Inspection on 03/01/06 for Swallow Wood Care Home

This inspection was carried out on 3rd January 2006.

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

Swallow Wood Care Home 21/11/07

Swallow Wood Care Home 12/12/06

Swallow Wood Care Home 23/03/05

Swallow Wood Care Home 06/10/04

Swallow Wood Care Home 18/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Swallow Wood Care Home Wath Rd Mexborough South Yorkshire S64 9RQ Lead Inspector Mike Hamstead. Unannounced Inspection 07:25 3 January 2006 rd 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 Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 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. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Swallow Wood Care Home Address Wath Rd Mexborough South Yorkshire S64 9RQ 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) 01709 571477 01709 585505 swallowwood@trinitycare.co.uk Trinity Care Ltd Leonie Shepherd Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age of places (38) Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To accommodate and provide nursing care for one named person who is terminally ill aged below 65 years old. One specific service user under the age of 65, named on variation V8248 dated 9th June 2004, may reside at the home To admit one named person under the age of 65 in need of nursing care 12th September 2005. Date of last inspection Brief Description of the Service: Swallow Wood Care home was purpose built and is registered with thirty-eight beds. The home is situated on the main Mexborough road within a residential area to the west of the town centre of Mexborough, shops and amenities are close by. Accommodation is provided on two levels, the upper floor being serviced by a shaft lift, and there are several lounges situated around the home on both floors. The home is set in enclosed gardens, comprising of shrubs, mature trees, lawn and patio area which as suitable access for service users either on foot or in a wheelchair. Car parking spaces are available at the front of the home. The home trades has Trinity Care plc, which is part of the Southern Cross Healthcare group The company was founded on and continues to be managed in accordance with Christian principles but is not aligned to any one denomination. Residents admitted do not have to be practicing Christians. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager deputy care manager and staff on duty, an examination of the homes records and the progress made since the last inspection. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection was commenced at 07:25 and finished at 13:40 and included talking to members of staff, residents, and visiting relatives. What the service does well: What has improved since the last inspection? The home has responded to the requirements and recommendations identified at the last inspection in September 2005, specifically that: Window blinds have been fitted in certain residents bedrooms to maintain their privacy and dignity. Steps have been taken to promote residents and staff safety with regard to floor covering in the home. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 6 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. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 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 Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, & 4. All residents are issued with a written contract/ statement of terms and conditions that accurately describes the terms of occupancy, and the home does not accept residents whose needs cannot be met. Arrangements must be made to have a condition of registration no longer applicable removed from the registration certificate, and also amended in the homes documentation. EVIDENCE: The home has a condition of registration relating to an under 65 years of age resident that is no longer applicable and the home must apply to have this condition removed from their registration certificate. This information must also be amended in the Statement of Purpose and Service User Guide. A contract and terms of conditions is provided to residents ensuring they are informed about their rights and obligations. The contracts clearly set out the care services provided, but is to be amended in the near future because of the Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 9 company’s acquisition of other homes and the need to standardise documentation. A number of residents spoken to said that “they were looked after very well. “ , and one resident said that “he could not put into words what he felt about the home other than to say that it was superb” A thorough assessment of needs is undertaken prior to any resident being admitted, and all specialised needs are provided as required. Care staff continue to undertake statutory training and NVQ training as a means of ensuring that the home can meet the residents needs. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 11. The homes documentation enables the needs of residents to be accurately assessed and monitored, and residents continue to be generally well looked after in terms of their health and personal care needs. The care manager should monitor the difficulties being encountered with a particular GP practice and take action as described in this report. EVIDENCE: A number of plans of care were examined at random that were comprehensive in detail, easy to understand and revealed that a range of specialist services were available if required. These included ready access to a GP, and the district nursing team, dentist, chiropodist, and hospital specialists, such as physiotherapists and occupational therapists. An observation made was that staff need to be more rigorous in ensuring that risk assessments are signed and dated, and that there is also a planned date to evaluate risk assessments for continuing relevancy or not. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 11 The health care needs of residents are being met and there was evidence to this effect. Access to all the primary health care services is facilitated by staff, and residents are generally able to keep their own GP. The inspector learned that GP services were generally satisfactory but that the home was experiencing some problems with a particular practice and are monitoring this at the present time. If there is no improvement, the home should report this to the Family Practitioner Service, and also to the Primary Care Trust covering their area. The Community Nursing Service visits as directed by the GP and was willing to comment that there were no problems with the care provided by staff in the home. Two of the residents have pressure sores at present that are healing as a result of care and attention by staff. Staff have the necessary equipment to deal with such occurrences, and would seek the advice of the tissue viability nurse where required. The district nurse is involved in other cases in order that the necessary specialised equipment can be requisitioned by her. Those residents whose condition demands it are weighed on a monthly basis, and action is taken via the GP/nutritionist/ speech and language therapist if there is a problem. Other residents are all weighed on a regular basis, to safe guard their interests. The home seeks advice from the continence advisor as required to safeguard residents dignity that is the case at the present time for a number of residents, and a member of care staff has a designated liaison role between the continence advisor and the homes nursing staff specifically for this purpose. A medication policy and procedure is available, and all medication is administered by a member of staff who has received accredited training. The medication procedures were observed on the morning shift and were carried out in a satisfactory manner. None of the residents self medicates at the present time, and a sample number of MAR sheets were looked at throughout the home and found to be recorded satisfactorily. The organisation that collects the homes medication waste have obtained a Waste Management Licence as required by the NHS from the 1st April 2005. There is a policy and procedure on how to deal with residents who are ill and in the later stages of their lives and where the funeral arrangements are unknown, the staff group will tactfully try to obtain this information from residents/relatives where possible and record this in their files. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents can enjoy a lifestyle suited to their particular expectations and preferences and receive staff support to achieve this aim. EVIDENCE: Residents are generally encouraged to lead their lives with as much control as is possible, and it was seen that a number of residents are early risers and like to have a drink in the dining room awaiting breakfast, whilst others like to stay in bed longer and rise at a more leisurely pace. There are some other residents who on occasions for reasons of confusion or illness are unable to make this choice themselves but receive the support of staff and this was clearly observed. Residents spoken to said that daily routines were flexible and varied. They confirmed they were able to choose how they spent their day and what leisure activities to join in with. Activities are arranged by a lead person carer who works 21 hours per week in conjunction with residents, assisted by another carer for 1 day per week a total of 28 hours per week. There is an activities board on display to inform residents of what has been arranged for every day of the week, and there are photographs of residents relatives and staff displayed covering past events. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 13 A wide variety of internal and external activities and events are provided throughout the year including reminiscence work, and staff have provided a varied selection of Christmas options including, bell ringers and the Lost Chord a musical group visiting the home. There have also been visits from junior school children and older children from Mexborough comprehensive school, as well as visits from the Salvation Army and local churches. One resident commented that she had a “wonderful Christmas” The home provides many trips out to various places such as Bakewell, various garden centres and shopping trips, all demonstrating community involvement, and is looking towards extending this to organising trips to the coast later this year. There are two residents who exercise control of their financial affairs and two others who do this with help from their relatives. Information is provided on the notice board about Advocacy services and Age Concern in particular for any resident who may need this service. Residents are able to bring their own personal possessions and memorabilia into the home, and there were many examples of this in evidence, and residents have access to their personal records if they want to see them with staff ensuring that confidentiality is maintained at all times. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The home has a complaints system and procedure that is made available to residents, but it is suspected that some complaints may not be being recorded, because they are either seen as trivial by staff or are dealt with during the course of a shift, and the care manager is to address this situation. EVIDENCE: There is a complaints procedure in operation, but no complaints have been recorded since the last inspection. A discussion with the care manager revealed that it was likely that some complaints from residents were being dealt with by staff as and when they were raised, but were not being recorded in the complaints book, and this will be discussed at the next staff meeting. Some staff received training with regard to abuse last year, and further training is arranged for February 2006. There is a policy on how to deal with residents physical/verbal aggression and staff are to receive training in February 2006. There is also a protocol covering the monies and financial affairs of residents including the administration of personal allowances to protect their interests. All residents are made aware of their right to vote, and this is generally done by a postal vote where 6 residents used postal votes at the general election in May last year. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 15 There is a statement precluding staff from becoming involved in the making of, or benefiting from residents wills contained in the staff handbook that safeguards the interests of residents. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, & 25. The fabric and furnishings of the home are generally well maintained, providing a safe environment for residents to live in, and Swallow Wood presents as a welcoming and homely setting with suitable furnishings and decorations to meet all the residents individual tastes. EVIDENCE: The premises are in good decorative condition, and there is an ongoing programme of redecoration and refurbishment. The care manager has a budget for the general maintenance of the home, and most of the home has been redecorated over the past year. Some refurbishment to the fixtures and fittings has been carried out since the last inspection, for example: 1. 5 new beds have been purchased for nursing residents. 2. 2 new airwave mattresses have been purchased. 3. A new washer has been purchased. 4. Blinds have been fitted in certain bedrooms to maintain residents privacy. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 17 In addition, proposed work includes the purchasing of new side tables for the lounges and quotations have been submitted to Head Office. The home is awaiting new keypad security systems to be fitted to the staircases, and the companies Estates Department is due to visit to assess the external premises for possible re-varnishing of the wooden exteriors. Residents generally have private, furnished, and comfortable accommodation, and most rooms are personalised to varying degrees, including the residents own furniture and personal memorabilia The care manager and staff have asked all residents whether they require all the requirements of this standard, and provided the additional furnishing where requested. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, & 29. Care and ancillary staffing levels appeared to be satisfactory to meet the needs of residents and ensure their welfare is safeguarded, and staff are well trained to meet the residents needs. The care manager must pay attention to the views of relatives about staffing issues mentioned at this inspection. EVIDENCE: When at full occupancy of 38 residents, staffing levels comprise of 1 registered nurse and 5 care staff per shift on both the day and afternoon shifts, and there is 1 registered nurse and 3 care staff at nights. The staffing complement at this inspection was a trained nurse and 4 care staff for 33 residents. The staffing hours are determined by the dependency levels of residents and the home deploys its staff complement between the ground and first floors in the home. Two relatives spoken to both said that they felt that the dependency levels had increased and that staff appeared under pressure in the evenings, when residents when residents were ready to go to bed, and this has been referred to the care manager for assessment. All staff have an individual training file, that provides evidence of all training completed including statutory training, and when updates are required. NVQ training is on going and the home has achieved 42 of care staff with level 2 or 3 NVQ. A particular problem identified in terms of meeting this standard for Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 19 50 of care staff to have achieved NVQ Level 2 by 2005, is that this percentage is bound to fluctuate and is dependent upon the home maintaining a stable staff team because when qualified staff leave they may be replaced withy new unqualified staff who then have to start the NVQ qualification. There is a policy and procedure for the recruitment and selection of staff, and the files of 2 new members of staff employed since the last inspection were checked and found to be satisfactory. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36, & 38. Residents benefit from a home run well and in their best interests where their health and safety is generally promoted. The home must check its “evacuation” policy with the Fire Service. Relationships between staff and the manager are very good and this contributes to the overall care provided to residents. The care manager is continuing studying for the Registered Managers Award that she hopes to complete as soon as possible. EVIDENCE: The registered manager is a registered nurse and is responsible for the dayto-day running of the home. She has gained her BA Hons degree in Health Studies and is continuing with the registered managers award. She also continues to undertake periodic training to update her knowledge skills and competence whilst managing the home. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 21 The manager feels that her style of management is open, approachable and fair, and all the staff interviewed spoke freely and positively about the care manager and her open door and inclusive approach. Staff said that they had confidence in her ability and were happy to be working under her leadership and management. The care manager has an annual development plan and holds budget expenditure headings that are determined centrally by the homes Head Office, but monitored by the care manager. It is not clear whether the parent company Southern Cross submits annual statements to CSCI to verify their financial viability. A sample of 3 resident’s monies was checked and found to be accurate and satisfactorily recorded, with receipts available, demonstrating a responsible approach to resident’s finances. Formal supervision is not being carried out to the required frequency and must receive attention if residents are to be protected by the homes supervision policy. All the safe working practice certificates were examined and were satisfactory but the home must obtain written authorisation from the Fire Service that their fire drills and “evacuation policy” are acceptable and safeguards the interests of all residents. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 22 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 2 3 x 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 4 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 x x 3 3 3 x 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 3 3 x 3 3 2 x 2 Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 4&5 Requirement The registered person must ensure that arrangements are made to have a condition of registration no longer applicable removed from the registration certificate, and also amended in the homes documentation. The registered person must ensure that all risk assessments for residents are signed, dated, and evaluated. The registered person must ensure that staff supervision is carried out at the required frequency. The registered person must ensure that written authorisation is obtained from the Fire Service that their fire drills and “evacuation policy” are acceptable and safeguard the interests of all residents. Timescale for action 31/01/06 2 OP7 15 31/01/06 3 OP36 18 31/01/06 4 OP38 23 31/01/06 Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 24 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 OP28 OP31 Good Practice Recommendations A minimum ratio of 50 trained members of care staff (NVQ Level 2) is achieved by 2005, excluding those members of care staff who are registered nurses The registered manager should achieve an NVQ level 4 in management or equivalent qualification in the year 2005. Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Swallow Wood Care Home DS0000015875.V274068.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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