delivered by Dudley MBC. One senior has received training to enable him to deliver abuse awareness training to the staff team. The manager said, New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 17 “when seniors have all received the one day training I will then nominate the rest of the staff for the same training. The home has a copy of Dudley Council’s adult protection procedures; it was not clear however, if all staff have read these. The quick reference flow chart designed to give staff contact details if an allegation or incident of abuse were to occur must be amended to add names and telephone numbers of persons that need to be contacted, an example being, The Commission. It was very concerning to read in one resident’s daily notes, “ Attacked x2 by …, shook up”. Yet there was no evidence to demonstrate that this incident had been reported to the manager or senior on duty and therefore was not actioned appropriately or reported as it should have been. The manager during the inspection was made aware of what had been written and has been required to undertake an investigation. New Swinford Hall DS0000038656.V309457.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25,26. The overall outcome for this group of standards is judged to be good. Generally the home is safe and well maintained. Attention is needed to decorating needs in corridors; to ensure safety concerning lighting in corridors and ensure that the heating system is working as it should. The layout of the home is fit for purpose and has adequate communal space both internally and externally. The home is clean, pleasant and hygienic. EVIDENCE: Generally the home is well maintained in terms of décor and fabric. An outstanding requirement remains for the corridors to be re-decorated. Lounges and communal areas viewed were all good in terms of decoration and furniture provided. The home has a generous sized garden. Parts of this viewed looked maintained; the grass cut and pathways clear of moss and weeds. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 19 The home is divided internally into three units. Each unit has its own lounge/dining space and kitchenette. A smoking lounge and library are also available within the home in addition to an activity room. A number of residents complained during the last inspection about the excess heat. Evidence was available to prove that an engineer has looked into this but as the heating was not on at the time, was unable to make a judgement. The manager confirmed that the engineer would return in the autumn when the heating is put back on to assess and rectify if needed. The corridors have appeared to be dimly lit as a consequence a lux assessment has been carried out which confirmed that the corridors do not conform to lux standards. The manager has been told by Dudley Property Consultancy that other lighting would in all probability not improve the situation. The manager is to monitor any accidents in this area or complaints received then if needed reevaluate the situation. The home was seen to be clean and hygienic. No mal odour was detected. Most staff have received infection control training. Protective clothing and ‘hand wash’ signs were available in all risk areas. The home has a mechanical sluice and a large, well equipped laundry which has two areas to segregate clean and dirty washing. It is extremely positive that eleven of the eleven completed resident questionnaires received all confirmed that the home was always fresh and clean. One resident commented; “Very clean”. New Swinford Hall DS0000038656.V309457.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be good. Service users needs are met by the number and skill mix of staff. Service users are in safe hands at all times. Service users are protected by the homes recruitment policies and practices. Staff are trained and competent to do their jobs. EVIDENCE: The home is staffed as follows; AM 5 carers PM 4 carers. Night 2 carers. On each day time shift there is also 1 (sometimes 2 seniors) plus the manager during weekdays. Everyday dedicated cleaning and catering staff are provided. Care staff at the present time have the responsibility of laundry tasks. It has been noted during the last 6 months occupancy and dependency levels have risen. With this in mind a requirement has been made for the manager to consider employing laundry staff to remove this task from carers who are having to work under increased pressure. Seven of eleven completed resident questionnaires received confirmed that there are always staff available when needed. Four answered usually to this question. One resident said; “ The other night I had a fall. The staff were there in seconds”. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 21 Positive comments were received about the staff and included, “ The staff are so nice, so thoughtful. Nothing is too much trouble”. It is extremely positive that 66 of the staff to date have achieved N.V.Q level 2 or above in care. The files of three staff members were examined. It is positive that all three contained the required documents demonstrating that effective recruitment processes are in place. Evidence was available to demonstrate that induction processes for new staff are in place. The manager obtained the new Skills for Care induction standards during the inspection to peruse. A training matrix was seen which includes training required. The manager is actively securing any training for staff that it needed. New Swinford Hall DS0000038656.V309457.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall outcome for this group of standards is judged to be good. The manager has been approved as a fit person to be in charge of the home. Quality assurance processes need further development. Service users’ financial interests are safeguarded. Staff supervision needs some improvement in terms of frequency. The health and safety of service users and staff is promoted. EVIDENCE: The manager has been approved by the Commission as a fit person to run and be in charge of the home. She has recently commenced onto a N.V.Q level 4 course in management. The manager is a first level registered nurse. New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 23 It is clear that the manager has effective leadership skills and uses these to give direction and support to the staff team. Quality assurance processes have progressed since the last inspection in terms of using of relative satisfaction surveys. The results of the surveys are displayed in the entrance hall. The home has an up to date business plan. A shortfall identified is the monitoring of processes against the National Minimum Standards for older people which must be established. Small amounts of resident money is held in safekeeping. Records and amounts for three residents were assessed and were found to be correct. The home has a system whereby safe keys are handed over to seniors between shifts. Although evidence was available to demonstrate that staff are receiving one to one supervision sessions these do not equate to the required frequency of 6 in a twelve month period. The manager and seniors at the present time however, are taking action to rectify this. Staff training was assessed. In general staff have received the required training or it has been arranged. Shortfalls identified were first aid and fire drills which need action. It was noted that not all staff first aid certificates detailed how long the certificate was valid for making planning for future training difficult. The kitchen was not assessed as it was assessed by Environmental Health in September 2006 who only gave two requirements. The manager confirmed that she would send a copy of the report for this inspection to the Commission when received for perusal. Maintenance and service records were examined concerning for example fire fighting equipment and hoisting equipment and were found to be in order. It is positive that the majority of staff since the last inspection have received health and safety training. New Swinford Hall DS0000038656.V309457.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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 x 18 1 3 3 x x x x 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 5(1)(b) Requirement The registered person and manager must ensure that where residents exceed the five week non- paying period and charges are made that the weekly fee applicable is detailed on their contract. The registered person and manager must ensure that where residents exceed the usual five week stay that a professional visit record is put into operation to enable auditing of health care services received. The registered persons must ensure that where medication records are produced by the home that the information transferred from containers to the medication records are verified by two staff. Timescale of 15/02/06 not fully met. 4 OP9 13(2) The registered person and manager must ensure that short life preparations for example; topical medication is date DS0000038656.V309457.R01.S.doc Timescale for action 01/10/06 2 OP8 12(1)(a) 13(1)(b) 01/10/06 3 OP9 13(2) 20/10/06 01/10/06 New Swinford Hall Version 5.2 Page 26 5 OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) 8 OP18 13(6) labelled when opened. The registered person and manager must ensure that the precise dosage for all medications ( Movical) is recorded on the medication record. The registered person and manager must ensure that where medication that has been counted and accepted by the home is returned to relatives than a process for recording and receipt must be implemented. The registered person and manager must ensure that all medication totals are carried over onto new medication records to ensure that full auditing can be undertaken. The registered persons must ensure that all staff read, sign and date Dudley MBC’s protection procedures ‘ Safeguard and protect’. Timescale of 01/04/06 not fully met. The registered person and manager must ensure that; Staff know that they must Report all incidents of violence or abuse between residents to the manager/senior in charge immediately. All incidents of violence or abuse between residents is reported as per Dudley Councils adult protection procedures and to the CSCI in accordance with Regulation 37. 01/10/06 20/10/06 20/10/06 20/10/06 9 OP18 13(6) 01/10/06 10 OP18 13(6) The registered person and manager must ensure that; The flow chart concerning Dudley 20/10/06 New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 27 MBC adult protection processes clearly details the appropriate names and telephone numbers this to include the CSCI. 11 OP19 23(2)(d) The registered person and manager must ensure corridors in the home are redecorated. Timescale of 01/12/05 and 01/04/06 not met. 12 OP25 13(4)(a)2 3(2)(p) The registered person and manager must ensure that a risk assessment is produced concerning the inadequate lux recordings in the corridors. If accidents or other occur in these areas than the lights must be changed immediately. The registered persons must ensure that; An engineer or other suitably qualified person fully assesses the heating system. The engineer or suitably qualified other must produce a report of their assessment. A copy of which must be forwarded to the CSCI. Approved room temperatures are maintained at all times. 14 OP27 18(1)(a) The registered person and manager due to increased dependency and occupancy levels must consider employing dedicated laundry staff. Care staff time must not be depleted by undertaking laundry tasks. DS0000038656.V309457.R01.S.doc 01/12/06 20/10/06 13 OP25 13(4)23 (2)(p) 20/10/06 01/11/06 New Swinford Hall Version 5.2 Page 28 15 OP33 24(1)(a) (b) The registered person and 01/12/06 manager must implement systems to ensure that the whole of standard 33 is being met. This standard/ requirement requires attention to ensure that all elements are being met. Timescales of 25/02/05, 01/11/05 and 01/05/06 not fully met. 16 OP36 18(2) 17 OP38 23(2) 18 OP38 13(4) The registered person and manager must ensure that staff supervision sessions are increased so that all staff receive six in any 12 month period. The registered person and manager must increase staff fire drill sessions to ensure that all staff receive 2 in any 12 month period and know what to do if a fire were to occur. The registered person and manager must ensure that the duration of validity is clearly detailed on staff first aid certificates. 01/11/06 01/11/06 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations New Swinford Hall DS0000038656.V309457.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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