Inspection on 04/09/07 for New Swinford Hall

This inspection was carried out on 4th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 20/09/06

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 Ms Linda Elsaleh Key Unannounced Inspection 10:00 4 & 5 September 2007 th th 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.V342802.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.V342802.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 helen.j.green@dudley.gov.uk 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.V342802.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 Metropolitan 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 40 years of age and over. By the 30 September 2003 water available from bedroom/bathroom taps together with any exposed pipe works shall not exceed 43 degrees Celsius. In the interim, following risk assessments, strategies are implemented to safeguard service users. 20th September 2006 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 reablement. Up to 18 residents at any one time can receive care from this service, the ultimate aim for them is to enhance or re-learn 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 with a few shops and facilities available within the vicinity. There is adequate outdoor space and 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. Each unit has its own living, dining and kitchen facilities. An assisted bath is situated on all units. All bedrooms are single occupancy, each having en-suite facilities to include a walk in shower, hand wash basin and toilet. Two Occupational Therapists and 1 assistant is employed by the home to produce rehabilitation and re-ablement programmes. The hospital and Primary Care Trusts provide physiotherapy. Care staff are trained to continue with these programmes as directed by the therapists. 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.V342802.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 on 4th & 5th September 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Older People and report on the progress made to address requirements made at the previous inspection. The inspector’s findings are based on the information received by the Commission for Social Care Inspection, examination of relevant records and documents kept at the home, discussions with the manager, staff and service users, comments provided from relatives and a tour of the premises. The atmosphere within the home was relaxed and friendly and service users, relatives and friends all expressed satisfaction with the care being provided. Here is selection of comments made to the inspector about the service; “All staff are wonderful.” “We are treated with respect and helped to regain our confidence.” “The home fills the needs of all people.” What the service does well: Prospective service users are provided with detailed information about the home’s services. Assessments continue to be carried to identify individual needs. The home’s ‘open’ policy enables service users to receive visitors at any time that suits them. Good arrangements are in place to ensure service users live in a comfortable and well-maintained home. Aids and adaptations are available to enable service users to navigate around the home safely. Service users are cared for by a stable staff team who are trained to meet their individuals needs. Health care needs are met and regular arrangements are made for service users to consult with relevant healthcare professionals. Service users enjoy well-balanced and nutritious meals. A varied activity programme continues to be provided. These are monitored regularly and revised to meet the needs and interests of service users. The views of service users and their relatives/representatives continue to be sought as part of the home’s quality assurance system. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. New Swinford Hall DS0000038656.V342802.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 New Swinford Hall DS0000038656.V342802.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): 1, 2, 3, 5 & 6 Quality in this outcome area is good. Information about the service is provided to prospective service users. Individuals and/or their relatives and friends may visit the home to assess its facilities and suitability. Prospective service users needs are assessed. Written confirmation is provided stating the home is able to meet the individual’s needs. Each service users contract should include details of which service is being provided and, where applicable, the fee charged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the services provided by the home is provided to all prospective service users. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 9 This includes the Statement of Purpose, Service User Guide and a leaflet explaining the re-ablement service. It is advisable that these documents are dated to ensure prospective service users are provided with the most recent copy. A copy of these and the most recent CSCI (Commission for Social Care Inspection) inspection report are on display in the foyer. A random selection of care files for three service users were examined in detail. The home does not take emergency referrals. Assessments for prospective service users are obtained from the referring agencies and are available on their files. The files examined also include assessments carried out by the home. These assessments focussed on the service users physical needs using a ‘tick box’ to identify strengths and areas where support is required. The home provides written confirmation that it is able to meet the individual’s needs prior to admission. Each service user is accommodated in one of the three suitable equipped units. The records kept by the home demonstrate its multi-disciplinary team works closely with service users to support them to return to their own home. All files contained signed and dated contracts and information about the rehabilitation and re-ablement service provided by the home. However, it does not identify which of these services is being provided to the individual. Information is also included about long-term residential care. The home does not provide this service and, therefore, this should be removed from the contracts to avoid confusion. The Annual Quality Assurance Assessment (AQAA) self-assessment form completed by the home and discussions with staff stated prospective “Service users with increased anxiety levels are encouraged to visit the home.” A relative who spoke to the inspector confirmed they were able to visit prior to the service user being accommodated. New Swinford Hall DS0000038656.V342802.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, & 10 Quality in this outcome area is good. Individual health and personal care plans are produced based on the information obtained from service users assessments. Suitable arrangements are made to ensure their heath care needs are met. Service users are encouraged and supported to retain control of their medication. Service users well-being will be better protected once the home has addressed minor shortfalls in its medication procedures and practice. Service users confirmed they are treated with respect by staff and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 11 EVIDENCE: Detailed care plans continue to be produced by the home and are based, initially, on the information provided from assessments. The plans identify what support is to be provided to service users. The therapists also provide plans, where applicable, and records are kept of the individual’s progress. The key worker regular reviews the care plans. Amendments are agreed to reflect the service user’s progress. For example one service user’s review showed her/his mobility had improved. Comments from service users praised the care and support given to them by staff. One service user said, “They (the staff) have treated me well and given me my confidence back”. Staff are actively involved, with external agencies, in producing and implementing plans for service users to return home. Some service users are able to continue to access health care services from their own GP surgery. Where this is not possible, they are registered as temporary patients with a local surgery. Consultations with health care professionals visiting service users in the home are held in the privacy of her/his bedroom. A system for recording health care visits has been implemented, making it easy to track visits made by/to GP, chiropodist, optician and others. The inspector was unable to find evidence to show a replacement hearing aid had been sought for one of the service users. This was brought to the attention of a senior member of staff. However, health care records appear to be generally well maintained. Records are also kept, where applicable, for monitoring other health related issues such as weight, dietary and fluid intake. The home reviewed its policy for the safe handling of medication with the local pharmacist in 2005. Good arrangements are in place for the receipt and return of the medication to the pharmacy. A senior member of staff explained the recording process for medication taken out of the home. A written procedure for this practice is needed and should include obtaining signatures from service users, relatives or others who take medication out of the home. The home keeps records of service users medication heir individual files. Service users medication details are also kept in a folder on the unit they are accommodated in. This folder provides easier access to the most current information about service users medication and administering arrangements. A service user who managers her/his own medication said, “Staff supervised me taking my medication for the first few days, but I now look after my own medication”. Suitable storage facilities are provided for all service users who self-medicate and for the storage of medication managed by the home. The records show service users are encouraged and supported, wherever possible, to retain/take control of their own medication. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 12 All senior and experienced care staff responsible for managing medication have received suitably training. A copy of each person’s training certificate is available at the home. A random selection of medication administration record sheets (MAR) examined during this visit was completed to a satisfactory standard, with the exception of recordings in respect of medication quantities, which was confusing. A clearer and more consistent recording practice needs to be identified to aid the auditing process. Service users preferred form of address is determined during the assessment. Staff were observed using the correct term when speaking to service users. All bedrooms are single occupancy and have en-suite facilities. Documentary evidence is available to show service users are offered keys for their bedrooms when they move in. A pay phone is available in the reception area. Suitable arrangements are made for service users to make and receive calls in private. Comments were complimentary about the care and support provided by staff. A relative reported that, “All the staff have been wonderful. They have cared for my mother and made her feel safe.” New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 13 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. Service users are encouraged to make their own decisions and are generally, well supported to continue to follow their chosen lifestyle. Relatives and friends are welcome to visit the home at times suitable to the service users. The home provides meals that meet service users dietary needs, are well presented and served in a pleasant environment. Service users are also supported to prepare their own meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a varied activities programme. Service users are consulted about activities during house meetings. A movement to music session was being held on the first day of this inspection. The service users commented on how much they enjoyed this session, the ‘parachute’ game and bingo. Further discussions and observations demonstrated that service users are provided with a range of group activities. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 14 On a more personal level, the Service User Guide states service users, “can continue to go to your day centre (transport permitting) or go on outings with your friends.” However, little evidence was presented to demonstrate that suitable arrangements are made to support service users to follow their individual interests. The inspector was informed the home has a qualified aroma-therapist on the staff team and arrangements were being made for regular sessions to be provided. A certificate of training was not available and no reference to this training was included in the member of staff’s file. Visitors are generally welcome at the home at anytime. However, they are requested to show consideration for periods in the day when service users are being supported to meet their needs, such as physiotherapy sessions and preparing their own meals. The records kept by the home demonstrate that service users are involved in their assessment, care planning and reviews. Relatives commented that, “Staff are happy to answer questions and to provide information about how to contact other services.” The home works closely with relevant agencies to produce suitable care packages to support service users when they return home. Senior staff stated there has been an increase in the number of service users who are unable to return to an independent living situation. In such circumstances, contact details are provided to enable service users to obtain information about what options are available to them, such as sheltered accommodation or long-term residential care. Information about healthy eating and dietary needs are available throughout the home. Each unit has a kitchen and dining area and service users participate in laying the table and washing up. Meals and snacks are prepared in the main kitchen by the catering staff. There is a separate domestic style kitchen for service users to cook their own meals, as they would do in their own home. This forms part of the rehabilitation programme for most service users. Care staff and catering staff are on hand to monitor progress and provide advice and support where required. Service users are consulted about meals on an individual and group basis. All staff have a basic food hygiene certificate. During this visit some staff were attending a healthy eating training programme. The majority of service users who commented about the meals said the home provides varied menus and tasty meals. One service user said, “Meals at the home are nice, but the sweets are not so nice”. Service users are also consulted about the day-to-day running of the service during regular house meetings. Minutes are kept of these meetings that shows service users who choose to attend participate fully in the discussions. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 15 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. Service users and their relatives and friends are confident any concerns they may have will be listened to and addressed appropriately. The home must ensure all relevant agencies are notified of any issues that may affect the well-being of all service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose refers the reader to a detailed booklet about how to make a comment, compliment or complaint about the service. A copy of this is provided in the service users’ information folder and available in the home’s reception area. The self-assessment completed by the manager reports that the process for dealing with and recording informal complaints is being developed. The inspector was informed no complaints had been received during the last twelve months. The home has received many comments and compliments from service users and relatives expressing their thanks to staff for all their hard work. A copy of Dudley’s Safeguarding Vulnerable Adults Multi-Agency Procedure is available in the home. All staff have received training in adult abuse issues. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 16 However, the manager is advised to ensure staff sign the procedures to confirm they have read and understand the content. A quick reference flow chart has been made available that highlights the reporting process and includes contact details for all relevant agencies. This provides staff with a quick point of reference should an allegation or incident of abuse be brought to their attention. The minutes for a staff meeting held on 7th August 2007 contained reference to a report of an agency worker allegedly being asleep on duty during a daytime shift. The inspector was informed the matter was reported to the agency, investigated and appropriately dealt with. The Commission for Social Care Inspection (CSCI) was not appropriately notified of this allegation. The home is required under the Care Homes Regulations 2001 to report, “without delay”, “Any allegation of misconduct by the registered person or any persons who work at the care home”. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. Service users are provided with a clean, safe, well-maintained environment in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home is available in the reception area. There are three units each accommodates six service users. The units comprise of lounge, kitchenette and dining area. Communal areas include an activities room and reading room. There is a small room for service users who wish to smoke. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 18 The corridors were in the process of being re-decorated at the time of this visit. Bedrooms are suitably furnished. Some service users have brought a few personal possessions with them. Aids and adaptations are fitted throughout the home to enable service users to navigate around the home safely. Assisted bathrooms are located on each unit for use by service users. The home provides service users with access to secluded and well-kept garden. Outdoor furniture is provided on the patio area. There is a lawn area and a variety of plants and shrubs. The home plans to create a sensory garden. Attention does need to be given to the upkeep of the rear parking area, as litter has been allowed to gather and there are some discarded items that need to be disposed of. The home is clean and hygienic. There are good arrangements in place for infection control. The laundry is suitable equipped and has designated areas for clean and dirty washing. Staff are provided with protective clothing and ‘hand wash’ signs are displayed in high-risk areas. Cleaning materials are stored in a locked cupboard and information is available on the Control of Substances Hazardous to Health (COSHH). Staff have attended training for infection control. Service users and visitors confirmed the home is always clean and tidy. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 19 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. Service users are protected by the home’s recruitment policies and practices. The home provides competent and trained staff in sufficient numbers to meet the needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently staffed by a minimum of six care workers during the morning and five during the afternoon. Laundry duties are the responsibility of the care staff. However, the home does employ staff to carry out other domestic duties. Catering staff are provided by Dudley Metropolitan Council. A senior member of staff is also on duty to provide supervision and support. Two staff are on duty to care for service users during the nighttime hours. Service users commented that staff are always friendly and available to provide assistance. The home has a good record for staff retention and staff spoke positively about the training and support they receive. A random selection of three staff files was examined. Each file contained the required recruitment information and evidence that appropriate safety checks had been carried out. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 20 The home is to be commended on its pro-active approach to training. It reports 83 of the current staff team hold the Level 2 National Vocational Qualification (NVQ) Certificate, or above. Other members of staff are working towards achieving this certificate. Certificates and training records are kept and an easy reference matrix has been produced to help the manager to plan training. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35 & 38 Quality in this outcome area is excellent. Service users live in a home that is run in their best interests. Staff are supported by their managers to meet service users needs. Procedures are in place to ensure the health and safety of service users and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was not able to be present during this inspection. However, the records examined, observations made and discussions held during the visit demonstrates that the home is well managed. New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 22 The senior care staff stated the manager has completed the National Vocational Qualification (NVQ) Level 4 in Management. Information kept about service users is securely stored to ensure confidentiality is maintained. The home has a policy on service users rights to access their personal records. Information is also available about how independent advocate services can be contacted. Small amounts of service users’ money are held in safekeeping and appropriate records are kept. Regular meetings are held for senior, care and domestic staff. The minutes of these meetings were made available to the inspector. Records of supervision sessions are kept on individual files. The senior on duty stated the home is aware that the frequency of these sessions needs to improve. Hence, the home has produced a planned programme for the year identifying supervision dates for each member of staff. As previously stated, training is provided for staff in respect of health and safety matters. Suitable records are kept of inspections and servicing of appliances and equipment. Environmental risks assessments are also undertaken and regularly reviewed. A senior member of staff has been designated responsible for monitoring the accidents and incidents records. A formal process should be developed for reporting back to staff any action required to prevent similar occurrences. The home continues to develop its quality assurance system. Information on the home’s performance is displayed in the reception area. New Swinford Hall DS0000038656.V342802.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 3 3 3 X 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 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 X X 3 New Swinford Hall DS0000038656.V342802.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. 1. Standard OP18 Regulation 37 Requirement The manager must ensure any allegation of misconduct by staff is reported to CSCI without delay. Timescale for action 08/10/07 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 OP2 OP2 Good Practice Recommendations The service, rehabilitation or re-ablement, being provided should be included in the service user’s contract. The details included in service users contracts in respect of long-term residential care should be removed, as this service is not provided. A suitable written procedure for medication being taken out of the home should be produced to ensure the safety and well-being of service users. 3. OP9 New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 25 4. OP9 A clear and consistent practice for recording the quantities of medication on MAR sheets should be implemented to aid the auditing process. Discussions with service users about their individual interests and arrangements made to support them should be detailed more fully in their care plan. Suitable documentation should be obtained of any specialist qualification held by staff prior to them being allowed to practice for example aromatherapy. Staff should read, sign and date Dudley MBC’s protection procedures ‘ Safeguard and protect’ to confirm they understand its contents. Arrangements should be made to ensure debris at the rear of the premises is removed promptly and the area is kept free from litter. A formal process for reporting back to staff should be included in the home’s system for monitoring accidents and incidents. 5. OP12 6. OP12 7. OP18 8. OP19 9. OP33 New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 26 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: 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 New Swinford Hall DS0000038656.V342802.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!