Inspection on 03/12/07 for Swallowfields Care Centre

This inspection was carried out on 3rd December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Swallowfields Care Centre 02/12/08

Swallowfields Care Centre 03/10/06

Swallowfields Care Centre 09/01/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Swallowfields Care Centre Swallowfields Care Centre 45 Alexandra Road Epsom Surrey KT17 4DB Lead Inspector Joseph Croft Unannounced Inspection 3rd December 2007 10:00 Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 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 Swallowfields Care Centre DS0000064389.V349752.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 Adults 18-65. 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. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swallowfields Care Centre Address Swallowfields Care Centre 45 Alexandra Road Epsom Surrey KT17 4DB 01372 720908 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) Leighton House Limited To be confirmed Care Home 8 Category(ies) of Learning disability (8), Mental disorder, registration, with number excluding learning disability or dementia (8), of places Physical disability (3) Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be within the category of learning disability (LD) but may also have needs associated with the category mental disorder (MD) 3rd October 2006 Date of last inspection Brief Description of the Service: Swallowfields Care Centre is a residential care home, based in a large detached house within easy access to Epsom Town Centre. The home has eight single bedrooms, three on the ground floor and five on the first floor; all with en-suite toilet and bath/shower facilities. The service is able to cater for three service users with a physical disability in the first floor bedrooms. There is no lift in this home so service users using the second floor bedrooms must be able to negotiate the stairs The home offers service users two spacious sitting rooms, dining room, kitchen, and conservatory for those service users who wish to smoke. Service users also benefit from the home’s specialist facilities, which include an occupational therapy room, which can be used for a wide range of therapies and life skills development, gymnasium and sensory room. Service users also have access to a good sized and secure garden to the rear of the property and there is ample off road parking to the front of the premises. Overall the home provides a good standard of accommodation for younger adults with needs in the learning and physical disabilities categories of registration. The acting manager stated that the weekly fees for this home are £2650.00 per week. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 3rd December 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the acting manager assisted him throughout. This site visit took place over a period of eight hours, commencing at 10:00 and concluding at 18:00. The inspection process included a tour of the premises and sampling of service users’ care plans and risk assessments. Other documents sampled included the menu, policies and procedures, staff training records, recruitment files and records of medication. The Inspector had discussions with members of staff on duty, and three service users. Service users informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Service users stated that the food was good and they choose the menu each week. During observations staff and service users were interacting in an appropriate manner, and service users were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the acting manager of the home has been used as a source of evidence in this report. Only two completed surveys from relatives, and one from staff were returned to the Commission For Social Care Inspection. The inspector would like to thank the acting manager, members of staff and service users for their time during this visit. Feedback was provided to the acting manager at the end of this site visit. What the service does well: Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 6 Assessment documentation is in place to ensure the individual needs of service users can be met. People who use the service have care plans and risk assessments in place. Service users are encouraged by staff to participate in activities both within the home and the local community, which enables them to exercise choice and control over their lives. Meals are varied with individual choices and preferences, ensuring that service users receive a balanced diet. Physical and health care is offered in the way service users prefer. People who use the service have access to a complaints system that enables residents and their families to raise concerns. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere. What has improved since the last inspection? What they could do better: The health care needs of the identified service user must be appropriately maintained to ensure all their health care needs are being met. Accurate records of all medication received into the home must be maintained. All staff working at the care home must receive training in regard to Safeguarding Adults. The malodour in the identified bedroom must be eliminated. Staff recruitment files must contain the information and documents specified in paragraphs 1 to 9 of the Care Homes Regulation 2001 (amended) and Schedule 2. Staff must receive the minimum of six formal supervision sessions per year. Fire doors must not be kept open through the use of wedges or other objects. Annual testing of Portable Appliance Testing (PAT) and the testing for Legionella must be undertaken to ensure unnecessary risk to the health and safety of service users are identified and as far as possible eliminated. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 7 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. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of service users can be met. EVIDENCE: The home has a Referral and Admissions Policy and Procedure that was last reviewed in May 2007. The care file of the person most recently admitted to the home was viewed. This provided evidence that a pre- admission assessment had been undertaken prior to admission to the home, and a copy of the Care Programme Approach care plan had been obtained. Pre-admission assessments included information in regard to the personal, physical and mental health care needs. The acting manager informed the Inspector that once all the assessments have been completed, a care proposal is submitted to the prospective service user’s care manager. When the funding has been agreed for the placement, the individual is invited to visit the home to meet the other service users and staff. During discussions, service users informed the Inspector that they did visit the home prior to moving in. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 10 Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place that ensures their needs are met. Service users are supported by staff to lead active lives. EVIDENCE: Three care plans were sampled during this site visit. Care plans included information in regard to the assessed needs of the service user including their personal, pschyciatric and physical care needs, ethnicity, religious beliefs and self-help skills. Service users also have occupational and art therapy input into their care plans. Service users had signed the care plans sampled, which was a requirement made at the previous inspection. Two care plans had had an annual review undertaken that included the service user and their relatives. The third care plan was that of the most recent admission to the home, who had moved in two weeks prior to this site visit. However, the care plan had been developed and the key work worker was Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 12 knowledgeable about the care plan and the needs of the individual. Each service user has a Person Centred Plan and Goal Plan. During discussions, staff stated that the care plans are updated every three months. Service user plans include input from the Occupational Therapist and Art Therapist who aim to promote independence and teach new skills to service users. During discussions with staff and service users, and observations made throughout the site visit, it was clear that service users make decisions in regard to their daily lives. The Inspector observed a meeting with the service users where they were discussing nutrition and food. The week’s menu was also planned, with each service user being encouraged to make decisions for meals. Pictures of different meals were also used to aid decisions to be made. Service users informed the Inspector that they make choices about their activities and what they like to do. One service user stated that they “make lots of choices.” Service users have monthly meetings where they discuss day-to-day choices, the environment, menus and activities. Risk assessments were in place on the care plans sampled, however, it was noted that for one service user these had not been signed or dated. A good practice recommendation in regard to this has been made. Information provided in the Annual Quality Assurance Assessment (AQAA) informs that service users are to be supported by staff and other therapists to further promote service users’ independence. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in activities both within the home and the local community, which enables them to exercise choice and control over their lives. Meals are varied with individual choices and preferences, ensuring that service users receive a balanced diet. EVIDENCE: Care plans sampled included a list of the weekly activities each service user undertakes. Activities include attending a day centre, art and craft, swimming and shopping. Service users have access to the local community and go to the local restaurants, pubs and leisure centre. One service user informed the Inspector that they go swimming at the local leisure centre, and they had made friends with people at the day centre they attend. During discussions, service users stated that they like doing the food shopping, cooking, art and craft and going to the local town. One service user currently undertakes voluntary work at a local church, where they clean the church and attend to the maintenance of the garden. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 14 The acting manager informed the Inspector that service users attend activities in the local community with staff support, which is to encourage service users to work towards becoming independent. During the site visit staff were observed to be interacting with service users in a professional manner, addressing them by their preferred names, and allowing time for them to respond to questions asked. All the service users living at the home are of white British origin and hold Christian beliefs. The acting manager informed the Inspector that service users are encouraged and supported to practice their religious beliefs. This was confirmed during discussions with staff and service users. Family and friends are welcome to visit the home, and the only restriction is if the service user stated that they do not want to see them. Service users and staff informed the Inspector that they could see their visitors in the privacy of their bedrooms if they wish to. Two completed surveys were returned from relatives. One informed that they are always kept up to date with important issues affecting their relative; one informed that they are usually informed. Service users receive telephone calls in private, and receive their own mail unopened. Staff support service users as and when required with the reading of their letters. Staff stated they respect service users’ privacy and dignity through knocking on bedroom doors, calling service users by their preferred names and providing personal care in the privacy of their bedrooms. Evidence of these practices were observed during this site visit. Service users had access to the communal parts of the home that included an appropriately maintained garden to the rear of the premises. The home plans the weekly menus with the service users every week, after which they undertake the weekly shopping. Menus were viewed. These offer a variety of meals that included meat, fish, pasta, fresh vegetables and fruit. Service users are supported to make lunch of their choosing every day. The evening meal is prepared and cooked by staff and service users. Service users informed the Inspector that they like the food, one stated that “sometimes you get too much,” another stated that they liked to help with the cooking and choosing the menu. The acting manager stated that daily records of fridge/freezer and cooking temperatures are maintained. Information provided in the Annual Quality Assurance Assessment (AQAA) informs that service users are using the community amenities more effectively through using the library, regular visits to the cinema and pubs. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 15 Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Physical and health care is offered in the way service users prefer. The personal, physical and health care needs are recorded, however, identified issues in regard to one service user must be attended to. The recording of medication must be improved to safeguard residents. EVIDENCE: The sampling of the care plans provided evidence that service users receive the agreed personal care and support as recorded. Staff informed the Inspector that service users are able to attend to their personal needs, but advice, prompts and support is offered as and when appropriate. If and when support is provided, this is undertaken with the consent of the service user and in the privacy of their bedrooms and/or bathrooms. During discussions, and the sampling of records and care plans, evidence was provided that service users are registered with the local GP practice, Community Dentist, Optician, and have access all National Health Services. Service users have Health Care Action plans in their care files. Information provided in the AQAA informed that the Health Care Action plans are updated Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 17 according to the service users’ needs and wishes. However, it was noted that for one identified service user this information was missing. The same service user wears glasses, but it was noted that they were not wearing these, and the last appointment with the optician was eighteen months ago. A requirement has been made that the health care needs of the identified service user must be appropriately maintained to ensure all their health care needs are being met. The home follows the Organisation’s Medical Policy and Procedure that was last reviewed in August 2007. The home uses the Medical Administration Record sheets (MARs) that are provided by the local Pharmacy. The MARs sheets sampled had a photograph of the service user and specimen signatures of all staff authorised to administer medication. Two identified medicines had not been accurately recorded on the MAR sheets, and therefore an audit trail of these was not maintained by the home. This was discussed with the acting manager, and a requirement has been made that accurate records of all medication received into the home must be maintained. Medication was observed to be appropriately stored in a locked metal medicine cabinet. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a complaints system that enables residents and their families to raise concerns. Policies and procedures are in place to ensure that residents are safeguarded from abuse, however, staff require training in Protection of Vulnerable Adults to ensure residents are fully protected. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the care home. The acting manager informed the Inspector that the home had not received a complaint during the last twelve months. Records of complaints are recorded on a form and would be kept in the service user’s file. Discussions took place with the acting manager in regard to maintaining a complaints/compliments book that would record the date, nature of the complaint and the date the outcome was discussed with the complainant. A good practice recommendation has been made in regard to this. The home has a Complaints Policy and Procedure that includes the timescale for responding to complainants and the correct contact details for the Commission For Social Care Inspection. Each service user has a copy of this document in their Service Users Guide that they keep in their bedrooms. During discussions, service users stated that they would talk to the staff if they needed to make a complaint, but they had not needed to do this. Surveys returned from relatives informed that they all know how to make a complaint about the home. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 19 The home follows the organisation’s Protection of Vulnerable Adults Policy and Procedure that was reviewed in August 2007. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. During discussions staff were able to demonstrate an understanding of Safeguarding Adults issues. Staff stated they would report all concerns to the manager, and would not hesitate in reporting bad practice. The sampling of four staff training records provided evidence that staff had received training in regard to Safeguarding Adults, however, two of these were undertaken in 2007, the other two in 2004. The acting manager informed the Inspector that another four staff had attended this training in 2007, but five staff had not received any training in this area of their work. Information provided in the AQAA informs that only 60 of staff had attended training in regard to Safeguarding Adults. A requirement has been made that all staff working at the care home must receive training in Safeguarding Adults. This will ensure that service users are protected from abuse. The acting manager informed the Inspector that service users and/or their relatives are responsible for their finances; however, the home does hold a small amount of money for service users. Records were viewed, and the money held balanced with the records maintained by the home. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere. However, the identified issue requiring attention must be addressed to ensure service users continue to live in a safe and well maintained environment. EVIDENCE: A tour of the premises was undertaken, however, not all bedrooms were viewed during this site visit. The accommodation consists of eight single bedrooms, three on the ground floor and five on the first floor, all with en-suite toilet and bath/shower facilities. There are two spacious sitting rooms, a dining room and kitchen. Service users also benefit from the home’s specialist facilities, which include an occupational therapy room that can be used for a wide range of therapies and life skills development, gymnasium and sensory room. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 21 Service users have access to a good sized and secure garden to the rear of the property. Bedrooms and communal areas were brightly decorated, clean and tidy. Service users’ had their own possessions in their bedrooms that included television, stereos and family photographs. Each bedroom had a lockable facility for service users. All en-suite facilities and communal bathrooms and toilets had liquid soap dispensers and paper towels. The laundry room has a lockable facility for the safe storage of Control Of Substances Hazardous to Health (COSHH). It was observed that the light covers on the first floor require cleaning to ensure all insects are removed. Bedroom three had a malodour that must be addressed. A requirement in regard to this has been made. An issue in regard to the Health and Safety of service users has been addressed under the Conduct and Management part of this report. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of the service users. People who use the service are protected by the organisation’s recruitment policy and procedures; however, staff recruitment files require further information. EVIDENCE: Information provided in the AQAA informed that the home employs seventeen members of staff. The acting manager informed the Inspector that there are fifteen care staff and two Occupational Therapists employed at the home. The duty rota was viewed during the site visit. This provided evidence that there were three members of staff on duty each shift, with the acting manager as supernumery, and two waking night staff cover the night time duties. The home employs a multi-cultural staff team that consists of male and female staff. The acting manager stated that six staff hold the NVQ level two and above, two of who are currently undertaking the NVQ level four. One member of staff is a qualified nurse. Information provided in the AQAA acknowledges that the home has not achieved 50 of the work force holding a minimum of an NVQ Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 23 level two or above. A good practice recommendation has been made that the manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. The home follows the organisation’s Recruitment Policy and Procedure that was last reviewed in August 2007. Three recruitment files were sampled during this site visit. Each file contained an application form, two written references, Criminal Record Bureau reference numbers and proof of identity. However, one application form did not provide a full employment history. A requirement has been made in regard to this. It was not possible to identify if staff had commenced their employment prior to the organisation receiving the Criminal Record Bureau clearance, as the dates staff commenced employment at the home were not recorded in the staff files sampled. A recommendation has been made in regard to this. The acting manager informed the Inspector that the home is currently recruiting a further five members of staff that would allow four members of staff to be on duty each shift. The sampling of staff training files provided evidence that mandatory training is taking place. The acting manager informed the Inspector that the organisation had recently employed a training co-ordinator who will have the responsibility for ensuring all staff receive the training required. Other training staff had received included Mental Health, Autistic Spectrum Disorders, Equality and Diversity and Aggressive Behaviours. Regular, formal, recorded, one-to-one supervision of care staff is not being undertaken as required. The acting manager informed the Inspector that this had not been undertaken. A requirement has been made that all staff must receive the minimum of six formal supervision sessions per year to ensure all aspects of care practices and career development are discussed and monitored. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, however, issues in regard to safeguarding training, staffing, recruitment and health and safety must be addressed to ensure the safety of residents is met. EVIDENCE: The acting manager has been working at the home since October 2005, and is a qualified Registered Mental Health Nurse. He was appointed to the role of acting manager when the registered manager resigned in November 2005. The acting manager informed the Inspector that he had submitted an application to be considered for registration to the South East Regional Registration Team (SERRT) in September 2007. However, the Inspector Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 25 contacted the SERRT on the 04/12/07 and was informed that no application to register had been received from the care home. Information provided in the AQAA informs that plans for improvement include the appointing and registering of a permanent manager and deputy manager in place of the acting manager. The home has been without a permanent registered manager for two years. A requirement has been made that the organisation must review the management arrangements at the home in order to ensure the health, safety and welfare of the service users is continually promoted and protected. Discussions took place with the acting manager in regard to the use of Close Circuit Television Cameras in the corridors and communal areas of the home. The acting manager was advised that further investigations into the use of this equipment would be sought and addressed with the registered provider, as this may be seen as an infringement to service users’ privacy and dignity. The acting manager must attend to the issues in regard to safeguarding training, staffing, recruitment and health and safety. One survey received from a relative raised an issue in regard to an incident that affected the welfare of one identified service user. This was discussed with the acting manager, who informed the Inspector that this was discussed with the relative concerned when it happened. Records were maintained of the incident, however, this incident had not been notified to the Commission For Social Care Inspection through a Regulation 37 notification. A requirement has been made that all accidents and incidents affecting the welfare of service users must be notified to the Commission For Social Care Inspection through the use of the Regulation 37 notification. The home conducts monthly meetings with residents where they discuss activities, choices and every day aspects of living at the home. Weekly meetings in regard to the menus were evidenced during this site visit. Service users are encouraged and supported to make choices. The registered provider conducts Regulation 26 visits, and copies of these reports are maintained at the home. Information provided in the AQAA informs that annual testing of Health and Safety equipment had been undertaken. The home has a copy of the organisation’s Health and Safety policy, however, this document had not been adhered to Portable Appliance Testing (PAT). It was also noted that testing for Legionella had not been undertaken. The acting manager should contact the relevant authorities for specialist advice in regard to the prevention of Legionella, and ensure that a risk assessment is drawn up, and a policy is put in place for the prevention of legionella in the home. A requirement has been made that that these tests must be carried out to ensure the health and safety of service users and staff at the home. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 26 During the site visit records of fire risk assessments, testing of the fire alarm systems and fire drills were viewed. The home had a visit from the Surrey Fire and Rescue Team on the 22/01/07 when they recommended that the fire risk assessments should be reviewed on a regular basis. The acting manager informed the Inspector that a second visit is taking place on the 19/12/07, during which the Fire Officer would again examine the fire risk assessments. It was noted during the site visit that fire doors were being kept open through the use of wedges and other objects. The acting manager immediately removed these. A requirement has been made in regard to this. Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 28 No 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 YA19 Regulation 13 (1) (b) Requirement The health care needs of the identified service user must be appropriately maintained to ensure all their health care needs are being met. Accurate records of all medication received into the home must be maintained. All staff working at the care home must receive training in regard to Safeguarding Adults. This will ensure that service users are protected from abuse. The malodours in the identified bedroom must be eliminated. This will ensure that residents continue to live in a safe and hygienic environment. Staff recruitment files must contain the information and documents specified in paragraphs 1 to 9 of the Care Homes Regulation 2001 (amended) and Schedule 2. Staff must receive the minimum of six formal supervision sessions per year to ensure all aspects of care practices and DS0000064389.V349752.R01.S.doc Timescale for action 03/01/08 2. 3. YA20 YA23 13 (2) 13 (6) 04/12/07 03/02/08 4. YA30 16 (2) (k) 31/12/07 5. YA34 19 (1) (b 03/01/08 6. YA36 18 (2) 03/02/08 Swallowfields Care Centre Version 5.2 Page 29 7. YA37 8 8. YA37 37 (1) (e) career development are discussed and monitored. The organisation must review the management arrangements at the home in order to ensure the health, safety and welfare of the service users is continually promoted and protected. All accidents and incidents affecting the welfare of service users must be notified to the Commission For Social Care Inspection through the use of the Regulation 37 notification. 03/01/08 04/12/07 9. YA42 23 (4) (c) (i) Fire doors must not be kept open 04/12/07 through the use of wedges or other objects. This is to ensure that the health, safety and welfare of residents is maintained at all times. Annual Portable Appliance Testing (PAT) must be undertaken. The relevant authorities must be contacted for specialist advice in regard to the prevention of Legionella. This will ensure that unnecessary risk to the health and safety of service users are identified and as far as possible eliminated. 10. YA42 13 (3) (4) 23 (2) (c) 03/02/08 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 YA9 Good Practice Recommendations Risk assessments must be signed and dated to ensure that DS0000064389.V349752.R01.S.doc Version 5.2 Page 30 Swallowfields Care Centre these are being reviewed on a regular basis. 2. YA22 The home should maintain a complaints/compliments book that would record the date, nature of the complaint and the date the outcome was discussed with the complainant. The acting manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. Staff recruitment files should include the dates employment commenced at the home. 3. 4. YA32 YA34 Swallowfields Care Centre DS0000064389.V349752.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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