Inspection on 07/09/06 for Swallownest Care Home

This inspection was carried out on 7th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Swallownest Care Home 12/03/07

Swallownest Care Home 15/03/06

Swallownest Care Home 21/09/05

Swallownest Care Home 08/03/05

Swallownest Care Home 06/07/04

Swallownest Care Home 06/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Swallownest Nursing Home Chesterfield Road Swallownest Sheffield South Yorkshire S26 4TL Lead Inspector Marina Warwicker Unannounced Inspection 7th September 2006 09:35 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 Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swallownest Nursing Home Address Chesterfield Road Swallownest Sheffield South Yorkshire S26 4TL 0114 2540608 0114 254 8846 none None Southern Cross Care Homes No 2 Limited 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) ** Post Vacant *** Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Swallownest is a care home providing nursing care for 27 and residential care for 65 older people. It is located in the village of Swallownest, which is on the Sheffield/Rotherham border and near the M1 motorway. The home is within easy reach of local shops and other community services. The home was purpose built and was developed in three phases and the design of the unit is in three wings, each with its own lounge and dining area. All bedrooms are single occupancy and seventeen of the bedrooms have ensuite facilities. The garden area is fitted with seating and raised flowerbeds; they also have a rear patio with access to the garden from the sun lounge and dining areas. The weekly fees range from £329.00 to £440.00. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Thursday 7th September 2006 between 9.35am and 5.30pm. On the following day site visit was continued between 7.50am and 1pm. Fifteen residents, ten relatives were consulted and eight staff were interviewed. A further ten relatives were contacted by post to obtain feedback about the service. The management will be informed of the comments received from the survey. Time was spent observing and interacting with staff and the service users. The deputy manager was present during the inspection. The premise was inspected which included bedrooms of service users and the communal areas inside and outdoors. Samples of records were checked. They were care plans, medication records, some service reports and staff recruitment & training files. During the inspection the deputy manager was informed of the findings. The operations manager was also informed of the summary of findings. On the final day of the site visit the deputy manager and the administrator were informed of the findings in detail and notes were taken at the feedback. I would like to thank the service users, visiting relatives, deputy manager, the administrator and all the staff for their honest and constructive contribution to this inspection report. What the service does well: What has improved since the last inspection? Staff training has improved. The central heating in the service users’ rooms has been repaired and the service users are able to control the temperature in their rooms. Staff receive handover between shifts. Staff recruitment records have improved and now comply with the Care Home Regulations. The activities co-ordinator has a list of leisure activities the service users prefer. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 The overall quality in this outcome area is: Poor. The above judgement is based on the information gathered from the staff, the service users and by checking the relevant documentation. Prospective service users and their representatives have the information needed to choose the home, which will meet their needs. Although the service users have their needs assessed by the staff at the home; in some cases the home does not have the capacity to meet the needs of the service users who are admitted out of category. The new contracts clearly tell the service users about the service they will receive. However, the service users are not in receipt of these. EVIDENCE: The service user guide did not reflect the service provided at the home. Three service users’ contracts were checked and these needed updating with the present terms and conditions. A relative questioned about having to bring toiletries for the service user and s/he expected toiletries to be included in the weekly fee; when verifying this it was noted that this service user had not received the most up-to-date contract. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 9 Three service users files were checked and the staff were interviewed. The full needs assessments and the instructions obtained for the care plans prior to admission did not give sufficient information. The staff did not have the knowledge or the skills to care for service users with elderly mentally ill –EMI-needs. However, there were some service users with EMI needs admitted by the care manager to the home. Service users who require nursing care were placed in the personal care units and these service users were not provided with essential nursing care. Four relatives said that they had the opportunity to visit the home and speak to the service users and staff to find out about the home. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 The overall quality in this outcome area is: Poor. The above judgement is based on the information gathered from relatives, staff and by checking the relevant documentation. The health and personal care, which the service users receive is often not based on their individual needs. Since the needs are not reflected in the care plans. Most of the time the principles of respect, dignity and privacy are put into practice by the staff working at the home. EVIDENCE: Three care plans were checked. Six service users were consulted and four staff were interviewed. The following findings were made: The care plans did not have a comprehensive assessment. Although they set out in detail actions to be taken to address the care needs, the risk assessments were not filled in correctly. Therefore the care plans did not reflect the actual care needed by the service users. There were gaps in the information within the care plans. The care supervisors had not checked the care plans. Care plan reviews were unplanned and did not include the service users or the relatives. Service users Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 11 and relatives said that the staff informed them when they had to make changes to the care plans. Service users who needed nutritional support did not have the appropriate monitoring systems. (i.e. weight charts, food intake chart) Those service users who were at risk of falling did not have appropriate interventions; instead the incident forms of falls were completed and filed away in the individual files and the staff used methods of restraint to deal with service users who were wandering and at risk of falls. The staff said that none of the service users were able to self medicate. The supplying pharmacist had checked the medication management at the home. There had been advice and recommendations made. These will be checked on the next site visit. Four Medication Administration Sheets were checked and they were recorded satisfactorily. The service users and the relatives said that the staff respected the privacy and dignity of all. But sometimes some carers could be curt and they said that this was due to them being overworked and tired. Two relatives said, “They are rushing around and this can be a demanding job. We understand”. “The majority of them are very good. They are interested in making the residents look nice and comfy and make it home from home”. The service users looked well groomed and were wearing their own clothes. Staff said that they have not had formal training on end of life care however they have had experience looking after those who were dying. One staff said that s/he had received on the job training. The staff stated during the interview that they, “Make them comfortable. Try not to leave them alone. Speak to them in a calm manner. Look after the relatives and be sympathetic and supportive towards them.” Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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): 12, 13, 14 & 15 The overall quality in this outcome area is: Poor. The above judgement is based on the information gathered from relatives, staff and direct observation, also by checking the relevant documentation. Residents are able to choose their life style and social activity to a degree. Service users are able to keep in contact with family and friends. The social, cultural and recreational activities offered at the home meet most resident’s expectations. There is a lack of team work and supervision between the care staff and the kitchen staff which has an adverse impact on the service users receiving a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The service users are offered a variety of leisure activities in the home. However some relatives and service users commented how much they enjoyed trips out and that they wished the home had access to a minibus. On questioning the staff they said that there was a minibus available for trips and that it was shared between nine care homes. On the days of the site visits the service users were seen participating in activities. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 13 Service users received visitors and they were able to speak to them in private. Those relatives consulted said that they had not been invited to meetings and they said that it would be a good idea for them to be involved and kept informed of the changes by the management of the home. The relatives also asked when a permanent manager would be appointed. The service users or their next of kin handle the financial affairs. Service users were able to bring personal possessions with them and these were kept in their bedrooms. The service users were offered three meals a day and they were able to have snacks and drinks when they wanted. During consultation with the service users, staff and through direct observations, it was ascertained that the service users were not consulted about their likes and dislikes and they were given meals by the staff, as they deemed appropriate. The service users did not use the menus displayed and therefore the service users did not choose their meals. There was no information for the kitchen staff of the service users’ likes and dislikes and if any service user was on special diets. At breakfast time the service users were brought to the dining room by staff. It was noted that the staff left service users in wheel chairs instead of transferring them onto the dining chairs. A service user was left in a bucket chair where the table was above his/her head and s/he was seen struggling to feed him/her-self. The staff were instructed to rectify this immediately by the inspector. Two service users said that their legs were hurting since the dining chairs were too low. One of the service users commented that the dining tables were too high. The staff were not available at breakfast to help service users and the kitchen staff were seen helping those in the dining room. At teatime service users were seen having their tea in their rooms or in the lounges. They said that they were not given the option of eating in the dining room. However this was not the practice in the Ellis Unit. The above findings were passed on to the deputy manager. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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 overall quality in this outcome area is: Adequate. The above judgement is based on the information gathered from relatives, staff and direct observation, also by checking the relevant documentation. Service users have access to the home’s complaints procedure. The service users are protected from abuse and have their legal rights protected by the policies of the home. There is a lack of documentary evidence that complaints have been investigated fully and the action taken in response. There were records of two complaints but the outcomes were not recorded and there was no system to check that similar concerns did not arise. The staff competency with regards to dealing with adult protection issues needs to be addressed by the management of the home so that the staff are able to follow appropriate procedures. EVIDENCE: The service users, relatives and the staff knew that the home had a complaint policy. During consultation with the service users and the relatives it became apparent that there had been several complaints and that the staff at the home had dealt with them. The staff were not clear when they should report concerns and complaints to the management. Staff said that they had video training on dealing with adult abuse and protecting vulnerable adults. Not all staff knew of the Sheffield Adult Protection Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 15 contact details or where they could find it. Staff said that they had heard of the Whistle Blowing policy but unable to recollect what it was about. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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, 22, 23, 24, 25 & 26 The overall quality in this outcome area is: Adequate. The above judgement is based on the information gathered from relatives, staff and direct observation, also by checking the relevant documentation. The physical design and layout of the home requires extra staff to enable residents to live in a safe, well-maintained and comfortable environment, promoting independence. EVIDENCE: The home is divided into three units. The Ellis and the Stuart units are the residential units where service users requiring personal care are placed. These are separate units either side of the nursing unit which is known as the Kendal unit. All three units were visited with the help of a team leader who was well versed in the layout of the home and the service users spoke to him/her affectionately. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 17 The following observations were made. • The home looked generally clean, safe and free from unpleasant odour. • There was a lack of storage space for wheel chairs and hoists. • Some wheelchairs and moving & handling equipment were dusty and dirty. • One bathroom was not in use since there was a problem with the water flow. • Two bathrooms needed maintenance work; Side of bath needed repairing and a bath hoist base was rusty needing replacement. • Kendall dining room tables were too high and the chairs were too low. The service users made comments suggesting that it was uncomfortable sometimes when sitting at the table. • Kendall lounge was very large and looked impersonal. Service users were sat against the walls. • The laundry in the Ellis unit was not locked when not in use. Instead the staff used a towel to ‘jam’ the door shut. • There was access to outdoor garden. • The service users had access to bathrooms and toilets. • The bedrooms of service users were personalised and looked cosy and comfortable. • There was an adequate number of moving & handling equipment for the use of staff. • The rooms were individually and naturally ventilated and the window openings conformed to recognised standards. • The central heating system had been repaired and during the site visit the system was being serviced. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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 & 30 The overall quality in this outcome area is: Poor. The above judgement is based on the information gathered from relatives, staff and direct observation, also by checking the relevant documentation. The staff at the home are skilled to look after older peoples’ personal and nursing care. Due to the layout of the home and the dependency levels of the service users living at the home the staffing numbers allocated to shifts need to be revised to fulfil the aims and objectives of the home and meet the changing needs of residents. An immediate action has been sought with regards to admitting service users out of category and thereby placing the service users and staff at risk. EVIDENCE: The ratio of care staff to service users did not reflect the assessed needs of the service users at the home during the site visit. The staffing numbers did not take into account the layout of the three units. Additional staff were needed during the peak time of activities during the day and this was not provided. There was a record of staff rota showing which staff were on duty. 43 of care staff had achieved NVQ level 2 in care. Four staff files were checked and they were satisfactory. The files had all of the information required by the Care Home Regulation 2002. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 19 Four staff training files were checked. In the last twelve months, All four staff had attended Fire safety and health & safety training Three staff had attended moving & handling Two had attended Infection control training Three had attended Adult Protection There were no records of these four staff having had training on continence care, nutritional assessment, tissue viability or end of life care. The above findings highlights that the staff training was patchy and not all staff had received mandatory training. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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, 33, 36, 37 & 38 The overall quality in this outcome area is: Poor. The above judgement is based on the information gathered from relatives, staff and direct observation, also by checking the relevant documentation. The management and administration of the home is based on openness and respect to those who are using the service. There has not been an effective quality assurance system in place. Therefore the service has not been assessed for achieving its aims. The home has not had a registered manager since 3rd February 2006. There have been several changes to the management structure of Southern Cross, which has left staff at the home, unsupervised and unsupported. EVIDENCE: There has not been a manager in place for seven months. The deputy manager worked night duty at the home and was not familiar with the running of the Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 21 home. She/he had been left to manage the home with no management support from the company. Service users, staff and relatives made this comment. Although the deputy manager and the administrator had tried running the home in an open and transparent manner they have not had the required management support. There was no evidence of quality monitoring or service users’ meetings staff meetings or relatives’ meetings to seek the views of those who were using the service. The staff said that they had not had supervision and that the last manager spoke about appraisals and supervision but nothing has happened so far. Individual records and the homes’ records were kept safe by the staff at the home. There were no risk assessments available for the safe working practice at the home. The staff had not reported all accidents, injuries and illness to the Commission for Social Care Inspection under Regulation 37. During the interview the staff did not know what and whom they should report the incidents to. Therefore a copy of the requirements outlined in Regulation 37 was given to the staff for reference. The staff induction and foundation training needs to be updated to meet the National Training Organisation Workforce training targets. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 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 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 2 X 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x x 1 2 2 Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 service user guide must reflect the aims, objectives and facilities at the home. The service user guide must be regularly updated. Previous requirement 15/05/06 Partially achieved. 2. 3. OP2 OP3 5 14,15 Each service user must have an up to date contract. No service user must move into the home without having had a needs assessment and assured by the management at the home that the identified needs would be met. Immediate action. 4. OP4 14 The staff at the home must not admit service users who are out of category. Immediate action. 5. OP7 15 The service user plans must reflect how the health and DS0000003089.V311069.R01.S.doc Timescale for action 17/11/06 28/10/06 08/09/06 08/09/06 08/09/06 Swallownest Nursing Home Version 5.2 Page 24 welfare needs of the individuals are to be met. The information must be accurate and must be kept under review. Immediate action. 6. OP8 13,14,17 Appropriately trained staff must carry out risk assessments so that the information is accurate and the care plans could be revised on the basis of the outcome of the risk assessments. All staff must respect the service users and their visitors and treat them with dignity. Immediate action. 8. OP11 12 The staff must receive formal training on offering comfort to those who are dying and their families and how to support them. Previous requirement. Time scales 21/11/05, 15/05/06 not met. 9. OP15 12,16 The service users must be given options of menus to choose. Staff must be available to help service users at meal times. The kitchen staff must be made aware of special diets by the care staff. The staff must ensure that all service users are seated comfortably at the table when having their meals. All service users must be given the opportunity to have their Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 25 28/10/06 7. OP10 12,18 08/09/06 17/11/06 08/09/06 meals in the dining room. Immediate action 10. OP16 22 The staff must be aware that all complaints are to be recorded and the home is expected to keep a summary of the complaints made during the proceeding twelve months and the action that was taken in response. All staff must receive training on protection of vulnerable adults and formal procedures as to who needs to be involved. Previous requirement 21/11/05, 15/05/06.Partially achieved. 12. 13. OP20 OP27 23 18 The communal lounge in the Kendal unit is impersonal and requires reorganisation. The staff on duty must reflect the size and layout of the building and the dependencies of the service users. Previous requirement. 31/05/05,21/11/05,15/03/06. Not achieved Immediate action. 14. OP30 12,18 The staff training and development programme must meet the needs of staff employed and the service users’ needs. Previous requirement. 21/11/05,15/05/06. Partially achieved. 15. OP31 9 The organisation must employ an appropriately qualified, experienced individual to manage the home. DS0000003089.V311069.R01.S.doc 28/10/06 11. OP18 12 28/10/06 17/11/06 08/09/06 17/11/06 17/11/06 Swallownest Nursing Home Version 5.2 Page 26 16. OP33 24,15,12, 26 Previous requirement. 15/05/06 not achieved. The responsible individual with the help of the management must carry out effective quality assurance and monitoring of operations at the home. The staff must be given regular feedback on their performance. The Responsible Individual must carry out monthly, unannounced visit, monitor the running of the home and produce a meaningful report. Previous requirement. 15/05/06, reports were not comprehensive. 29/09/06 17. OP36 18 All staff must receive formal supervision at least six times a year and there must be documentary evidence to support this. Previous requirement. Time scale set 31/05/05, 21/11/05 and 15/05/06. Not achieved. 17/11/06 18. OP37 15,17 19. OP38 13,16,23 The records required by regulation for the protection of service users must be up to date and accurate All staff must receive mandatory training. Previous requirement. Time scale set 21/11/05,30/04/06. Partially achieved. 29/09/06 17/11/06 20. OP38 37 All deaths, accidents, injuries and incidents of illness or communicable disease must be recorded and reported to Commission for Social Care Inspection and the relevant DS0000003089.V311069.R01.S.doc 08/09/06 Swallownest Nursing Home Version 5.2 Page 27 authorities. Immediate action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP12 Good Practice Recommendations When issuing new contracts, the service users and/or their next of kin should be informed of any changes to the contracts. The service users should have access to the minibus more often that now. Swallownest Nursing Home DS0000003089.V311069.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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