Inspection on 06/09/05 for New Swinford Hall

This inspection was carried out on 6th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

New Swinford Hall 04/09/07

New Swinford Hall 20/09/06

New Swinford Hall 31/01/06

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 Marley Drive Stourbridge West Midlands DY9 7DE Lead Inspector Cathy Moore Unannounced 6 September 2005 th 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 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 E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service New Swinford Hall Address Marley Drive, Stourbridge, West Midlands, DY9 7DE Telephone number Fax number Email 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 Dudley Metropolitan Borough Council Helen Green - Acting Manager Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25.01.05 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 aquire new skills to enhance their independence in respect of daily living.The maximum lenghth of stay at this home for each resident is five weeks. The home is a tradtitional style property. It is located between Lye and Stourbridge in the Borough of Dudley. The home is sited on a residential estate. Unfortunatley 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 physio Therapist and two Occupational Therapists work within the home producing rehabilitation and re-ablement programmes. Staff are trained to continue with these programmes during all hours. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector during 07.40 and 14.20 hours. The inspection was the first of the home’s two routine statutory inspections for this inspection year. Two residents’ were selected for case tracking. Their personal files were assessed which included assessment of need documentation, care plans and medication records. Both residents’ were spoken to and their bedrooms were viewed. The premises were briefly viewed to include the lounge/ dining area on Romsley Unit, the sluice rooms, laundry and assisted bathrooms on two floors. Records pertaining to fire and health and safety, staff recruitment, general maintenance and staff training were also perused. What the service does well: The home is unique as it offers short term rehabilitation and re-ablement programmes. Staff within the unit are trained to work with each resident to enhance or relearn skills in relation to daily living and independence. One Physiotherapist and two Occupational Therapists are on site 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 with en-suite facilities (walk in shower, hand wash basin and toilet) provided. Bedrooms are appointed to a good standard. The home offers a range of aids and adaptations to enhance mobility, individual potential examples being a passenger lift, grab rails, assisted bathing, training kitchen and laundry. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 6 Records overall are produced and maintained to a good standard. The manager, senior team and staff appear motivated and committed to providing a good standard of service to the residents’ in their care. The attitude of staff appeared to be positive. Positive interactions were observed between staff and residents’. One resident commented “ I did not really want to come in here but was advised to by the doctors’ and my family. I have been pleasantly surprised. The staff are very friendly and helpful. I was worried about calling the staff in the night but they have been great, responded quickly and are friendly. The food is very good. The appointment of the home is very good I am surprised it is not full”. The majority of requirements made following the last inspection have been met. Sixty one percent of the staff have attained N.V.Q 2 or above in care. The home has received a number of thank you cards and compliments from both relatives and residents’ who have returned home. 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. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,6 No resident moves into the home without having had their needs assessed. Residents’ assessed and referred for rehabilitation or re-ablement care are all helped to maximise their independence and return home or to other suitable accommodation in the community. EVIDENCE: There was documentary evidence available to demonstrate that all residents’ moving into the home have their needs assessed. This is either carried out by a representative from the home or by dedicated hospital staff who are fully aware of the homes access criteria. There was no information available to demonstrate that the home gives written acknowledgement to each resident of how their needs will be met. The home provides short term rehabilitation and re-ablement care. In general the maximum stay at the home is five weeks. During this time residents’ are assisted and enabled to regain or learn skills to enhance independence to allow them ultimately to return home. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9,10. Care plans need further development to ensure full instructions are applied to each area of need . Residents’ health care needs are fully met. Overall medication systems are satisfactory with the exception of secondary dispensing of medication which needs further exploration to prevent risk to residents’. Residents’ spoken to felt that they are treated with respect and their right to privacy is being upheld. EVIDENCE: A plan of care was included on the two residents’ files viewed. The design of the care plans reflect an assessment process rather than complex care plan. Needs are identified but little instruction was detailed of how these needs will be met. There was ample evidence to demonstrate that health care services are being accessed for the residents’. A physiotherapist and two occupational therapists work on site. The local doctor’s practice has a practice nurse who visits the home on a frequent basis. As the stays at this home are only five weeks unless residents’ live within the area they are registered with a local doctor. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 10 Apart from two medication errors that have occurred which were reported and have been dealt with medication systems appear to be satisfactory. All staff who have a responsibility for medication have received accredited medication training. No signature gaps were identified on the medication records there was evidence that all incoming medication and medication returns are recorded. A concern was identified in that for independence training purposes secondary dispensing of medication occurs in that staff place medications from their original containers into monitored dosage containers. The medication policy has recently been revised. Whilst the policy is much improved there was no evidence to suggest that the policy had been endorsed by the home pharmacy provider or mention of homely remedies.. All bedrooms are single occupancy with en-suite ( walk in shower, wash hand basin and toilet) facilities which enhances privacy and dignity. Bedroom doors have a lockable facility which residents’ are offered a key to. Staff observed spoke to the residents’ with respect. One resident commented, “the staff are very polite”. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,13 Further work is required to ensure that the lifestyle experienced by residents’ matches their expectations and preferences. The home actively encourages residents’ to maintain contact with family and friends. EVIDENCE: There was evidence of good communication between residents,’ relatives’ and staff. Individual reviews are held frequently (at least twice) during each residents’ stay at the home. Residents’ meetings are also held regularly. There was little evidence that the preferred daily routines of residents’ are established and recorded in terms of rising, retiring and meal times which is important as most residents’ return home after their stay at the home and may need to maintain their normal daily patterns. Activity provision is very much centred around need and rehabilitation/reablement programmes. Recreational in-house activities are provided, it was noted however, that the activities/ hobbies section of the two residents’ care plans viewed had not been completed. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 12 Visiting times are open and flexible. Residents’ very much encouraged to maintain contact with their family and friends during their stay. One resident commented “ my sisters are coming to visit me this afternoon”. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 13 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 standard(s) Nil These standards were not assessed during this inspection. EVIDENCE: New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19,25,26 Overall the residents’ stay at this home is in a safe, well maintained environment. Generally the residents’ live in safe comfortable surroundings. The home is clean, pleasant and hygienic, no offensive odours were identified EVIDENCE: The parts of the home viewed during the visit were of a reasonable standard in terms of décor, furnishings and fittings. The shortfall identified being the corridors which are showing signs of wear and tear. The home has a routine maintenance programme. Lighting in the home appears adequate. An outstanding requirement remains in respect of the adequacy of the up-lighters in the hall ways. Radiators throughout the home are guarded. Confirmation of risk assessment in respect of the water system was not available. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 15 The sluice rooms, assisted bathrooms and laundry were assessed. Personal hygiene products were seen in one bathroom, extraneous items in the sluice rooms and bathroom (including electrical items). The laundry is well equipped with commercial washing machines and dryers. Sluice programmes are available. Red disposable bags also available to cater for heavily soiled or infectious washing. The laundry floor and walls are satisfactory. The home has a sluice room on each floor complete with a mechanical sluicing disinfector. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Residents’ needs are met by the numbers and skill mix of staff. Residents’ are in safe hands. Residents’ are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staffing levels were seen to be satisfactory. Generally the home is staffed as follows; AM shift One senior and five carers. (During the week the manager is on duty. At others times a second senior may also be on duty). PM shift. One senior and four carers. Night shift. Two carers. The home all days has dedicated domestic and catering staff. During the week a Physiotherapist and Two Occupational Therapists are available. Sixty one percent of the care staff team have attained N.V.Q level 2 or above in care. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 17 Two staff files were assessed, these included Enhanced Disclosures/ Protection Of Vulnerable Adult list checks, at least two sources of identity and satisfactory references. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,38 Further work is needed to be undertaken to ensure that the home is completely run in the best interests of the residents’. Further clarification is required in respect of key handovers and key holding during the night. Staff are appropriately supervised. In general the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: There was evidence to demonstrate that the home has in place processes to ascertain the views of the residents an example being satisfaction questionnaires. There was little evidence to suggest that the home seeks views from other stakeholders such as doctors’ and district nurses, or that the home has established quality monitoring systems to measure compliance against policies and procedures. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 19 Further decision making must be carried out regarding the checking of resident monies between shifts and the handover and safe keeping of keys at night. There was evidence to demonstrate that staff are receiving regular formal supervision which is satisfactory in respect of areas focussed on. In general all maintenance and fire fighting equipment is being serviced on a regular basis. There was however, no evidence of recent lift and hoist servicing. A training matrix has been produced. In general staff have received all of the required mandatory training or it has been identified where gaps are present. The major shortfall in respect of training is the lack of health and safety training for staff. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x 2 3 x 2 New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 21 Yes 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 OP3/OP4 Regulation 14(1)(d) Requirement The registered person and manager must confirm in writing to the resident that having regard to the assessment the care home is suitable for the purpose of meeting his/her needs. The registered person and manager must ensure explore alternative methods for training residents to administer their own medication rather than practising secondary dispensing. If no solution can be found the manager must contact the CSCI pharmacist for advise whose name and office base were provided during the inspection. The registered person and manager must ensure that the homes pharmacy provider approves the homes medication policy. The registered person and manager must ensure that a policy statement is made in the homes medication policy to reflect the homes stance on homley remedies. The registered person and manager must determine, record Timescale for action 25.09.05 2. OP9 13(2) 25.09.05 3. OP9 13(2) 25.09.05 4. OP9 13(2) 25.09.05 5. OP12 12(3) 25.09.05 Page 22 New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 6. OP12 12(3) 16(2)(m) 7. OP19 23(2)(d) 8. OP25 13(4)(a) 23(2)(p) 9. OP25 13(4)(a) 23(2)(p) 10. OP26 13(3) and where possible honour residents preferred daily routines. The registered person and manager must ensure that the hobbies/interests section of the care plan is completed for each resident on admission. The registered person and manager must ensure that corridors in the home are redecorated. The registered person and manager must ensure that the up-lighters by assessing whether or not they meet the correct lux requirements/meet the requirements of the home. The registered person and manager must ensure that a documented risk assessment of the homes water system is carried out by a quailfied person. A copy of this must be forwarded to the CSCI office. Timescale of 10.2.05 not met. The registered person and manager must ensure that: No personal hygiene items are left in the bathrooms these must be returned to the residents bedrooms after use. 25.09.05 1.12.05 1.02.06 1.11.05 25.09.05 11. OP33 24(1)(a) (b) That all extraneous items are removed from the sluice rooms and laundry. The registered person and 1.11.05 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. Timescale of 25.2.05 not fully met. New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 23 12. OP35 16(2)(l) The registered person and manager must ensure that an effective handover of service user money ( between senior shifts is established) Timescale of 25.2.05 not fully met. The registered person and manager must identify and establish a system for the holding of safe keys overnight. Timescale of 25.2.05 not fully met. The registered person and manager must ensure that evidence is available on site at all times to demonstrate that the lift and hoisting equipment is being serviced 6 monthly. The registered person and manager must ensure that staff receive health and safety training. 1.10.05 13. OP35 16(2)(l) 1.10.05 14. OP38 23(2)( c) 25.09.05 15. OP38 18(1)(a) 1.12.05 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 Good Practice Recommendations New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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. Extracts may not be used or reproduced without the express permission of CSCI New Swinford Hall E55 S38656 Unannounced New Swinford V241775 060905 Stage 4.doc Version 1.40 Page 25 - 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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